Rules of Department of Health and Senior Services Division 30—Division of Regulation And

Rules of Department of Health and Senior Services Division 30—Division of Regulation and Licensure Chapter 86—Residential Care Facilities and Assisted Living Facilities

Title Page

19 CSR 30-86.012 Construction Standards for Assisted Living Facilities and Residential Care Facilities...... 3 19 CSR 30-86.022 Fire Safety and Emergency Preparedness Standards for Residential Care Facilities and Assisted Living Facilities...... 4 19 CSR 30-86.032 Physical Plant Requirements for Residential Care Facilities and Assisted Living Facilities ...... 10 19 CSR 30-86.042 Administrative, Personnel and Resident Care Requirements for New and Existing Residential Care Facilities ...... 12 19 CSR 30-86.043 Administrative, Personnel, and Resident Care Requirements for Facilities Licensed as a Residential Care Facility II on August 27, 2006 that Will Comply with Residential Care Facility II Standards ...... 19 19 CSR 30-86.045 Standards and Requirements for Assisted Living Facilities Which Provide Services to Residents with a Physical, Cognitive, or Other Impairment that Prevents the Individual from Safely Evacuating the Facility with Minimal Assistance ...... 23 19 CSR 30-86.047 Administrative, Personnel, and Resident Care Requirements for Assisted Living Facilities ...... 24 19 CSR 30-86.052 Dietary Requirements for Residential Care Facilities and Assisted Living Facilities ...... 33

JOHN R. ASHCROFT (5/31/20) CODE OF STATE REGULATIONS 1 Secretary of State Chapter 86—Residential Care Facilities and Assisted Living Facilities 19 CSR 30-86

Title 19—DEPARTMENT OF specifications and completed within a period November 13, 1980, are exempt from this HEALTH AND SENIOR SERVICES of three (3) years, the facility shall resubmit requirement. II Division 30—Division of Regulation plans to the department for its approval and and Licensure shall amend them, if necessary, to comply (11) One (1) tub or shower bath shall be pro- Chapter 86—Residential Care Facilities with the then current rules before construc- vided for each twenty (20) residents or major and Assisted Living Facilities tion work is started or continued. III fraction of twenty (20). Facilities exceeding twenty (20) residents shall have separate 19 CSR 30-86.012 Construction Standards (4) If the facility employs more than fifteen bathing facilities for each sex. II for Assisted Living Facilities and Residen- (15) people, it shall conform with section 504 tial Care Facilities of the Rehabilitation Act of 1973. Any facility (12) One (1) toilet and lavatory shall be pro- that houses handicapped residents shall have vided for each six (6) residents or major frac- PURPOSE: This rule establishes construction the first floor rooms and living areas tion of six (6). Facilities formerly licensed as standards for Residential Care Facilities and designed to be accessible to these residents. residential care facilities II and in operation Assisted Living Facilities. III or whose plans were approved prior to November 13, 1980 are required to provide PUBLISHER’S NOTE: The secretary of state (5) Facilities shall not house residents on a one (1) toilet for each ten (10) beds or major has determined that the publication of the level where the outside grade line is more fraction of ten (10) and one (1) lavatory for entire text of the material which is incorpo- than three feet (3') above the floor level on every fifteen (15) residents or major fraction rated by reference as a portion of this rule the window side of the room. II of fifteen (15). II would be unduly cumbersome or expensive. This material as incorporated by reference in (6) Facilities whose plans were approved after (13) Separate toilet rooms shall be provided this rule shall be maintained by the agency at December 31, 1987, shall provide a mini- for each sex if common rooms with multi- its headquarters and shall be made available mum of seventy (70) square feet per resident stalls and stools are provided. II to the public for inspection and copying at no in private and multiple occupancy bedrooms. (14) Bath and toilet facilities shall be conve- more than the actual cost of reproduction. This square footage calculation shall include This note applies only to the reference mate- niently located so that residents can reach the floor space used for closets and built-in them without passing through the kitchen, rial. The entire text of the rule is printed furniture and equipment if these are for resi- here. another bedroom, or auxiliary service areas. dent use and the closet space does not exceed Facilities formerly licensed as residential care five (5) square feet per resident. Private bed- AGENCY NOTE: All rules relating to long- facilities II and in operation or whose plans rooms in existing facilities that are required term care facilities licensed by the depart- were approved prior to November 13, 1980 to comply with the requirements of 19 CSR ment are followed by a Roman Numeral which are exempt from this requirement. III 30-86.043 or 19 CSR 30-86.047, and multi- refers to the class (either class I, II or III) of ple occupancy bedrooms in facilities licensed (15) Bath and toilet facilities shall be ventilat- standard as designated in section 198.085.1, between November 13, 1980 and December ed. III RSMo 2000. 31, 1987, shall have a minimum of sixty (60) square feet of floor space per resident. II (16) Facilities whose plans were approved or (1) These standards apply to assisted living were initially licensed after December 31, facilities and residential care facilities as indi- 1987, shall have a community living and din- cated in the rule. (7) Ceilings in bedrooms shall be a minimum of seven feet (7') in height or if a room with ing area separate from resident bedrooms sloping ceiling is used, only the area where with at least twenty-five (25) square feet per (2) A facility shall submit a copy of plans of resident. The community living and dining the ceiling height is at least seven feet (7') proposed new construction, additions to or area may be combined with footage required can be used to meet the required minimum major remodeling of an existing facility to the for another long-term care facility when the square footage per resident. II Section for Long Term Care of the Depart- facility is on the same premises as another ment of Health and Senior Services (here- licensed facility. Facilities that are required to inafter—the department). If the facility is to (8) Facilities shall provide bedrooms with at comply with the requirements of 19 CSR 30- be licensed for more than nine (9) residents, least one (1) functional outside window with 86.043 licensed prior to November 13, 1980, a registered architect or registered profes- screen. Window size shall be not less than must have a living room area but they are sional engineer shall prepare the plans and one-twentieth (1/20) or five percent (5%) of exempt from minimum size requirements. specifications for new construction or addi- the required floor area. II Facilities licensed between November 13, tions to an existing facility in conformance 1980 and December 31, 1987, shall have a with Chapter 327, RSMo. III (9) Facilities shall provide resident rooms community living area with twenty (20) with a full nonlouvered door that swings into square feet per resident for the first twenty (3) Construction of facilities shall begin only the room. Facilities formerly licensed as res- (20) residents and an additional fifteen (15) after the plans and specifications have idential care facilities II and existing prior to square feet per resident over a census of received the written approval of the depart- November 13, 1980, are exempt from this twenty (20). II ment. Facilities shall then be built in confor- requirement. II mance with the approved plans and specifica- (17) Facilities shall provide the following in tions. The facility shall notify the department (10) Facilities shall permit no more than four the dietary area: a kitchen, dishwashing, when construction begins. If construction of (4) beds per bedroom, regardless of the room refrigeration, and garbage disposal facilities. the project is not started within one (1) year size. Facilities formerly licensed as residen- The facility shall arrange the kitchen and after the date of approval of the plans and tial care facilities II and existing prior to equipment to efficiently and sanitarily enable

JOHN R. ASHCROFT (5/31/20) CODE OF STATE REGULATIONS 3 Secretary of State 19 CSR 30-86—DEPARTMENT OF HEALTH AND SENIOR SERVICES Division 30—Division of Regulation and Licensure

the storage, preparation, cooking and serving between December 31, 1987 and December 11, 1998, effective Dec. 30, 1998. Moved to of food and drink to residents. II 31, 1998, shall have at least one (1) hydraulic 19 CSR 30-86.012, effective Aug. 28, 2001. or electric motor-driven elevator if there are Amended: Filed Nov. 15, 2004, effective May (18) Residential care facilities and assisted more than twenty (20) residents with bed- 30, 2005. Amended: Filed Aug. 23, 2006, living facilities shall provide a designated rooms above the first floor. The elevator effective April 30, 2007. Amended: Filed attendant’s working area which includes: a installation(s) shall comply with all local and March 13, 2008, effective Oct 30, 2008. storage space for records; locked storage state codes, American Society for Mechani- space for medications; a handwashing sink cal Engineers (ASME) A17.1, Safety Code *Original authority: 198.073, RSMo 1979, amended with hot and cold running water, a soap dis- for Elevators, Dumbwaiters, and Escalators, 1984, 1992, 1999, 2006, 2007, and 198.076, RSMo 1979, penser and paper towels; and a telephone and the National Fire Protection Associa- amended 1984, 2007. conveniently located to the area. Facilities tion’s applicable codes. All facilities with licensed for twelve (12) or fewer residents are plans approved on or after January 1, 1999, 19 CSR 30-86.022 Fire Safety and Emer- exempt from a separate working area. III shall comply with all local and state codes, ASME A17.1, 1993 Safety Code for Eleva- gency Preparedness Standards for Residen- (19) Facilities shall have a laundry area in a tors and Escalators, and the 1996 National tial Care Facilities and Assisted Living separate room for storing, sorting, washing, Electrical Code. These references are incor- Facilities drying and distributing linen and personal porated by reference in this rule and available clothing. Laundry facilities of a licensed at: American Society for Mechanical Engi- PURPOSE: This rule establishes fire safety long-term care facility located on the same neers, Three Park Avenue, New York, NY and emergency preparedness standards for premises may be used. Facilities licensed for 10016-5990; and The American National residential care facilities and assisted living twelve (12) or fewer residents will be exempt Standards Institute, 11 West 42nd Street, 13th facilities. from having a separate room for laundry but Floor, New York, NY 10036. This rule does the laundry room shall be separate from the not incorporate any additional amendments PUBLISHER’S NOTE: The secretary of state kitchen and shall not be located in a room or additions. II has determined that the publication of the used by residents. III entire text of the material which is incorpo- (26) Facilities whose plans were approved or rated by reference as a portion of this rule (20) All newly licensed facilities shall be of which were initially licensed after December would be unduly cumbersome or expensive. sturdy construction with permanent founda- 31, 1987, shall provide an air-conditioning This material as incorporated by reference in tions. III system, or individual room air-conditioning this rule shall be maintained by the agency at units, capable of maintaining resident-use its headquarters and shall be made available (21) In buildings built prior to September 28, areas at eighty-five degrees Fahrenheit (85 °F) to the public for inspection and copying at no 1979, corridors shall have a minimum width (29.4 °C) at the summer design temperature. more than the actual cost of reproduction. of thirty-six inches (36"). First-floor resident II This note applies only to the reference mate- room doors shall be a minimum of thirty-two rial. The entire text of the rule is printed (27) Home-Like Requirements with Respect inches (32") wide. Resident room doors of here. these buildings on the second floor and above to Construction Standards. (A) Any assisted living facility formerly shall be a minimum of thirty inches (30") AGENCY NOTE: All rules relating to long- licensed as a residential care facility shall be wide. II/III term care facilities licensed by the Depart- more home-like than institutional with ment of Health and Senior Services are fol- respect to construction and physical plant (22) In newly licensed buildings constructed lowed by a Roman Numeral notation which standards. II on or after September 28, 1979, all resident refers to the class (either class I, II, or III) of room doors shall be a minimum of thirty-two (B) Any assisted living facility licensed as a residential care facility II prior to August standard as designated in section 198.085, inches (32") wide on all floors. Corridors RSMo 2000. shall be a minimum of forty-eight inches 28, 2006, shall qualify as being more home- (48") wide and interior stairs shall be at least like than institutional with respect to con- (1) Definitions. For the purpose of this rule, thirty-six inches (36") wide. II/III struction and physical plant standards. II (C) Any assisted living facility that is built the following definitions shall apply: (23) Exit doors in newly licensed facilities or has plans approved on or after August 28, (A) Accessible spaces—shall include all shall be at least thirty-six inches (36") wide, 2006, shall be more home-like than institu- rooms, halls, storage areas, basements, attics, at least seventy-two inches (72") high and tional with respect to construction and physi- lofts, closets, elevator shafts, enclosed stair- shall swing outward. II/III cal plant standards. II ways, dumbwaiter shafts, and chutes; (B) Area of refuge—a space located in or (24) Residential care facilities that accept AUTHORITY: sections 198.073 and 198.076, immediately adjacent to a path of travel lead- deaf residents, shall have appropriate assis- RSMo Supp. 2007.* This rule originally filed ing to an exit that is protected from the tive devices to enable each deaf person to as 13 CSR 15-15.012. Original rule filed July effects of fire, either by means of separation negotiate a path to safety, including, but not 13, 1983, effective Oct. 13, 1983. Emergency from other spaces in the same building or its limited to, visual or tactile alarm systems. amendment filed Aug. 1, 1984, effective Aug. location, permitting a delay in evacuation. II/III 13, 1984, expired Dec. 10, 1984. Amended: An area of refuge may be temporarily used as Filed Sept. 12, 1984, effective Dec. 13, 1984. a staging area that provides some relative (25) Residential care facilities and facilities Amended: Filed May 13, 1987, effective Aug. safety to its occupants while potential emer- formerly licensed as residential care facilities 13, 1987. Amended: Filed Aug. 1, 1988, gencies are assessed, decisions are made, II whose plans were initially approved effective Nov. 10, 1988. Amended: Filed May and, if applicable, evacuation has begun;

4 CODE OF STATE REGULATIONS (5/31/20) JOHN R. ASHCROFT Secretary of State Chapter 86—Residential Care Facilities and Assisted Living Facilities 19 CSR 30-86

(C) Major renovation—shall include the 9101; www.nfpa.org; by telephone at (617) of an ABC-rated extinguisher in the kitchen following: 770-3000 or 1-800-344-3555. This rule does cooking areas. II 1. Addition of any room(s), accessible not incorporate any subsequent amendments (C) Fire extinguishers shall have a rating of by residents, that either exceeds fifty percent or additions to the materials listed above. at least: (50%) of the total square footage of the facil- This rule does not prohibit facilities from 1. Ten pounds (10 lbs.), ABC-rated or ity or exceeds four thousand five hundred complying with the standards set forth in the equivalent, in or within fifteen feet (15') (4,500) square feet; newer editions of the incorporated by refer- of hazardous areas as defined in 19 CSR 30- 2. Repairs, remodeling, or renovations ence material listed in this subsection of this 83.010; and that involve structural changes to more than rule, if approved by the department. 2. Five pounds (5 lbs.), ABC-rated or fifty percent (50%) of the building; (B) Facilities that were complying prior to the equivalent, in other areas. II 3. Repairs, remodeling, or renovations the effective date of this rule with prior edi- (D) All fire extinguishers shall bear the that involve structural changes to more than tions of the NFPA provisions referenced in label of the Underwriters’ Laboratories (UL) four thousand five hundred (4,500) square this rule shall be permitted to continue to or the Factory Mutual (FM) Laboratories and feet of a smoke section; or comply with the earlier editions, as long as shall be installed and maintained in accor- 4. If the addition is separated by two- there is not an imminent danger to the health, dance with NFPA 10, 1998 edition. This (2-) hour fire-resistant construction, only the safety, or welfare of any resident or a sub- includes the documentation and dating of a addition portion shall meet the requirements stantial probability that death or serious phys- monthly pressure check. II/III for NFPA 13, 1999 edition, sprinkler system, ical harm would result as determined by the unless the facility is otherwise required to department. (4) Range Hood Extinguishing Systems. meet NFPA 13, 1999 edition; (C) All facilities shall notify the depart- (A) In facilities licensed on or before July (D) Fire-resistant construction—type of ment immediately after the emergency is 11, 1980, or in any facility with fewer than construction in residential care and assisted addressed if there is a fire in the facility or twenty-one (21) beds, the kitchen shall pro- living facilities in which bearing walls, premises and shall submit a complete written vide either: columns, and floors are of noncombustible fire report to the department within seven (7) 1. An approved automatic range hood material in accordance with NFPA 101, 2000 days of the fire, regardless of the size of the extinguishing system properly installed and edition. All load-bearing walls, floors, and fire or the loss involved. II/III maintained in accordance with NFPA 96, roofs shall have a minimum of a one- (1-) (D) The department shall have the right of 1998 edition; or hour fire-resistant rating; and inspection of any portion of a building in 2. A portable fire extinguisher of at least (E) Concealed spaces—shall include areas which a licensed facility is located unless the ten pounds (10 lbs.) ABC-rated, or the equiv- within the building that cannot be occupied or unlicensed portion is separated by two- (2-) alent, in the kitchen area in accordance with used for storage. hour fire-resistant construction. No section of NFPA 10, 1998 edition. II/III (2) General Requirements. the building shall present a fire hazard. I/II (B) In licensed facilities with a total of (A) All National Fire Protection Associa- (E) Following the discovery of any fire, the twenty-one (21) or more licensed beds and tion (NFPA) codes and standards cited in this facility shall monitor the area and/or the whose application was filed after July 11, rule: NFPA 10, Standard for Portable Fire source of the fire for a twenty-four- (24-) 1980, and prior to October 1, 2000: Extinguishers, 1998 edition; NFPA 13R, hour period. This monitoring shall include, at 1. The kitchen shall be provided with a Installation of Sprinkler Systems, 1996 edi- a minimum, hourly visual checks of the area. range hood and an approved automatic range tion; NFPA 13, Installation of Sprinkler Sys- These hourly visual checks shall be docu- hood extinguishing system unless the facility tems, 1976 edition; NFPA 13 or NFPA 13R, mented. I/II has an approved sprinkler system. Facilities Standard for the Installation of Sprinkler Sys- (F) The facility shall maintain the exterior with range hood systems shall continue to tems in Residential Occupancies Up to and premises in a manner as to provide for fire maintain and test these systems; and Including Four Stories in Height, 1999 edi- safety. II 2. The extinguishing system shall be tion; NFPA 13, Standard for the Installation (G) Residential care facilities that accept installed, tested, and maintained in accor- of Sprinkler Systems, 1999 edition; NFPA 96, deaf residents shall have appropriate assistive dance with NFPA 96, 1998 edition. II/III Standard for Ventilation Control and Fire devices to enable each deaf person to negoti- (C) The range hood and its extinguishing Protection of Commercial Cooking Opera- ate a path to safety, including, but not limited system shall be certified at least twice annu- tions, 1998 edition; NFPA 101, The Life to, visual or tactile alarm systems. II/III ally in accordance with NFPA 96, 1998 edi- Safety Code, 2000 edition; NFPA 72, Nation- (H) Facilities shall not use space under tion. II/III al Fire Alarm Code, 1999 edition; NFPA stairways to store combustible materials. I/II 72A, Local Protective Signaling Systems, (5) Fire Drills and Emergency Preparedness. 1975 edition; NFPA 25, Standard for the (3) Fire Extinguishers. (A) All facilities shall have a written plan Inspection, Testing, and Maintenance of (A) Fire extinguishers shall be provided at to meet potential emergencies or disasters Water-Based Fire Protection Systems, 1998 a minimum of one (1) per floor, so that there and shall request consultation and assistance edition; and NFPA 101A, Guide to Alterna- is no more than seventy-five feet (75') travel annually from a local fire unit for review of tive Approaches to Life Safety, 2001 edition, distance from any point on that floor to an fire and evacuation plans. If the consultation with regard to the minimum fire safety stan- extinguisher. I/II cannot be obtained, the facility shall inform dards for residential care facilities and assist- (B) All new or replacement portable fire the state fire marshal in writing and request ed living facilities are incorporated by refer- extinguishers shall be ABC-rated extinguish- assistance in review of the plan. An up-to- ence in this rule and available for purchase ers, in accordance with the provisions of date copy of the facility’s entire plan shall be from the National Fire Protection Agency, 1 NFPA 10, 1998 edition. A K-rated extin- provided to the local jurisdiction’s emergency Batterymarch Park, Quincy, MA 02269- guisher or its equivalent shall be used in lieu management director. II/III

JOHN R. ASHCROFT (5/31/20) CODE OF STATE REGULATIONS 5 Secretary of State 19 CSR 30-86—DEPARTMENT OF HEALTH AND SENIOR SERVICES Division 30—Division of Regulation and Licensure

(B) The plan shall include, but is not lim- (6) Fire Safety Training Requirements. 3. Only one (1) of the required exits may ited to, the following: (A) The facility shall ensure that fire safety be a two- (2-) hour rated horizontal exit. I/II 1. A phased response ranging from relo- training is provided to all employees: (B) In facilities with plans approved after cation of residents to an immediate area with- 1. During employee orientation; December 31, 1987, doors to resident use in the facility; relocation to an area of refuge, 2. At least every six (6) months; and rooms shall not be more than one hundred if applicable; or to total building evacuation. 3. When training needs are identified as feet (100') from an exit. In facilities equipped This phased response part of the plan shall be a result of fire drill evaluations. II/III with a complete sprinkler system in accor- consistent with the direction of the local fire (B) The training shall include, but is not dance with NFPA 13 or NFPA 13R, 1999 unit or state fire marshal and appropriate for limited to, the following: edition, the exit distance may be increased to the fire or emergency; 1. Prevention of fire ignition, detection one hundred fifty feet (150'). Dead-end cor- 2. Written instructions for evacuation of of fire, and control of fire development; ridors shall not exceed thirty feet (30') in each floor including evacuation to areas of 2. Confinement of the effects of fire; length. II refuge, if applicable, and a floor plan show- 3. Procedures for moving residents to an ing the location of exits, fire alarm pull sta- area of refuge, if applicable; (C) In residential care facilities and facili- tions, fire extinguishers, and any areas of 4. Use of alarms; ties formerly licensed as residential care facil- refuge; 5. Transmission of alarms to the fire ities II, floors housing residents who require 3. Evacuating residents, if necessary, department; the use of a walker, wheelchair, or other assis- from an area of refuge to a point of safety 6. Response to alarms; tive devices or aids, or who are blind, must outside the building; 7. Isolation of fire; have two (2) accessible exits to grade or such 4. The location of any additional water 8. Evacuation of immediate area and residents must be housed near accessible exits sources on the property such as cisterns, building; as specified in 19 CSR 30-86.042(33) for res- wells, lagoons, ponds, or creeks; 9. Preparation of floors and facility for idential care facilities and 19 CSR 30- 5. Procedures for the safety and comfort evacuation; and 86.043(31) for facilities formerly licensed as of residents evacuated; 10. Use of the evacuation plan as residential care facilities II unless otherwise 6. Staffing assignments; required by section (5) of this rule. II/III prohibited by 19 CSR 30-86.045 or 19 CSR 7. Instructions for staff to call the fire 30-86.047, facilities equipped with a com- department or other outside emergency ser- (7) Exits, Stairways, and Fire Escapes. plete sprinkler system, in accordance with vices; (A) Each floor of a facility shall have at NFPA 13 or NFPA 13R, 1999 edition, with least two (2) unobstructed exits remote from 8. Instructions for staff to call alterna- sprinkler coverage in attics, and smoke parti- tive resource(s) for housing residents, if nec- each other. I/II tions, as defined by subsection (10)(I) of this essary; 1. For a facility whose plans were rule, may house such residents on floors that 9. Administrative staff responsibilities; approved on or before December 31, 1987, do not have accessible exits to grade if each and or a facility licensed for twenty (20) or fewer 10. Designation of a staff member to be beds, one (1) of the required exits from a required exit is equipped with an area of responsible for accounting for all residents’ multi-story facility shall be an outside stair- refuge as defined and described in subsec- whereabouts. II/III way or an enclosed stairway that is separated tions (1)(B) and (7)(D) of this rule. I/II (C) The written plan shall be accessible at by one- (1-) hour rated construction from (D) An “area of refuge” shall have— all times and an evacuation diagram shall be each floor with an exit leading directly to the 1. An area separated by one- (1-) hour posted on each floor in a conspicuous place outside at grade level. Existing plaster or rated smoke walls, from the remainder of the so that employees and residents can become gypsum board of at least one-half inch (1/2") building. This area must have direct access to familiar with the plan and routes to safety. thickness may be considered equivalent to the exit stairway or access the stair through a II/III one- (1-) hour rated construction. The other section of the corridor that is separated by (D) A minimum of twelve (12) fire drills required exit may be an interior stairway smoke walls from the remainder of the build- shall be conducted annually with at least one leading through corridors or passageways to ing. This area may include no more than two (1) every three (3) months on each shift. At outside or to a two- (2-) hour rated horizontal (2) resident rooms; least four (4) of the required fire drills must exit as defined by paragraph 3.3.61 of the 2. A two- (2-) way communication or be unannounced to residents and staff, 2000 edition NFPA 101. Neither of the intercom system with both visible and audible excluding staff who are assigned to evaluate required exits shall lead through a furnace or signals between the area of refuge and the staff and resident response to the fire drill. boiler room. Neither of the required exits bottom landing of the exit stairway, atten- shall be through a resident’s bedroom, unless The fire drills shall include a resident evacu- dants’ work area, or other primary location ation at least once a year. II/III the bedroom door cannot be locked. I/II as designated in the written plan for fire drills (E) The facility shall keep a record of all 2. For a facility whose plans were and evacuation; fire drills. The record shall include the time, approved after December 31, 1987, for more date, personnel participating, length of time than twenty (20) beds, the required exits shall 3. Instructions on the use of the area to complete the fire drill, and a narrative be doors leading directly outside, one- (1-) during emergency conditions that are located notation of any special problems. III hour enclosed stairs or outside stairs or a in the area of refuge and conspicuously post- (F) The fire alarm shall be activated during two- (2-) hour rated horizontal exit as defined ed adjoining the communication or intercom all fire drills unless the drill is conducted by paragraph 3.3.61 of 2000 edition NFPA system; between 9 p.m. and 6 a.m., when a facility- 101. The one- (1-) hour enclosed stairs shall 4. A sign at the entrance to the room generated predetermined message is accept- exit directly outside at grade. Access to these that states “AREA OF REFUGE IN CASE able in lieu of the audible and visual compo- shall not be through a resident bedroom or a OF FIRE” and displays the international nents of the fire alarm. II/III hazardous area. I/II symbol of accessibility;

6 CODE OF STATE REGULATIONS (5/31/20) JOHN R. ASHCROFT Secretary of State Chapter 86—Residential Care Facilities and Assisted Living Facilities 19 CSR 30-86

5. An entry or exit door that is at least a of sturdy construction, using at least two-inch corridors, spaces open to corridors, and in one and three-fourths inch (1 3/4") solid core (2") lumber. Exit doors to these fire escapes accessible spaces not protected by the sprin- wood door or has a fire protection rating of shall be at least thirty-six inches (36") wide kler system, as required by NFPA 72, 1999 not less than twenty (20) minutes with smoke and the door shall swing outward. II/III edition. Smoke detectors shall be no more seals and positive latching hardware. These (K) If a ramp is required to meet residents’ than thirty feet (30') apart with no point on doors shall not be lockable; needs under 19 CSR 30-86.042, the ramp the ceiling more than twenty-one feet (21') 6. A sign conspicuously posted at the shall have a maximum slope of one to twelve from a smoke detector. Smoke detectors shall bottom of the exit stairway with a diagram (1:12) leading to grade. II/III not be installed in areas where environmental showing each location of the areas of refuge; influences may cause nuisance alarms. Such 7. Emergency lighting for the area of (8) Exit Signs. areas include, but are not limited to, kitchens, (A) Signs bearing the word EXIT in plain, refuge; and laundries, bathrooms, mechanical air han- legible letters shall be placed at each required 8. The total area of the areas of refuge dling rooms, and attic spaces. In these areas, exit, except at doors directly from rooms to on a floor shall equal at least twenty (20) heat detectors interconnected to the complete square feet for each resident who is blind or exit passageways or corridors. Letters of all fire alarm system shall be installed. Bath- requires the use of a wheelchair or walker exit signs shall be at least six inches (6") high rooms not exceeding fifty-five (55) square housed on the floor. II and principle strokes three-fourths of an inch feet and clothes closets, linen closets, and (E) If it is necessary to lock exit doors, the (3/4") wide, except that letters of internally pantries not exceeding twenty-four (24) locks shall not require the use of a key, tool, illuminated exit signs shall not be less than special knowledge, or effort to unlock the four inches (4") high. II square feet are exempt from having any door from inside the building. Only one (1) (B) Directional indicators showing the detection device if the walls and ceilings are lock shall be permitted on each door. Delayed direction of travel shall be placed in corri- surfaced with limited-combustible or non- egress locks complying with section dors, passageways, or other locations where combustible material as defined in NFPA 7.2.1.6.1 of the 2000 edition NFPA 101 shall the direction of travel to reach the nearest exit 101, 2000 edition. Concealed spaces of non- be permitted, provided that not more than one is not apparent. II/III combustible or limited combustible construc- (1) such device is located in any egress path. (C) All required exit signs and directional tion are not required to have detection Self-locking exit doors shall be equipped with indicators shall be positioned so that both devices. These spaces may have limited a hold-open device to permit staff to reenter normal and emergency lighting illuminates access but cannot be occupied or used for the building during the evacuation. I/II them. II/III storage. I/II (F) If it is necessary to lock resident room A. In facilities licensed prior to doors, the locks shall not require the use of a (9) Complete Fire Alarm Systems. November 13, 1980, smoke detectors located key, tool, special knowledge, or effort to (A) All facilities shall have a complete fire every fifty feet (50') will be acceptable if the unlock the door from inside the room. Only alarm system installed in accordance with distance is within the manufacturer’s specifi- one (1) lock shall be permitted on each door. NFPA 101, Section 18.3.4, 2000 edition. cations. I/II Every resident room door shall be designed The complete fire alarm shall automatically 3. For facilities that are not required to to allow the door to be opened from the out- transmit to the fire department, dispatching have a sprinkler system, smoke detectors side during an emergency when locked. The agency, or central monitoring company. The interconnected to the complete fire alarm sys- facility shall ensure that facility staff have the complete fire alarm system shall include visu- tem shall be installed in all accessible spaces, means or mechanisms necessary to open res- al signals and audible alarms that can be as required by NFPA 72, 1999 edition, within ident room doors in case of an emergency. heard throughout the building and a main the facility. Smoke detectors shall be no more I/II panel that interconnects all alarm-activating than thirty feet (30') apart with no point on (G) All stairways and corridors shall be devices and audible signals. Manual pull sta- the ceiling more than twenty-one feet (21') tions shall be installed at or near each easily negotiable and shall be maintained free from a smoke detector. Smoke detectors shall required attendant’s station and each required of obstructions. II not be installed in areas where environmental exit. I/II (H) Outside stairways shall be constructed influences may cause nuisance alarms. Such to support residents during evacuation and 1. For facilities with a sprinkler system areas include, but are not limited to, kitchens, shall be continuous to the ground level. Out- in accordance with NFPA 13, 1999 edition, laundries, bathrooms, mechanical air han- side stairways shall not be equipped with a smoke detectors interconnected to the com- dling rooms, and attic spaces. In these areas, counter-balanced device. They shall be pro- plete fire alarm system shall be installed in all heat detectors interconnected to the fire alarm tected from or cleared of ice or snow. II/III corridors and spaces open to corridors. (I) Facilities with three (3) or more floors Smoke detectors shall be no more than thirty system shall be installed. Bathrooms not shall comply with the provisions of Chapter feet (30') apart with no point on the ceiling exceeding fifty-five (55) square feet and 320, RSMo which requires outside stairways more than twenty-one feet (21') from a clothes closets, linen closets, and pantries not to be constructed of iron or steel. II smoke detector. I/II exceeding twenty-four (24) square feet are (J) Fire escapes constructed on or after A. In facilities licensed prior to exempt from having any detection device if November 13, 1980, whether interior or November 13, 1980, smoke detectors located the walls and ceilings are surfaced with limit- exterior, shall be thirty-six inches (36") wide, every fifty feet (50') will be acceptable if the ed-combustible or noncombustible material shall have eight-inch (8") maximum risers, distance is within the manufacturer’s specifi- as defined in NFPA 101, 2000 edition. Con- nine-inch (9") minimum tread, no winders, cations. I/II cealed spaces of noncombustible or limited- maximum height between landings of twelve 2. For facilities with a sprinkler system combustible construction are not required to feet (12'), minimum dimensions of landings in accordance with NFPA 13R, 1999 edition, have detection devices. These spaces may of forty-four inches (44"), landings at each smoke detectors interconnected to the com- have limited access but cannot be occupied or exit door, and handrails on both sides and be plete fire alarm system shall be installed in all used for storage. I/II

JOHN R. ASHCROFT (5/31/20) CODE OF STATE REGULATIONS 7 Secretary of State 19 CSR 30-86—DEPARTMENT OF HEALTH AND SENIOR SERVICES Division 30—Division of Regulation and Licensure

A. In facilities licensed prior to system flow alarm, smoke detectors, heat not be a transom above the door that would November 13, 1980, smoke detectors located detectors, manual pull stations, and activation permit the passage of smoke. II every fifty feet (50') will be acceptable if the of the rangehood extinguishment system. (F) Atriums open between floors will be distance is within the manufacturer’s specifi- II/III permitted if resident room corridors are sep- cations. I/II arated from the atrium by one- (1-) hour rated (B) Facilities that are required to install a (10) Protection from Hazards. smoke walls. These corridors must have sprinkler system in accordance with section (A) In assisted living facilities and residen- access to at least one (1) of the required exits (11) of this rule shall comply with the follow- tial care facilities licensed on or after Novem- without traversing any space opened to the ing requirements: ber 13, 1980, for more than twelve (12) atrium. II 1. Until the required sprinkler system is beds, hazardous areas shall be separated by (G) All doors providing separation between installed, each resident room or any room construction of at least a one- (1-) hour fire- floors shall have a self-closing device designated for sleeping shall be equipped resistant rating. In facilities equipped with a attached. If the doors are to be held open, with at least one (1) battery-powered smoke complete fire alarm system, the one- (1-) electromagnetic hold-open devices shall be alarm installed, tested, and maintained in hour fire separation is required only for fur- used that are interconnected with either an accordance with manufacturer’s specifica- nace or boiler rooms. Hazardous areas individual smoke detector or a complete fire tions. In addition, the facility shall be equipped with a complete sprinkler system alarm system. II equipped with interconnected heat detectors are not required to have this one- (1-) hour (H) All facilities shall be divided into at installed, tested, and maintained in accor- fire separation. Doors to hazardous areas least two (2) smoke sections with each sec- dance with NFPA 72, 1999 edition, with shall be self-closing and shall be kept closed tion not exceeding one hundred fifty feet detectors in all areas subject to nuisance unless an electromagnetic hold-open device is (150') in length or width. If the floor’s alarms, including, but not limited to, used which is interconnected with the fire dimensions do not exceed seventy-five feet kitchens, laundries, bathrooms, mechanical alarm system. When the sprinkler option is (75') in length or width, a division of the air handling rooms, and attic spaces. I/II chosen, the areas shall be separated from floor into two (2) smoke sections will not be A. The facility shall maintain a writ- other spaces by smoke-resistant partitions and required. II ten record of the monthly testing and battery doors. The doors shall be self-closing or auto- (I) In facilities whose plans were approved changes. The written records shall be matic-closing. Facilities formerly licensed as or which were initially licensed after Decem- retained for one (1) year. I/II residential care facility I or II, and existing ber 31, 1987, for more than twenty (20) beds B. Upon discovery of a fault with any prior to November 13, 1980, shall be exempt and all facilities licensed after August 28, detector or alarm, the facility shall correct from this requirement. II 2007, each smoke section shall be separated the fault. I/II (B) The storage of unnecessary com- by one- (1-) hour fire-rated smoke partitions. (C) All facilities shall test and maintain the bustible materials in any part of a building in The smoke partitions shall be continuous complete fire alarm system in accordance which a licensed facility is located is prohib- from outside wall-to-outside wall and from with NFPA 72, 1999 edition. I/II ited. I/II floor-to-floor or floor-to-roof deck. All doors (D) All facilities shall have inspections and (C) Electric or gas clothes dryers shall be in this wall shall be at least twenty- (20-) written certifications of the complete fire vented to the outside. Lint traps shall be minute fire-rated or its equivalent, self-clos- alarm system completed by an approved qual- cleaned regularly to protect against fire haz- ing, and may be held open only if the door ified service representative in accordance ard. II/III closes automatically upon activation of the with NFPA 72, 1999 edition, at least annual- (D) In facilities that are required to comply complete fire alarm system. II ly. I/II with the requirements of 19 CSR 30-86.043 (J) In all facilities that were initially (E) Facilities shall test by activating the and were formerly licensed as residential care licensed on or prior to December 31, 1987, complete fire alarm system at least once a facilities II on or after November 13, 1980, and all facilities licensed for twenty (20) or month. I/II each floor shall be separated by construction fewer beds prior to August 28, 2007, each (F) Facilities shall maintain a record of the of at least a one- (1-) hour fire-resistant rat- smoke section shall be separated by a one- complete fire alarm tests, inspections, and ing. Buildings equipped with a complete (1-) hour fire-rated smoke partition that certifications required by subsections (9)(C) sprinkler system may have a nonrated smoke extends from the inside portion of an exterior and (D) of this rule. III separation barrier between floors. Doors wall to the inside portion of an exterior wall (G) Upon discovery of a fault with the between floors shall be a minimum of one and from the floor to the underside of the complete fire alarm system, the facility shall and three-fourths inches (1 3/4") thick and be floor or roof deck above, through any con- correct the fault. I/II solid core wood doors or metal doors with an cealed spaces, such as those above suspended (H) When a complete fire alarm system is equivalent fire rating. II ceilings, and through interstitial structural to be out-of-service for more than four (4) (E) In facilities licensed prior to November and mechanical spaces. Smoke partitions hours in a twenty-four- (24-) hour period, the 13, 1980, and multi-storied residential care shall be permitted to terminate at the under- facility shall immediately notify the depart- facilities formerly licensed as residential care side of a monolithic or suspending ceiling ment and the local fire authority and imple- facilities I licensed on or after November 13, system where the following conditions are ment an approved fire watch in accordance 1980, there shall be a smoke separation bar- met: The ceiling system forms a continuous with NFPA 101, 2000 edition, until the com- rier between the floors of resident-use areas membrane, a smoketight joint is provided plete fire alarm system has returned to full and any floor below the resident-use area. between the top of the smoke partition and service. I/II This shall consist of a solid core wood door the bottom of the suspended ceiling and the (I) The complete fire alarm system shall be or metal door with an equivalent fire rating at space above the ceiling is not used as a activated by all of the following: sprinkler the top or the bottom of the stairs. There shall plenum. Smoke partition doors shall be at

8 CODE OF STATE REGULATIONS (5/31/20) JOHN R. ASHCROFT Secretary of State Chapter 86—Residential Care Facilities and Assisted Living Facilities 19 CSR 30-86

least twenty- (20-) minute fire-rated or its (D) Single-story assisted living facilities (C) In facilities licensed for more than equivalent, self-closing, and may be held that provide care to one (1) or more residents twelve (12) beds, the new or replacement open only if the door closes automatically with a physical, cognitive, or other impair- floor covering and carpeting in buildings that upon activation of the complete fire alarm ment that prevents the individual from safely do not have a sprinkler system shall be Class system. II evacuating the facility with minimal assis- I in accordance with NFPA 253, 2000 edi- (K) Facilities whose plans were approved tance shall install and maintain an approved tion. II/III or which were initially licensed after Decem- sprinkler system in accordance with NFPA (D) All curtains and drapes in a licensed ber 31, 1987, for more than twenty (20) beds 13R, 1999 edition. I/II facility shall be certified or treated to be which do not have a sprinkler system, shall (E) Multi-level assisted living facilities that flame-resistant as defined in NFPA 101, 2000 have one- (1-) hour rated corridor walls with provide care to one (1) or more residents with edition. II one and three-quarters inch (1 3/4") solid a physical, cognitive, or other impairment core wood doors or metal doors with an that prevents the individual from safely evac- (14) Smoking. equivalent fire rating. II uating the facility with minimal assistance (A) Smoking shall be permitted in desig- (L) If two (2) or more levels of long-term shall install and maintain an approved sprin- nated areas only. Areas where smoking is care or two (2) different businesses are locat- kler system in accordance with NFPA 13, permitted shall be designated as such and ed in the same building, the entire building 1999 edition. I/II shall be supervised either directly or by a res- shall meet either the most strict construction (F) All facilities shall have inspections and ident informing an employee of the facility and fire safety standards for the combined written certifications of the approved sprin- that the area is being used for smoking. II/III facility or the facilities shall be separated kler system completed by an approved quali- (B) Ashtrays shall be made of noncom- from the other(s) by two- (2-) hour fire-resis- fied service representative in accordance with bustible material and safe design and shall be tant construction. In buildings equipped with NFPA 25, 1998 edition. The inspections shall provided in all areas where smoking is per- a complete sprinkler system in accordance be in accordance with the provisions of NFPA mitted. II/III with NFPA 13 or NFPA 13R, 1999 edition, 25, 1998 edition, with certification at least (C) The contents of ashtrays shall be disposed of properly in receptacles made of non- this separation may be rated at one (1) hour. annually by a qualified service representative. combustible material. II/III II I/II (G) When a sprinkler system is to be out- (15) Trash and Rubbish Disposal. (11) Sprinkler Systems. of-service for more than four (4) hours in a (A) Only metal or UL- or FM-fire-resis- (A) Facilities licensed on or after August twenty-four- (24-) hour period, the facility tant rated wastebaskets shall be used for 28, 2007, or any section of a facility in which shall immediately notify the department and trash. II a major renovation has been completed on or implement an approved fire watch in accor- (B) Trash shall be removed from the after August 28, 2007, shall install and main- dance with NFPA 101, 2000 edition, until the premises as often as necessary to prevent fire tain a complete sprinkler system in accor- sprinkler system has been returned to full service. I/II hazards and public health nuisance. II dance with NFPA 13, 1999 edition. I/II (C) No trash shall be burned within fifty (B) Facilities that have a sprinkler system (12) Emergency Lighting. feet (50') of any facility except in an approved installed prior to August 28, 2007, shall (A) Emergency lighting of sufficient inten- incinerator. I/II inspect, maintain, and test these systems in sity shall be provided for exits, stairs, resi- (D) Trash may be burned only in a mason- accordance with the requirements that were dent corridors, and required attendants’ sta- ry or metal container. II in effect for such facilities on August 27, tion. II (E) The container shall be equipped with a 2007. I/II (B) The lighting shall be supplied by an metal cover with openings no larger than one- (C) All residential care facilities, and emergency service, an automatic emergency half inch (1/2") in size. III assisted living facilities that do not admit or generator, or battery-operated lighting sys- retain a resident with a physical, cognitive, or tem. This emergency lighting system shall be (16) Standards for Designated Separated other impairment that prevents the individual equipped with an automatic transfer switch. Areas. from safely evacuating the facility with mini- II (A) When a resident resides among the mal assistance, that were licensed prior to (C) If battery-powered lights are used, they entire general population of the facility, the August 28, 2007, with more than twenty (20) shall be capable of operating the light for at facility shall take necessary measures to pro- residents, and do not have an approved sprin- least one and one-half (1 1/2) hours. II vide such residents with the opportunity to kler system in accordance with NFPA 13, explore the facility and, if appropriate, its 1999 edition, or NFPA 13R, 1999 edition, (13) Interior Finish and Furnishings. grounds. When a resident resides within a shall have until December 31, 2012, to install (A) In a facility licensed on or after designated, separated area that is secured by an approved sprinkler system in accordance November 13, 1980, for more than twelve limited access, the facility shall take neces- with NFPA 13 or 13R, 1999 edition. I/II (12) beds, wall and ceiling surfaces of all sary measures to provide such residents with 1. The department shall grant exceptions occupied rooms and all exitways shall be clas- the opportunity to explore the separated area to this requirement if the facility meets Chap- sified either Class A or B interior finish as and, if appropriate, its grounds. If enclosed ter 33 of NFPA 101, 2000 edition, and the defined in NFPA 101, 2000 edition. II or fenced courtyards are provided, residents evacuation capability of the facility meets the (B) In facilities licensed prior to November shall have reasonable access to such court- standards required in NFPA 101A, Guide to 13, 1980, all wall and ceiling surfaces shall yards. Enclosed or fenced courtyards that are Alternative Approaches to Life Safety, 2001 be smooth and free of highly combustible accessible through a required exit door shall edition. I/II materials. II be large enough to provide an area of refuge

JOHN R. ASHCROFT (5/31/20) CODE OF STATE REGULATIONS 9 Secretary of State 19 CSR 30-86—DEPARTMENT OF HEALTH AND SENIOR SERVICES Division 30—Division of Regulation and Licensure

for fire safety at least thirty feet (30') from adjacent to the door for routine use by staff. standard as designated in section 198.085.1, the building. Enclosed or fenced courtyards I/II RSMo 2000. that are accessible through a door other than a required exit shall have no size require- (17) Oxygen storage shall be in accordance (1) Definitions. For the purpose of this rule, ments. II with NFPA 99, 1999 Edition. II/III the following definitions shall apply: (B) The facility shall provide freedom of (A) Adult day health care program shall movement for the residents to common areas AUTHORITY: sections 198.073, 198.074, mean a program operated by a provider certified to provide Medicaid-reimbursed adult and to their personal spaces. The facility shall and 198.076, RSMo Supp. 2011.* This rule day health care services to Medicaid-eligible not lock residents out of or inside their originally filed as 13 CSR 15-15.022. Origi- participants in accordance with 19 CSR 70- rooms. I/II nal rule filed July 13, 1983, effective Oct. 13, 1983. Emergency amendment filed Aug. 1, 92.010; (C) The facility may allow resident room (B) Associated adult day health care pro- doors to be locked providing the residents 1984, effective Aug. 13, 1984, expired Dec. 10, 1984. Amended: Filed Sept. 12, 1984, gram shall mean an adult day health care pro- request to lock their doors. Any lock on a gram, which is connected physically with a resident room door shall not require the use effective Dec. 13, 1984. Amended: Filed May 13, 1987, effective Aug. 13, 1987. Amended: licensed long-term care facility but has sepa- of a key, tool, special knowledge, or effort to Filed Aug. 1, 1988, effective Nov. 10, 1988. rate designated space for an adult day health lock or unlock the door from inside the resi- Amended: Filed Feb. 28, 2000, effective Sept. care program which is above the licensed dent’s room. Only one (1) lock shall be per- 30, 2000. Moved to 19 CSR 30-86.022, effec- space requirement for the long-term care res- mitted on each door. The facility shall ensure tive Aug. 28, 2001. Amended: Filed Aug. 16, idents. An associated adult day health care program may share, in part, staff, equipment, that facility staff has the means or mecha- 2004, effective Feb. 28, 2005. Amended: utilities, dietary and security with the con- nisms necessary to open resident room doors Filed Aug. 1, 2005, effective Jan. 30, 2006. nected long-term care facility. Recipients of in case of an emergency. I/II Amended: Filed Aug. 23, 2006, effective adult day health care program may participate (D) The facility may provide a designated, April 30, 2007. Emergency amendment filed with the residents of the long-term care facil- separated area where residents, who are men- Nov. 24, 2008, effective Dec. 4, 2008, ity for some activities and programs; tally incapable of negotiating a pathway to expired June 1, 2009. Amended: Filed Nov. (C) Home-like—means a self-contained safety, reside and receive services and which 24, 2008, effective May 30, 2009. Amended: long-term care setting that integrates the psy- is secured by limited access if the following Filed March 15, 2012, effective Oct. 30, chosocial, organizational and environmental conditions are met: 2012. ** qualities that are associated with being at 1. Dining rooms, living rooms, activity home. Home-like may include, but is not lim- *Original authority: 198.073, RSMo 1979, amended rooms, and other such common areas shall be ited to the following: provided within the designated, separated 1984, 1992, 1999, 2006; 198.074, RSMo 2007; and 198.076, RSMo 1979, amended 1984, 2007. 1. A living room and common use areas area. The total area for common areas within for social interactions and activities; the designated, separated area shall be equal **Pursuant to Executive Orders 20-04 and 20-10, 19 CSR 30- 2. Kitchen and family style eating area 86.022, section (3), subsections (4)(A), (4)(C), (5)(D), (9)(C), to at least forty (40) square feet per resident; (9)(D), (11)(D), (11)(E), and (11)(F), and section 198.074.2-4, for use by the residents; II/III RSMo was suspended from April 23, 2020 through June 15, 2020. 3. Laundry area for use by residents; 2. Doors separating the designated, sep- 4. A toilet room that contains a toilet, arated area from the remainder of the facility lavatory and bathing unit in each resident’s or building shall not be equipped with locks 19 CSR 30-86.032 Physical Plant Require- room; that require a key to open; I/II ments for Residential Care Facilities and 5. Resident room preferences for resi- Assisted Living Facilities 3. If locking devices are used on exit dents who wish to share a room, and for res- doors egressing the facility or on doors idents who wish to have private bedrooms; PURPOSE: This rule establishes standards accessing the designated, separated area, 6. Outdoor area for outdoor activities for the physical plant of new or existing resi- and recreation; and delayed egress magnetic locks shall be used. dential care facilities I and II. These delayed egress devices shall comply 7. A place where residents can give and receive affection, explore their interests, with the following: PUBLISHER’S NOTE: The secretary of state exercise control over their environment, A. The lock must unlock when the has determined that the publication of the engage in interactions with others and have fire alarm is activated; entire text of the material which is incorpo- privacy, security, familiarity and a sense of B. The lock must unlock when the rated by reference as a portion of this rule belonging; and would be unduly cumbersome or expensive. power fails; (D) Non-licensed adult day care program This material as incorporated by reference in C. The lock must unlock within thirty shall mean a group program designated to (30) seconds after the release device has been this rule shall be maintained by the agency at its headquarters and shall be made available provide care and supervision to meet the pushed for at least three (3) seconds, and an needs of four (4) or fewer impaired adults for alarm must sound adjacent to the door; to the public for inspection and copying at no more than the actual cost of reproduction. periods of less than twenty-four (24) hours D. The lock must be manually reset This note applies only to the reference mate- but more than two (2) hours per day in a and cannot automatically reset; and rial. The entire text of the rule is printed long-term care facility. E. A sign shall be posted on the door here. that reads: PUSH UNTIL ALARM (2) The building shall be substantially con- SOUNDS, DOOR CAN BE OPENED IN 30 Editor’s Note: All rules relating to long-term structed and shall be maintained in good SECONDS; and I/II care facilities licensed by the department are repair and in accordance with the construc- 4. The delayed egress magnetic locks followed by a Roman Numeral notation which tion and fire safety rules in effect at the time may also be released by a key pad located refers to the class (either class I, II or III) of of initial licensing. II/III

10 CODE OF STATE REGULATIONS Chapter 86—Residential Care Facilities and Assisted Living Facilities 19 CSR 30-86

(3) Only activities necessary to the adminis- (7) Newly licensed facilities shall have stoves shall not be installed in assisted living tration of the facility shall be contained in any handrails and grab bars affixed in all toilet facilities. II building used as a long-term care facility and bathing areas. Existing licensed facilities except as follows: shall have handrails and grab bars available in (12) Fireplaces may be used only if there is a (A) Related activities may be conducted in at least one (1) bath and toilet area. The fore- protective screen in place; if there is direct buildings subject to prior written approval of going requirements are applicable to residen- staff supervision of residents while in use; these activities by the Department of Health tial care facilities. All assisted living facilities and the fire shall not be left burning and Senior Services (hereinafter—the depart- shall have handrails and grab bars affixed in overnight. II ment). Examples of these activities are Home all toilet and bathing areas. II Health Agencies, physician’s office, pharma- (13) In facilities that are constructed or have cy, ambulance service, child day care and (8) There shall be adequate storage areas for plans approved after July 1, 2005, electrical wiring shall be installed and maintained in food service for the elderly in the communi- food, supplies, linen, equipment and resident’s personal possessions. III accordance with the requirements of the ty; National Electrical Code, 1999 edition, (B) Adult day care may be provided for (9) Each room or ward in which residents are National Fire Protection Association, Inc., four (4) or fewer participants without prior housed or to which residents have reasonable incorporated by reference, in this rule and written approval of the department if the access shall be capable of being heated to not available by mail at One Batterymarch Park, long-term care facility meets the following less than eighty degrees Fahrenheit (80°F) Quincy, MA 02269, and local codes. This stipulations: under all weather conditions. Temperature rule does not incorporate any subsequent 1. The operation of the adult day care shall not be lower than sixty-eight degrees amendments or additions to the materials business shall not interfere with the care and Fahrenheit (68°F) and the reasonable comfort incorporated by reference. Facilities built delivery of services to the long-term care res- needs of individual residents shall be met. between September 28, 1979 and July 1, idents; I/II 2005 shall be maintained in accordance with 2. The facility shall only accept partici- the requirements of the National Electrical pants in the adult day care program appropri- (10) In newly licensed facilities or if a new Code, which was in effect at the time of the ate to the level of care of the facility and heating system is installed in an existing original plan approval and local codes. This whose needs can be met; licensed facility, the heating of the building rule does not incorporate any subsequent 3. The facility shall not change the phys- shall be restricted to steam, hot water, perma- amendments or additions. In facilities built ical layout of the facility without prior written nently installed electric heating devices or a prior to September 28, 1979, electrical approval of the department; warm air system employing central heating wiring shall be maintained in good repair and 4. The facility shall provide a private plants with installation such as to safeguard shall not present a safety hazard. All facili- area for adult day care residents to nap or the inherent fire hazard, or approved installa- ties shall have wiring inspected every two (2) rest; tion of outside wall heaters which bear the years by a qualified electrician. II/III 5. Adult day care participants shall not approved label of the American Gas Associa- be included in the census, and the number of tion or National Board of Fire Underwriters. (14) Lighting is restricted to electricity. II adult day care participants shall not be more The foregoing requirements are applicable to than four (4) above the licensed capacity of residential care facilities. In assisted living (15) Lighting in hallways, bathrooms, recre- the facility; and facilities, the heating of the building shall be ational and dining areas and all resident-use 6. The adult day care participants, while restricted to steam, hot water, permanently areas shall be provided with a minimum on-site, are to be included in the determina- installed electric heating devices or a warm intensity of ten (10) footcandles. All lights in air system employing central heating plants tion of staffing patterns for the long-term care resident-use areas shall be provided with a with installation such as to safeguard the shade to prevent direct glare to the residents’ facility; inherent fire hazard, or approved installation eyes. II/III (C) An associated adult day health care of outside wall heaters which bear the program may be operated without prior writ- approved label of the American Gas Associa- (16) Night lights shall be provided for corri- ten approval if the provider of the adult day tion or National Board of Fire Underwriters. dors, stairways and toilet areas. II health care services is certified in accordance For all facilities, oil or gas heating appliances with 19 CSR 70-92.010. II/III shall be properly vented to the outside and (17) A reading light shall be provided for the use of portable heaters of any kind is pro- each resident desiring to read. Additional (4) All stairways shall be equipped with per- hibited. If approved wall heaters are used, lighting shall be provided to meet the individ- manently secured handrails on at least one (1) adequate guards shall be provided to safe- ual needs of each resident. III side. III guard residents. I/II (18) If extension cords are used, they must be (5) There shall be a telephone in the facility (11) Wood-burning stoves shall not be Underwriters’ Laboratory (UL)-approved or and additional telephones or extensions as installed in newly licensed facilities or in shall comply with other recognized electrical necessary so that help may be summoned existing licensed facilities that did not previ- appliance approval standards and sized to promptly in case of fire, accident, acute ill- ously have a wood-burning stove. If wood- carry the current required for the appliance ness or other emergency. II/III burning stoves are used in an existing used. Only one (1) appliance shall be con- licensed facility, or wood-burning furnaces or nected to one (1) extension cord and only two (6) Bath and toilet facilities shall be provided fireplaces are used, flues or chimneys shall (2) appliances may be served by one (1) for the convenience, privacy, comfort and be maintained in good condition and kept free duplex receptacle. If extension cords are safety of residents. Fixed partitions or cur- of accumulation of combustible materials. used, they shall not be placed under rugs, tains shall be provided in toilet and bath- The foregoing requirements are applicable to through doorways or located where they are rooms to assure privacy. II/III residential care facilities. Wood-burning subject to physical damage. II/III

JOHN R. ASHCROFT (5/31/20) CODE OF STATE REGULATIONS 11 Secretary of State 19 CSR 30-86—DEPARTMENT OF HEALTH AND SENIOR SERVICES Division 30—Division of Regulation and Licensure

(19) If elevators are used, installation and (32) Each window shall be provided with a effective May 30, 2005. Amended: Filed Aug. maintenance shall comply with local and shade, drape or curtain to restrict the amount 23, 2006, effective April 30, 2007. ** state codes and the National Electric Code. of sunlight when necessary. III II/III *Original authority: 198.005, RSMo 2006; 198.073, (33) All assisted living facilities and all resi- RSMo 1979, amended 1984, 1992, 1999, 2006; and 198.076, RSMo 1979, amended 1984. (20) Air conditioning, fans or a ventilating dential care facilities whose plans are approved or which are initially licensed for system shall be available and used when the **Pursuant to Executive Orders 20-04 and 20-10, 19 CSR 30- room temperature exceeds eighty-five more than twelve (12) residents after Decem- 86.032, subsection (3)(A) was suspended from April 17, 2020 ber 31, 1987 shall be equipped with a call through June 15, 2020 and section (13) was suspended from April degrees Fahrenheit (85°F) and the reasonable 22, 2020 through June 15, 2020. comfort needs of individual residents shall be system consisting of an electrical intercom- met. I/II munication system, a wireless pager system, buzzer system or hand bells. An acceptable 19 CSR 30-86.042 Administrative, Person- mechanism for calling attendants shall be (21) Gas-fired water heaters shall be properly nel and Resident Care Requirements for located in each toilet room and resident bed- installed and vented and all water heaters New and Existing Residential Care Facili- room. Call systems for facilities whose plans shall be equipped with a temperature and ties pressure relief valve. II are approved or which are initially licensed after December 31, 1987 shall be audible in PURPOSE: This rule establishes standards (22) Furniture and equipment shall be main- the attendant’s work area. II/III for administration, personnel and resident tained in good condition and shall be replaced if broken, torn, heavily soiled or damaged. (34) Plumbing fixtures which are accessible care in residential care facilities I and II. Rooms shall be so designed and furnished to residents and which supply hot water shall that the comfort and safety of the residents be thermostatically controlled so that the Editor’s Note: All rules relating to long-term are provided for at all times. II/III water temperature at the fixture does not care facilities licensed by the department are exceed one hundred twenty degrees Fahren- followed by a Roman Numeral notation which (23) Rooms shall be neat, orderly and heit (120°F) (49°C) and the water shall be at refers to the class (either class I, II or III) of cleaned daily. II/III a temperature range between one hundred standard as designated in section 198.085.1, five degrees Fahrenheit (105°F) (41°C) and RSMo 1986. (24) An individual bed, in good repair and of one hundred twenty degrees Fahrenheit a rigid type, shall be provided to each resi- (120°F) (49°C). I/II (1) Definitions. For the purpose of this rule, dent. Beds shall be at least thirty-six inches (35) Home-Like Requirements with Respect the following definitions shall apply: (36") wide. Double beds of satisfactory con- (A) Department—Department of Health struction may be provided for married cou- to Construction and Physical Plant Standards. and Senior Services; ples. Rollaway, metal cots or folding beds (A) Any assisted living facility formerly shall not be used. II/III licensed as a residential care facility shall be (B) Outbreak—an occurrence in a commu- more home-like than institutional with nity or region of an illness(es) similar in (25) A minimum of three feet (3') shall be respect to construction and physical plant nature, clearly in excess of normal expectan- available between beds when parallel. III standards. II cy and derived from a common or a propagat- (B) Any assisted living facility licensed as ed source; and (26) Mattresses shall be clean, in good repair a residential care facility II prior to August (C) Evacuate the facility—moving to an and a minimum of four inches (4") in thick- 28, 2006, shall qualify as being more home- area of refuge or from one (1) smoke section ness to provide comfort. II/III like than institutional with respect to con- to another or exiting the facility. struction and physical plant standards. II (27) Each bed shall be provided with at least (C) Any assisted living facility that is built (2) For a residential care facility, a person one (1) clean, comfortable pillow. Extra pil- or has plans approved on or after August 28, shall be designated as administrator/manager lows shall be available to meet the needs of 2006, shall be more home-like than institu- who is either currently licensed as a nursing the residents. III tional with respect to construction and physi- home administrator or is at least twenty-one cal plant standards. II (21) years of age, has never been convicted of (28) Screens or curtains, either portable or permanently affixed, shall be available and an offense involving the operation of a long- AUTHORITY: sections 198.076, RSMo 2000 term care or similar facility and who attends used in multi-resident bedrooms to provide and 198.005 and 198.073, RSMo Supp. privacy as needed or if requested. III at least one (1) continuing education work- 2006.* This rule originally filed as 13 CSR shop within each calendar year given by or 15-15.032. Original rule filed July 13, 1983, (29) Each resident shall be provided with an approved by the department. When used in effective Oct. 13, 1983. Emergency amend- individual locker or other suitable space for this chapter of rules, the term manager shall ment filed Nov. 9, 1983, effective Nov. 19, storage of clothing and personal belongings. mean that person who is designated by the 1983, expired March 18, 1984. Amended: III operator to be in general administrative Filed Nov. 9, 1983, effective Feb. 11, 1984. charge of a residential care facility. It shall be (30) Each resident shall be provided with an Emergency amendment filed Aug. 1, 1984, considered synonymous to “administrator” as individual rack for a towel(s) and effective Aug. 13, 1984, expired Dec. 10, defined in section 198.006, RSMo and the washcloth(s) unless provided with a clean 1984. Amended: Filed Sept. 12, 1984, effec- terms administrator and manager may be washcloth(s) or towel(s) for use each time tive Dec. 13, 1984. Amended: Filed May 13, used interchangeably. II/III needed. III 1987, effective Aug. 13, 1987. Amended: Filed Aug. 1, 1988, effective Nov. 10, 1988. (3) The administrator/manager of a residen- (31) A comfortable chair shall be available Moved to 19 CSR 30-86.032, effective Aug. tial care facility shall have successfully com- for each resident’s use. III 28, 2001. Amended: Filed Nov. 15, 2004, pleted the state approved Level I Medication

12 CODE OF STATE REGULATIONS (5/31/20) JOHN R. ASHCROFT Secretary of State Chapter 86—Residential Care Facilities and Assisted Living Facilities 19 CSR 30-86

Aide course unless he or she is a physician, tion 198.070, RSMo shall work or volunteer residents unless the facility obtains verifica- pharmacist, licensed nurse or a certified in the facility in any capacity whether or not tion from the department that a good cause medication technician, or if the facility is employed by the operator. For the purpose of waiver has been granted and maintains a copy operating in conjunction with a skilled nurs- this rule, a volunteer is an unpaid individual of the verification in the individual’s person- ing facility or intermediate care facility on the formally recognized by the facility as provid- nel file; I/II same premises, or, for an assisted living facil- ing a direct care service to residents. The (B) Make an inquiry to the department, ity, if the facility employs on a full-time basis, facility is required to check the EDL for indi- whether the person is listed on the employee a licensed nurse who is available seven (7) viduals who volunteer to perform a service disqualification list as provided in section days per week. II/III for which the facility might otherwise have to 660.315, RSMo. The inquiry may be made hire an employee. The facility is not required via Internet at www.dhss.mo.gov/EDL/; (4) The operator shall be responsible to to check the EDL for individuals or groups II/III assure compliance with all applicable laws such as scout groups, bingo or sing-along (C) If the person has registered with the and regulations. The administrator/manager leaders. The facility is not required to check department’s Family Care Safety Registry shall be fully authorized and empowered to the EDL for an individual such as a priest, (FCSR), the facility may utilize the Registry make decisions regarding the operation of the minister or rabbi visiting a resident who is a in order to meet the requirements of subsec- facility and shall be held responsible for the member of the individual’s congregation. tions (1)(A) and (11)(B) of this rule. The actions of all employees. The However, if the minister, priest or rabbi FCSR is available via Internet at administrator/manager’s responsibilities shall serves as a volunteer facility chaplain, the www.dhss.mo.gov/EDL/; and II/III include oversight of residents to assure that facility is required to check the EDL since (D) For persons for whom the facility has they receive care appropriate to their needs. the individual would have potential contact contracted for professional services (e.g., II/III with all residents. I/II plumbing or air conditioning repair) that will have contact with any resident, the facility (5) The administrator/manager shall devote (11) Prior to allowing any person who has must either require a criminal background sufficient time and attention to the manage- been hired in a full-time, part-time or tempo- check or ensure that the individual is suffi- ment of the facility as is necessary for the rary position to have contact with any resi- ciently monitored by facility staff while in the health, safety and welfare of the residents. II dents the facility shall, or in the case of tem- facility to reasonably ensure the safety of all porary employees hired through or contracted residents. I/II (6) The administrator/manager shall desig- for an employment agency, the employment nate, in writing, a staff member in charge in agency shall prior to sending a temporary (12) A facility shall not employ as an agent or the administrator/manager’s absence. II/III employee to a provider: employee who has access to controlled sub- (A) Request a criminal background check stances any person who has been found guilty (7) The facility shall not care for more resi- for the person, as provided in section 43.540, or entered a plea of guilty or nolo contendere dents than the number for which the facility RSMo. Each facility must maintain in its in a criminal prosecution under the laws of is licensed. If the facility operates a non- record documents verification that the back- any state or of the United States for any licensed adult day care program within the ground checks were requested and the nature offense related to controlled substances. II licensed facility, the day care participants of the response received for each such (A) A facility may apply in writing to the shall be counted in the staffing determination request. II department for a waiver of this section for a during the hours the day care participants are 1. The facility must ensure that any specific employee. in the facility. II/III applicant or person hired or retained who dis- (B) The department may issue a written closes prior to the receipt of the criminal waiver to a facility upon determination that a (8) The facility’s current license shall be background check that he or she has been waiver would be consistent with the public posted in a conspicuous place and notices convicted of, pled guilty or pled nolo con- health and safety. In making this determina- provided to the facility by the department tendere to in this state or any other state or tion, the department shall consider the duties granting exception(s) to regulatory require- has been found guilty of a crime, which if of the employee, the circumstances surround- ments shall be posted alongside of the facili- committed in Missouri would be a class A or ing the conviction, the length of time since ty’s license. III B felony violation of Chapter 565, 566, or the conviction was entered, whether a waiver 569, RSMo or any violation of subsection has been granted by the department’s Bureau of Narcotics and Dangerous Drugs pursuant (9) All personnel responsible for resident 198.070.3, RSMo or of section 568.020, to 19 CSR 30-1.034 when the facility is reg- care shall have access to the legal name of RSMo, will not have contact with residents. istered with that agency, whether a waiver has each resident, name and telephone number of I/II been granted by the federal Drug Enforce- resident’s physician, resident’s designee or 2. Upon receipt of the criminal back- ment Administration (DEA) pursuant to 21 legally authorized representative in the event ground check, the facility must ensure that if CFR 1301.76 when the facility is also regis- of emergency. II/III the criminal background check indicates that tered with that agency, the security measures the person hired or retained by the facility has taken by the facility to prevent the theft and (10) All persons who have any contact with been convicted of, pled guilty or pled nolo diversion of controlled substances, and any the residents in the facility shall not knowing- contendere to in this state or any other state other factors consistent with public health ly act or omit any duty in a manner which or has been found guilty of a crime, which if and safety. II/III would materially and adversely affect the committed in Missouri would be a class A or health, safety, welfare or property of resi- B felony violation of Chapter 565, 566, or (13) The facility must develop and implement dents. No person who is listed on the 569, RSMo or any violation of subsection written policies and procedures which require Employee Disqualification List (EDL) main- 198.070.3, RSMo or of section 568.020, that persons hired for any position which is to tained by the department as required by sec- RSMo, the person will not have contact with have contact with any patient or resident have

JOHN R. ASHCROFT (5/31/20) CODE OF STATE REGULATIONS 13 Secretary of State 19 CSR 30-86—DEPARTMENT OF HEALTH AND SENIOR SERVICES Division 30—Division of Regulation and Licensure

been informed of their responsibility to dis- (F) Information regarding what constitutes shall meet the requirements of the employer’s close their prior criminal history to the facil- abuse/neglect and how to report abuse/ check regarding valid certification: ity as required by section 660.317.5, RSMo. neglect to the department (1-800-392-0210); (F) References, if available; The facility must also develop and implement (G) Information regarding the Employee (G) The results of background checks policies and procedures which ensure that the Disqualification List; required by section 660.317, RSMo; and a facility does not knowingly hire, after August (H) Instruction regarding the rights of res- copy of any good cause waiver granted by the 28, 1997, any person who has or may have idents and protection of property; and department, if applicable; contact with a patient or resident, who has (I) Instruction regarding working with res- (H) Position in the facility; been convicted of, plead guilty or nolo con- idents with mental illness. II/III (I) Written statement signed by a licensed tendere to, in this state or any other state, or physician or physician’s designee indicating has been found guilty of any class A or B (20) In addition to the orientation training the person can work in a long-term care facility and indicating any limitations; felony violation of Chapter 565, 566 or 569, required in section (19) of this rule any facil- (J) Documentation of the employee’s tuber- RSMo, or any violation of subsection 3 of ity that provides care to any resident having section 198.070, RSMo, or of section cilin screening status; Alzheimer’s disease or related dementia shall 568.020, RSMo. II/III (K) Documentation of what the employee provide orientation training regarding mental- was instructed on during orientation training; ly confused residents such as those with (14) All persons who have or may have con- and Alzheimer’s disease and related dementias as tact with residents shall at all time when on (L) Reason for termination if the employee follows: duty or delivering services wear an identifi- was terminated due to abuse or neglect of a (A) For employees providing direct care to cation badge. The badge shall give their resident, residents’ rights issues or resident such persons, the orientation training shall name, title and, if applicable, the status of injury. III include at least three (3) hours of training their license or certification as any kind of including at a minimum an overview of men- (22) Personnel records shall be maintained health care professional. This rule shall apply for at least two (2) years following termina- to all personnel who provide services to any tally confused residents such as those having tion of employment. III resident directly or indirectly. III Alzheimer’s disease and related dementias, communicating with persons with dementia, (23) There shall be written documentation (15) All personnel shall be able physically behavior management, promoting independence in activities of daily living, and under- maintained in the facility showing actual and emotionally to work in a long-term care hours worked by each employee. III facility. I/II standing and dealing with family issues; II/III (B) For other employees who do not provide direct care for, but may have daily con- (24) No one individual shall be on duty with (16) Personnel who have been diagnosed with responsibility for oversight of residents longer tact with, such persons, the orientation train- a communicable disease may begin work or than eighteen (18) hours per day except in a ing shall include at least one (1) hour of return to duty only with written approval by a residential care facility licensed for twelve physician or physician’s designee which indi- training including at a minimum an overview (12) or fewer residents. I/II cates any limitations. II of mentally confused residents such as those having dementias as well as communicating (25) Employees who are counted in meeting (17) The administrator/manager shall be with persons with dementia; and II/III the minimum staffing ratio and employees responsible for preventing an employee (C) For all employees involved in the care who provide direct care to the residents shall known to be diagnosed with communicable of persons with dementia, dementia-specific be at least sixteen (16) years of age. III disease from exposing residents to such dis- training shall be incorporated into ongoing ease. The facility’s policies and procedures in-service curricula. II/III (26) One (1) employee at least eighteen (18) must comply with the department’s regula- years of age shall be on duty at all times. I/II tions pertaining to communicable diseases, (21) The administrator/manager shall main- specifically 19 CSR 20-20.010 through 19 tain on the premises an individual personnel (27) Staffing for Residential Care Facility. CSR 20-20.100. II/III record on each facility employee, which shall (A) The facility shall have an adequate include the following: number and type of personnel on duty at all (18) The facility shall screen residents and (A) The employee’s name and address; times for the proper care of residents and staff for tuberculosis as required for long- (B) Social Security number; upkeep of the facility. At a minimum, one (1) employee shall be on duty for every forty (40) term care facilities by 19 CSR 20-20.100. II (C) Date of birth; (D) Date of employment; residents to provide protective oversight to residents and for fire safety. I/II (19) Prior to or on the first day that a new (E) Documentation of experience and edu- employee works in the facility he or she shall cation including for positions requiring licen- Staff Residents sure or certification, documentation evidenc- receive orientation of at least one (1) hour 1 1–40 appropriate to his or her job function. This ing competency for the position held, which 2 41–80 shall include at least the following: includes copies of current licenses, tran- 3 81–120 (A) Job responsibilities; scripts when applicable, or for those individ- 4 121–160 (B) Emergency response procedures; uals requiring certification, such as level I (B) The required staff person shall be in (C) Infection control and handwashing pro- medication aides (LIMA), certified nurse the facility awake, dressed and prepared to cedures and requirements; aides, certified medication technicians assist residents in case of emergency, except (D) Confidentiality of resident informa- (CMT) and insulin administration aides; that in a facility licensed for twelve (12) or tion; printing the Web Registry search results page fewer residents, this person may be asleep (E) Preservation of resident dignity; available at www.dhss.mo.gov/cnaregistry during the night hours. In a facility licensed

14 CODE OF STATE REGULATIONS (5/31/20) JOHN R. ASHCROFT Secretary of State Chapter 86—Residential Care Facilities and Assisted Living Facilities 19 CSR 30-86

for twenty (20) or fewer residents, the alerted of the need to evacuate the facility as (B) If specialized rehabilitative services for required staff person may be asleep if there is defined in subsection (1)(C) of this rule. I/II mental illness or mental retardation are a sprinkler system or if there is a complete required to enable a resident to reach and to automatic fire detection system. I/II (29) Residents suffering from short periods of comply with the individualized service plan, (C) In a facility of more than one hundred incapacity due to illness, injury or recupera- the facility must ensure the required services (100) residents, the administrator/manager tion from surgery may be allowed to remain are provided; and II shall not be counted when determining the or be readmitted from a hospital if the period (C) The facility shall maintain in the resi- personnel required. II of incapacity does not exceed forty-five (45) dent’s record the most recent progress notes (D) If the facility is opened in conjunction days and written approval of a physician is and personal plan developed and provided by with and is immediately adjacent to and con- obtained for the resident to remain in or be the Department of Mental Health or designat- tiguous to another licensed long-term care readmitted to the facility. II/III ed administrative agent for each resident facility and if— whose care is funded by the Department of Mental Health or designated administrative 1. The resident bedrooms of the residen- (30) The facility shall not admit or continue agent. III tial care facility are on the same floor or on to care for residents whose needs cannot be the ground floor immediately below that of met. If necessary services cannot be obtained (35) The use of interventions to manage dis- the other licensed facility; in or by the facility, the resident shall be 2. There is an approved call system in ruptive or assaultive resident behaviors shall promptly referred to appropriate outside be employed with sufficient safeguards to each resident’s bedroom and bathroom or a resources or discharged from the facility. I/II patient-controlled system connected to a nurs- ensure the safety, welfare and rights of the ing station of the other licensed facility; resident and shall be in accordance with the (31) In the event a resident is transferred therapeutic goals for the resident. I/II 3. There is a complete fire alarm system from the facility, staff shall forward a report in the residential care facility connected to of the resident’s current medical status, the complete fire alarm system in the other (36) Residents under sixteen (16) years of age physician’s orders/prescriptions, and if appli- shall not be admitted. III licensed facility; cable, a copy of the resident’s advanced 4. The staffing of the other licensed directives/living will to the facility to which facility is greater than their minimum (37) Residents admitted or readmitted to the the resident is being transferred. If the resi- requirements; and facility shall have an admission physical ex- dent is transferring to a private residence, 5. Periodic visits to the residential care amination by a licensed physician. Docu- facility staff shall provide the reports to the facility are made by a staff person to deter- mentation should be obtained prior to admis- resident or his or her designee or legally mine the welfare of the resident in the resi- sion but shall be on file not later than ten (10) dential care facility; then, for a facility serv- authorized representative. II/III days after admission and shall contain infor- ing twenty (20) or fewer residents, there need mation regarding the resident’s current medi- not be an attendant on duty during the day (32) Residents admitted to a facility on refer- cal status and any special orders or proce- and evening shifts and the attendant may be ral by the Department of Mental Health shall dures which should be followed. If the asleep during the night shift; or if the facility have an individual treatment plan or individ- resident is admitted directly from a hospital is on the same floor as the other licensed ual habilitation plan on file prepared by the or another long-term care facility and is facility, there need not be an attendant at Department of Mental Health, updated annu- accompanied on admission by a report which night. If there are more than twenty (20) res- ally. II reflects his/her current medical status, an idents, there shall be at least one (1) staff per- admission physical will not be required. II/III son awake and dressed at all times for every (33) Placement of residents in the building forty (40) residents or fraction of forty (40). shall be determined by their abilities. Those (38) The facility shall follow appropriate I/II residents who require the use of a walker or infection control procedures. The administra- (E) Those facilities which have only an who are blind shall be housed on a floor tor or his or her designee shall make a report asleep attendant during the night-time period which has direct exits at grade, a ramp or no to the local health authority or the department and those facilities which have only the min- more than two (2) steps to grade with a of the presence or suspected presence of any imum staff required by subsection (27)(D) handrail unless an area of refuge as defined in diseases or findings listed in 19 CSR 20- during the night-time period shall not accept 19 CSR 30-86.022 is provided. Those resi- 20.020, sections (1)–(3) according to the residents who are blind, use assistive devices, dents who use a wheelchair shall be able to specified time frames as follows: such as walkers or wheelchairs, or who need demonstrate the ability to transfer to and (A) Category I diseases or findings shall be care greater than can be provided with the from the wheelchair unassisted. They shall be reported to the local health authority or to the staffing pattern in those facilities. Those res- housed near an exit and there shall be a direct department within twenty-four (24) hours of idents who were living in a residential care exit at grade or a ramp or an area of refuge first knowledge or suspicion by telephone, facility prior to July 11, 1980, may remain in as defined in 19 CSR 30-86.022. II facsimile, or other rapid communication; that facility with an asleep attendant even I/II though they may be blind, deaf or use assis- (34) Requirements for facilities which admit (B) Category II diseases or findings shall tive devices provided they can demonstrate or retain residents with mental illness or be reported to the local health authority or the ability to reach safety unassisted or with mental retardation diagnosis and residents the department within three (3) days of first assistive devices. II with assaultive or disruptive behaviors: knowledge or suspicion; I/II (A) Each resident who exhibits mental and (C) Category III. The occurrence of an (28) All residents shall be physically and psychosocial adjustment difficulty(ies) shall outbreak or epidemic of any illness, disease mentally capable of negotiating a normal path receive treatment and services to address the or condition which may be of public health to safety unassisted or with the use of assis- resident’s needs and behaviors as stated in the concern, including any illness in a food han- tive devices within five (5) minutes of being individual service plan; I/II dler that is potentially transmissible through

JOHN R. ASHCROFT (5/31/20) CODE OF STATE REGULATIONS 15 Secretary of State 19 CSR 30-86—DEPARTMENT OF HEALTH AND SENIOR SERVICES Division 30—Division of Regulation and Licensure

food. This also includes public health threats physician’s written order or facility policy to ly in use in the facility may be provided by such as clusters of unusual diseases or mani- the contrary. Written approval for self-control any authorized facility medication staff mem- festations of illness and clusters of unex- of prescription medication shall be rewritten ber if the containers are labeled by the phar- plained deaths. Such incidents shall be as needed but at least annually and after any macy with complete pharmacy prescription reported to the local authority or to the period of hospitalization. II/III labeling for use. Original manufacturer con- department by telephone, facsimile, or other tainers of non-prescription medications, rapid communication within twenty-four (24) (46) All medication shall be safely stored at along with instructions for administration, hours of first knowledge or suspicion. I/II proper temperature and shall be kept in a may be provided by any authorized facility secured location behind at least one (1) medication staff member; II/III (39) Protective oversight shall be provided locked door or cabinet. Medication shall be (C) When medications are supplied by the twenty-four (24) hours a day. For residents accessible only to persons authorized to pharmacy in customized patient medication departing the premises on voluntary leave, administer medications. II/III packages that allow separation of individual the facility shall have, at a minimum, a pro- (A) If access is controlled by the resident, dose containers, the required number of con- cedure to inquire of the resident or resident’s a secured location shall mean in a locked guardian of the resident’s departure, of the container, a locked drawer in a bedside table tainers may be provided by any authorized resident’s estimated length of absence from or dresser or in a resident’s private room if facility medication staff member. The indi- the facility, and of the resident’s whereabouts locked in his or her absence, although this vidual dose containers shall be placed in an while on voluntary leave. I/II does not preclude access by a responsible outer container that is labeled with the name employee of the facility. II/III and address of the facility and the date; II/III (40) Residents shall receive proper care to (B) Schedule II controlled substances shall (D) When multiple doses of a medication meet their needs. Physician orders shall be be stored in locked compartments separate are required and it is not reasonably possible followed. I/II from non-controlled medications, except that to obtain prescription medication labeled by single doses of Schedule II controlled sub- the pharmacy, and it is not appropriate to (41) In case of behaviors that present a rea- stances may be controlled by a resident in send a container of medication currently in sonable likelihood of serious harm to himself compliance with the requirements for self- use in the facility, up to a twenty-four (24)- or herself or others, serious illness, signifi- control of medication of this rule. II/III hour supply of each prescription or non-pre- cant change in condition, injury or death, (C) Medication that is not in current use scription medication may be provided by a staff shall take appropriate action and shall and is not destroyed shall be stored separately licensed nurse in United States Pharmacopeia promptly attempt to contact the individual from medication that is in current use. II/III (USP) approved containers labeled with the listed in the resident’s record as the legally facility name and address, resident’s name, authorized representative, designee or place- (47) All prescription medications shall be medication name and strength, quantity, ment authority. The facility shall contact the supplied as individual prescriptions except attending physician or designee and notify the instructions for use, date, initials of individu- where an emergency medication supply is al providing, and other appropriate informa- local coroner or medical examiner immedi- allowed. All medications, including over-the- ately upon the death of any resident of the tion; II/III counter medications shall be packaged and (E) When no more than a single dose of a facility prior to transferring the deceased res- labeled in accordance with applicable profes- medication is required, any authorized facili- ident to a funeral home. II/III sional pharmacy standards and state and fed- ty medication staff member may prepare the eral drug laws. Labeling shall include acces- dose as for in-facility administration in a USP (42) The facility shall encourage and assist sory and cautionary instructions as well as each resident based on his or her individual the expiration date, when applicable, and the approved container labeled with the facility preferences and needs, to be clean and free of name of the medication as specified in the name and address, resident’s name, medica- body and mouth odor. II physician’s order. Medication labels shall not tion name and strength, quantity, instructions be altered by facility staff and medications for use, date, initials of person providing, and (43) Except in the case of emergency, the res- shall not be repackaged by facility staff except other appropriate information; ident shall not be inhibited by chemical as allowed by section (48) of this rule. Over- (F) The facility may have a policy that lim- and/or physical restraints that would limit the-counter medications for individual resi- its the quantity of medication sent with a res- self-care or ability to negotiate a path to safe- dents shall be labeled with at least the resi- ident without prior approval of the prescriber; ty unassisted or with assistive devices. I/II dent’s name. II/III II/III (G) Returned containers shall be identified (44) If the resident brings unsealed medica- (48) Controlled substances and other pre- as having been sent with the resident, and tions to the facility, the medications shall not scription and non-prescription medications shall not later be returned to the pharmacy for be used unless a pharmacist, physician or nurse examines, identifies and determines the for administration when a resident temporar- reuse; and II/III contents to be suitable for use. The individ- ily leaves a facility shall be provided as fol- (H) The facility shall maintain accurate ual performing the identification shall docu- lows: records of medications provided to and ment his or her review. II/III (A) Separate containers of medications for returned by the resident. II/III the leave period may be prepared by the phar- (45) Self-control of prescription medication macy. The facility shall have a policy and (49) Upon discharge or transfer of a resident, by a resident may be allowed only if approved procedure for families to provide adequate the facility shall release prescription medica- in writing by the resident’s physician and advance notice so that medications can be tions, including controlled substances, held allowed by facility policy. A resident may be obtained from the pharmacy; II/III by the facility for the resident when the physi- permitted to control the storage and use of (B) Prescription medication cards or other cian writes an order for each medication to be nonprescription medication unless there is a multiple-dose prescription containers current- released. Medications shall be labeled by the

16 CODE OF STATE REGULATIONS (5/31/20) JOHN R. ASHCROFT Secretary of State Chapter 86—Residential Care Facilities and Assisted Living Facilities 19 CSR 30-86

pharmacy with current instructions for use. physician’s policy to use the orders, they shall ident has already been immunized as recom- Prescription medication cards or other con- include: name of the medication, dosage, mended by the policy; II/III tainers may be released if the containers are frequency and route of administration and the 3. Provide the opportunity to refuse the labeled by the pharmacy with complete phar- orders shall be renewed at least every three immunization; and II/III macy prescription labeling. II/III (3) months. Computer generated signatures 4. Perform an assessment for contraindi- may be used if safeguards are in place to pre- cations. II/III (50) Injections shall be administered only by vent their misuse. Computer identification (B) The assessment for contraindications a physician or licensed nurse, except that codes shall be accessible to and used only by and documentation of the education and insulin injections may be administered by a the individuals whose signatures they repre- opportunity to refuse the immunization shall CMT or LIMA who has successfully com- sent. Orders that include optional doses or be dated and signed by the nurse performing pleted the state-approved course for insulin include pro re nata (PRN) administration fre- the assessment and placed in the medical administration, taught by a department- quencies shall specify a maximum frequency record. II/III approved instructor. A resident who requires and the reason for administration. II/III (C) The facility shall with the approval of insulin, may administer his or her own (C) Telephone and other verbal orders each resident’s physician, access screening insulin if approved in writing by the resi- shall be received only by a licensed nurse, and immunization through outside sources, dent’s physician and trained to do so by a medication technician, level I medication such as county or city health departments, licensed nurse or physician. The facility is aide or pharmacist and shall be immediately and the facility shall document in the medical responsible to monitor the resident’s condi- reduced to writing and signed by that individ- record that the requirements in subsection tion and continued ability for self-administra- ual. If a telephone or other verbal order is (53)(B) were performed by outside sources. tion. I/II given to a medication technician or level I II/III medication aide, an initial dosage shall not be (51) The administrator/manager shall develop administered until the order has been (54) Stock supplies of nonprescription medi- and implement a safe and effective system of reviewed by telephone, facsimile or in person cation may be kept when specific medications medication control and use, which assures by a licensed nurse or pharmacist. II are approved in writing by a consulting physi- that all residents’ medications are adminis- (D) The review shall be documented by the cian, a registered nurse or a pharmacist. No tered by personnel at least eighteen (18) years licensed nurse’s or pharmacist’s signature stock supply of prescription medication may of age, in accordance with physicians’ within seven (7) days. III be kept in the facility. II/III instructions using acceptable nursing tech- (E) The physician shall sign all telephone niques. The facility shall employ a licensed and other verbal orders within seven (7) days. (55) Records shall be maintained upon nurse eight (8) hours per week for every thir- III receipt and disposition of all controlled sub- ty (30) residents to monitor each resident’s (F) Medication staff shall record adminis- stances and shall be maintained separately condition and medication. Administration of tration of medication on a medication sheet or from other records, for two (2) years. medication shall mean delivering to a resi- directly in the resident’s record. If adminis- (A) Inventories of controlled substances dent his or her prescription medication either tration of medication is recorded on a medi- shall be reconciled as follows: II/III in the original pharmacy container, or for cation sheet, the medication sheet shall be 1. Controlled Substance Schedule II internal medication, removing an individual made part of the resident’s medical record. medications shall be reconciled each shift; dose from the pharmacy container and plac- The same individual who prepares and and II ing it in a small container or liquid medium administers the medication shall record the 2. Controlled Substance Schedule III–V for the resident to remove from the container administration. II/III medications shall be reconciled at least week- and self-administer. External prescription ly and as needed to ensure accountability. medication may be applied by facility person- (53) Influenza and pneumococcal polysaccha- II/III nel if the resident is unable to do so and the ride immunizations may be administered per (B) Inventories of controlled substances resident’s physician so authorizes. All indi- physician-approved facility policy after shall be reconciled by the following: viduals who administer medication shall be assessment for contraindications. 1. Two (2) medication personnel, one of trained in medication administration and, if (A) The facility shall develop a policy that whom is a licensed nurse; or not a physician or a licensed nurse, shall be a provides recommendations and assessment 2. Two (2) medication personnel, one of certified medication technician or level I parameters for the administration of such whom is the administrator/manager when no medication aide. I/II immunizations. The policy shall be approved nurse is available on staff; or by the facility medical director for facilities 3. Two (2) medication personnel either (52) Medication Orders. having a medical director, or by each resi- medication technicians or level I medication (A) Physician’s instructions, as evidenced dent’s attending physician for facilities that aides when neither a licensed nurse nor the by the prescription label or by signed order of do not have a medical director, and shall administrator/manager is available. II/III a physician, shall be accurately followed. If include the requirements to: (C) Receipt records shall include the date, the physician changes the order which is des- 1. Provide education regarding the source of supply, resident name and prescrip- ignated on a prescription label, there shall be potential benefits and side effects of the tion number when applicable, medication on file in the resident’s record a signed physi- immunization to each resident or the resi- name and strength, quantity and signature of cian’s order to that effect with the amended dent’s designee or legally authorized repre- the supplier and receiver. Administration instructions for use or until the prescription sentative; II/III records shall include the date, time, resident label is changed by the pharmacy to reflect 2. Offer the immunization to the resi- name, medication name, dose administered the new order. II/III dent or obtain permission from the resident’s and the initials of the individual administer- (B) Physician’s written and signed orders designee or legally authorized representative ing. The signature and initials of each medi- are not required, but if it is the facility’s or when it is medically indicated, unless the res- cation staff documenting on the medication

JOHN R. ASHCROFT (5/31/20) CODE OF STATE REGULATIONS 17 Secretary of State 19 CSR 30-86—DEPARTMENT OF HEALTH AND SENIOR SERVICES Division 30—Division of Regulation and Licensure

administration record must be signed in the 6. Local trends and other indicators of (D) After a resident has expired, medica- signature area of the medication record. diversion potential; II/III tions, except for controlled substances, may II/III (B) If an insignificant amount of such con- be released to the resident’s legal representa- (D) When self-control of medication is trolled substance is lost during lawful activi- tive upon written request of the legal repre- approved a record shall be made of all con- ties, which includes but are not limited to sentative that includes the name of the medi- trolled substances transferred to and adminis- receiving, record keeping, access auditing, cation and the reason for the request; tered from the resident’s room. Inventory administration, destruction and returning to (E) Medications may be returned to the reconciliation shall include controlled sub- the pharmacy, a description of the occurrence pharmacy that dispensed the medications pur- stances transferred to the resident’s room. shall be documented in writing and main- suant to 4 CSR 220-3.040 or returned pur- I/II tained with the facility’s controlled substance suant to the Prescription Drug Repository records. The documentation shall include the Program, 19 CSR 20-50.020; (56) Documentation of the wasting of con- reason for determining that the loss was (F) All other medications, including all trolled substances at the time of administra- insignificant. II/III controlled substances and all expired or oth- tion shall include the reason for the waste and erwise unusable medications, shall be the signature of another medication staff (58) A pharmacist or registered nurse shall destroyed within thirty (30) days as follows: member or the administrator who witnesses review the medication regimen of each resi- II/III the waste. If no medication staff member or dent. This shall be done at least every three 1. Medications shall be destroyed within the administrator is available at the time of (3) months in a residential care facility. The the facility by a pharmacist and a licensed administration, the controlled substance shall review shall be performed in the facility and nurse or by two (2) licensed nurses or when be properly labeled, clearly identified as shall include, but shall not be limited to, indi- two (2) licensed nurses are not available on unusable, stored in a locked area, and cation for use, dose, possible medication staff by two (2) individuals who have author- destroyed as soon as a medication staff mem- interactions and medication/food interactions, ity to administer medications, one (1) of ber or the administrator is available to wit- contraindications, adverse reactions and a whom shall be a licensed nurse or a pharma- ness the waste. When no medication staff review of the medication system utilized by cist; and II/III member or the administrator is available and the facility. Irregularities and concerns shall 2. A record of medication destroyed the controlled substance is contaminated by be reported in writing to the resident’s physi- shall be maintained and shall include the res- patient body fluids, the controlled substance cian and to the administrator/manager. If ident’s name, date, medication name and shall be destroyed immediately and the cir- after thirty (30) days, there is no action taken strength, quantity, prescription number, and by a resident’s physician and significant con- cumstances documented. II/III signatures of the individuals destroying the cerns continue regarding a resident’s or resi- medications; and II/III (57) At least every three (3) months in a res- dents’ medication order(s), the administra- (G) A record of medication released or tor/manager shall contact or recontact the idential care facility, a pharmacist or regis- returned to the pharmacy shall be maintained physician to determine if he or she received tered nurse shall review the controlled sub- and shall include the resident’s name, date, the information and if there are any new stance record keeping including reconciling medication name and strength, quantity, pre- instructions. II/III the inventories of controlled substances. This scription number, and signatures of the indi- shall be done at the time of the drug regimen viduals releasing and receiving the medica- (59) All medication errors and adverse reac- review of each resident. All discrepancies in tions. III tions shall be promptly documented and controlled substance records shall be reported reported to the administrator/manager and (61) Residents shall be encouraged to be to the administrator or manager for review the resident’s physician. If the pharmacy and investigation. The theft or loss of con- active and to participate in activities. In a res- made a dispensing error, it shall also be idential care facility licensed for more than trolled substances shall be reported as fol- reported to the issuing pharmacy. II/III lows: II/III twelve (12) residents, a method for informing (A) The facility shall notify the depart- the residents in advance of what activities are (60) Medications that are not in current use available, where they will be held and at what ment’s Section for Long Term Care (SLTC) shall be disposed of as follows: and other appropriate authorities of any theft times they will be held shall be developed, (A) Single doses of contaminated, refused, maintained and used. II/III or significant loss of any controlled substance or otherwise unusable non-controlled sub- medication written as an individual prescrip- stance medications may be destroyed by any (62) The facility shall maintain a record in tion for a specific resident upon the discovery authorized medication staff member at the the facility for each resident which shall of the theft or loss. The facility shall consider time of administration. Single doses of unus- include the following: at least the following factors in determining if able controlled substance medications shall (A) Admission information including the a loss is significant: be destroyed according to section (56) of this resident’s name; admission date; confiden- 1. The actual quantity lost in relation to rule; tiality number; previous address; birth date; the total quantity; (B) Discontinued medications may be sex; marital status; Social Security number; 2. The specific controlled substance retained up to one hundred twenty (120) days Medicare and Medicaid numbers (if applica- lost; prior to other disposition if there is reason to ble); name, address and telephone number of 3. Whether the loss can be associated believe, based on clinical assessment of the the resident’s physician and alternate; diagno- with access by specific individuals; resident, that the medication might be sis; name, address and telephone number of 4. Whether there is a pattern of losses, reordered; the resident’s legally authorized representa- and if the losses appear to be random or not; (C) Medications may be released to the tive or designee to be notified in case of 5. Whether the controlled substance is resident or family upon discharge according emergency; and preferred dentist, pharmacist a likely candidate for diversion; and to section (49) of this rule; and funeral director; III

18 CODE OF STATE REGULATIONS (5/31/20) JOHN R. ASHCROFT Secretary of State Chapter 86—Residential Care Facilities and Assisted Living Facilities 19 CSR 30-86

(B) A review monthly or more frequently, 19 CSR 30-86.043 Administrative, Person- time and attention to the management of the if indicated, of the resident’s general condi- nel, and Resident Care Requirements for facility as is necessary for the health, safety tion and needs; a monthly review of medica- Facilities Licensed as a Residential Care and welfare of the residents. II tion consumption of any resident controlling Facility II on August 27, 2006 that Will his or her own medication, noting if prescrip- Comply with Residential Care Facility II (6) The administrator cannot be listed or tion medications are being used in appropri- Standards function in more than one (1) facility at the ate quantities; a daily record of administra- same time unless s/he serves no more than tion of medication; a logging of the PURPOSE: This rule establishes require- four (4) facilities which are within a thirty medication regimen review process; a month- ments for administration, personnel and resi- (30)-mile radius and licensed to serve in total ly weight; a record of each referral of a resident care requirements for facilities licensed no more than one hundred (100) residents. dent for services from an outside service; and pursuant to section 198.005, RSMo that con- However, one (1) administrator may serve as a record of any resident incidents including tinue to comply with residential care facilities the administrator of more than one (1) behaviors that present a reasonable likelihood licensed facility if all facilities are on the of serious harm to himself or herself or oth- (RCF) II standards in effect on August 27, ers and accidents that potentially could result 2006. same premises. II/III in injury or did result in injuries involving the resident; and III AGENCY NOTE: All rules relating to long- (7) The administrator shall designate, in writ- (C) Any Physician’s Orders. Except as term care facilities licensed by the departing, a staff person in charge in his/her allowed by section (52) of this rule, the facil- ment are followed by a Roman Numeral nota- absence. If the administrator is absent for ity shall submit to the physician written ver- tion which refers to the class (either Class I, more than thirty (30) consecutive days, dur- sions of any oral or telephone orders within II, or III) of standard as designated in section ing which time s/he is not readily accessible four (4) days of the giving of the oral or tele- 198.085.1., RSMo. for consultation by telephone with the person phone order. III in charge or if the administrator is absent (1) This rule contains the administrative, per- from the facility for more than sixty (60) (63) A record of the daily resident census sonnel and resident care standards in effect working days during the course of a calendar shall be retained in the facility. III on August 27, 2006 for residential care facil- year the person designated to be in charge ity IIs (formerly published at 19 CSR 30- shall be an administrator currently licensed (64) Resident records shall be maintained by 86.042 (effective 12/31/05)). These stan- by the Missouri Board of Nursing Home the operator for at least five (5) years after a dards apply to facilities that were licensed as Administrators, in accordance with Chapter resident leaves the facility or after the resi- residential care facility IIs on August 27, 344, RSMo. II/III dent reaches the age of twenty-one (21), 2006 and that choose to be inspected under whichever is longer and must include reason these standards rather than the standards pub- (8) The facility shall not care for more resi- for discharge or transfer from the facility and lished at 19 CSR 30-86.047. dents than the number for which the facility cause of death, if applicable. III is licensed. II/III (2) A person shall be designated to be an AUTHORITY: sections 198.005 and 198.006, administrator who is currently licensed as an (9) The facility’s current license shall be RSMo Supp. 2006 and 198.076, RSMo administrator by the Missouri Board of Nurs- posted in a conspicuous place and notices 2000.* This rule originally filed as 13 CSR ing Home Administrators, in accordance with provided to the facility by the Department of 15-15.042. Original rule filed July 13, 1983, Chapter 344, RSMo. II Health and Senior Services (the department) effective Oct. 13, 1983. Emergency amend- granting exception(s) to regulatory requirement filed Aug. 1, 1984, effective Aug. 13, (3) By January 1, 1991, the administrator of ments shall be posted alongside of the facili- 1984, expired Dec. 10, 1984. Amended: a facility shall have successfully completed ty’s license. III Filed Sept. 12, 1984, effective Dec. 13, the state approved Level I Medication Aide 1984. Amended: Filed March 14, 1985, course unless s/he is a physician, pharmacist, (10) All personnel responsible for resident effective June 13, 1985. Amended: Filed May licensed nurse or a certified medication tech- care shall have access to the legal name of 13, 1987, effective Aug. 13, 1987. Amended: nician, or if the facility is operating in con- each resident, name and telephone number of Filed April 17, 1990, effective June 30, 1990. junction with a skilled nursing facility or physician and next of kin or responsible party Amended: Filed Feb. 13, 1998, effective Sept. intermediate care facility on the same premis- in the event of emergency. II/III 30, 1998. Moved to 19 CSR 30-86.042, effec- es, or if the facility employs on a full-time tive Aug. 28, 2001. Emergency amendment basis, a licensed nurse who is available seven (11) All persons who have any contact with filed Sept. 12, 2003, effective Sept. 22, 2003, (7) days per week. II/III the residents in the facility shall not knowing- expired March 19, 2004. Amended: Filed ly act or omit any duty in a manner which Sept. 12, 2003, effective Feb. 29, 2004. (4) The operator shall be responsible to assure would materially and adversely affect the Amended: Filed Aug. 23, 2006, effective compliance with all applicable laws and regu- health, safety, welfare, or property of resi- April 30, 2007. ** lations. The administrator shall be fully autho- dents. No person who is listed on the rized and empowered to make decisions Employee Disqualification List (EDL) main- *Original authority: 198.005, RSMo 2006; 198.006, regarding the operation of the facility and shall tained by the department as required by sec- RSMo 1979, amended 1984, 1987, 2003, 2006; and be held responsible for the actions of all tion 198.070, RSMo, shall work or volunteer 198.076, RSMo 1979, amended 1984. employees. The administrator’s responsibili- in the facility in any capacity whether or not ties shall include oversight of residents to employed by the operator. For the purpose of **Pursuant to Executive Orders 20-04 and 20-10, 19 CSR 30- 86.042, subsection (21)(I) and sections (50) and (51) was suspended assure that they receive appropriate care. II/III this rule, a volunteer is an unpaid individual from April 15, 2020 through June 15, 2020 and sections (7), (17), formally recognized by the facility as provid- (18), (37), and (58) was suspended from April 17, 2020 through June 15, 2020. (5) The administrator shall devote sufficient ing a direct care service to residents. The

JOHN R. ASHCROFT (5/31/20) CODE OF STATE REGULATIONS 19 Secretary of State 19 CSR 30-86—DEPARTMENT OF HEALTH AND SENIOR SERVICES Division 30—Division of Regulation and Licensure

facility is required to check the EDL for indi- Each facility shall maintain documents veri- (17) The administrator shall be responsible viduals who volunteer to perform a service fying that the EDL checks were requested, for monitoring the health of the employees. for which the facility might otherwise have to the date of each such request, and the nature II/III hire an employee. The facility is not required of the response received for each such to check the EDL for individuals or groups request. The inquiry may be made through (18) Prior to or on the first day that a new such as scout groups, bingo leaders, or sing- the department’s website; II/III employee works in the facility s/he shall along leaders. The facility is not required to (C) For persons for whom the facility has receive orientation of at least one (1) hour check the EDL for an individual such as a contracted for professional services (e.g., appropriate to his/her job function. This shall priest, minister, or rabbi visiting a resident plumbing or air conditioning repair) that will include, at a minimum, job responsibilities, who is a member of the individual’s congre- have contact with any resident, the facility how to handle emergency situations, the gation. However, if the minister, priest, or shall either require a criminal background importance of infection control and hand- rabbi serves as a volunteer facility chaplain, check or ensure that the individual is suffi- washing, confidentiality of resident informa- the facility is required to check the EDL ciently monitored by facility staff while in the tion, preservation of resident dignity, how to since the individual would have potential con- facility to reasonably ensure the safety of all report abuse/neglect to the department (1- tact with all residents. I/II residents; and I/II 800-392-0210), information regarding the (D) If the person has registered with the Employee Disqualification List and instruc- (12) Prior to allowing any person who has department’s Family Care Safety Registry tion regarding the rights of residents and pro- been hired in a full-time, part-time, or tem- (FCSR), the facility may utilize the FCSR in tection of property. II/III porary position to have contact with any res- order to meet the requirements of subsections ident, the facility shall, or in the case of tem- (12)(A) and (12)(B) of this rule. The FCSR is (19) The administrator shall maintain on the porary employees hired through or contracted available through the department’s website. premises an individual personnel record on for an employment agency, the employment each employee of the facility which shall agency shall, prior to sending a temporary (13) The facility must develop and implement include: the employee’s name and address; employee to a facility: written policies and procedures which require Social Security number; date of birth; date of (A) Request a criminal background check that persons hired for any position which is to employment; experience and education for the person, as provided in section have contact with any patient or resident have including documentation of specialized train- 660.317, RSMo. Each facility shall maintain ing on medication and/or insulin administra- been informed of their responsibility to dis- documents verifying that the background tion, or both; references, if available; the close their prior criminal history to the facil- checks were requested, the date of each such results of background checks required by sec- ity as required by section 660.317.5, RSMo. request, and the nature of the response tion 660.317, RSMo; position in the facility; The facility must also develop and implement received for each such request. II written statement signed by a licensed physi- policies and procedures which ensure that the 1. The facility shall ensure that any per- cian or physician’s designee indicating the facility does not knowingly hire, after August son hired or retained to have contact with any person can work in a long-term care facility 28, 1997, any person who has or may have resident who discloses that he or she has been and indicating any limitations; record that the contact with a patient or resident, who has convicted of, found guilty of, pled guilty to, employee was instructed on residents’ rights, been convicted of, plead guilty or nolo con- or pled nolo contendere to a crime, in this facility’s policies, job duties and any other tendere to, in this state or any other state, or state or any other state, which if committed in orientation and reason for termination. Per- Missouri would be a class A or B felony vio- has been found guilty of any Class A or B sonnel records shall be maintained for at least lation of Chapter 565, 566, or 569, RSMo, or felony violation of Chapter 565, 566 or 569, one (1) year following termination of employ- any violation of section 198.070.3., RSMo, or RSMo, or any violation of subsection 3 of ment. III section 568.020, RSMo, shall not be retained section 198.070, RSMo, or of section in such a position. I/II 568.020, RSMo. II/III (20) There shall be written documentation 2. Upon receipt of the criminal back- maintained in the facility showing actual ground check, the facility shall ensure that if (14) All persons who have or may have con- hours worked by each employee. III the criminal background check indicates that tact with residents shall at all times when on the person hired or retained by the facility has duty or delivering services wear an identifi- (21) No one individual shall be on duty with been convicted of, found guilty of, pled guilty cation badge. The badge shall give their responsibility for oversight of residents longer to, or pled nolo contendere to a crime, in this name, title and, if applicable, the status of than eighteen (18) hours per day. I/II state or any other state, which if committed in their license or certification as any kind of Missouri would be a class A or B felony vio- health care professional. This rule shall apply (22) Employees who are counted in meeting lation of Chapter 565, 566, or 569, RSMo, or to all personnel who provide services to any the minimum staffing ratio and employees any violation of section 198.070.3., RSMo, or resident directly or indirectly. III who provide direct care to the residents shall section 568.020, RSMo, the person shall not be at least sixteen (16) years of age. III have contact with any resident unless and until (15) All personnel shall be able physically the facility obtains verification from the and emotionally to work in a long-term care (23) One (1) employee at least eighteen (18) department that a good cause waiver has been facility. I/II years of age shall be on duty at all times. I/II granted for each qualifying offense and maintains a copy of the verification in the individ- (16) Personnel who have been diagnosed with (24) Staffing. ual’s personnel file; I/II a communicable disease may begin work or (A) The facility shall have an adequate (B) Make an inquiry to the department, as return to duty only with written approval by a number and type of personnel for the proper provided in section 660.315, RSMo, as to physician or physician’s designee which indi- care of residents and upkeep of the facility. At whether the person is listed on the EDL. cates any limitations. II a minimum, the staffing pattern for fire safety

20 CODE OF STATE REGULATIONS (5/31/20) JOHN R. ASHCROFT Secretary of State Chapter 86—Residential Care Facilities and Assisted Living Facilities 19 CSR 30-86

and care of residents shall be one (1) staff than six (6) hours. III unassisted. They shall be housed near an exit person for every fifteen (15) residents or (E) There shall be a licensed nurse and there shall be a direct exit at grade or a major fraction of fifteen (15) during the day employed by the facility to work at least eight ramp. II shift, one (1) person for every twenty (20) (8) hours per week at the facility for every residents or major fraction of twenty (20) thirty (30) residents or additional major frac- (32) Residents admitted or readmitted to the during the evening shift and one (1) person tion of thirty (30). The nurse’s duties shall facility shall have an admission physical for every twenty-five (25) residents or major include, but shall not be limited to, review of examination by a licensed physician. Docu- fraction of twenty-five (25) during the night residents’ charts, medications and special mentation should be obtained prior to admis- shift. I/II diets or other orders, review of each resi- sion but shall be on file not later than ten (10) dent’s adjustment to the facility and observa- days after admission and shall contain infor- Time Personnel Residents tion of each individual resident’s general mation regarding the resident’s current medi- 7 a.m. to 3 p.m. physical and mental condition. The nurse cal status and any special orders or proce- (Day)* 1 3–15 shall inform the administrator of any prob- dures which should be followed. If the 3 p.m. to 9 p.m. lems noted and these shall be brought to the resident is admitted directly from a hospital (Evening)* 1 3–20 attention of the resident’s physician. II/III or another long-term care facility and is 9 p.m. to 7 a.m. accompanied on admission by a report which (Night)* 1 3–25 (25) All residents shall be physically and reflects his/her current medical status, an mentally capable of negotiating a normal path admission physical will not be required. II/III *If the shift hours vary from those indicated, to safety unassisted or with the use of assis- the hours of the shifts shall show on the work tive devices. I/II (33) If at any time a resident or prospective schedules of the facility and shall not be less resident is diagnosed with a communicable than six (6) hours. III (26) Residents suffering from short periods of disease, the department shall be notified (B) The required staff shall be in the facil- incapacity due to illness, injury or recupera- within seven (7) days and if the facility can ity awake, dressed and prepared to assist res- tion from surgery may be allowed to remain meet the resident’s needs, the resident may be idents in case of emergency. I/II or be readmitted from a hospital if the period admitted or does not need to be transferred. (C) In a facility of more than one hundred of incapacity does not exceed forty-five (45) Appropriate infection control procedures (100) residents, the administrator shall not be days and written approval of a physician is shall be followed if the resident remains in or counted when determining the personnel obtained for the resident to remain in or be is accepted by the facility. I/II required. II readmitted to the facility. II/III (D) If the facility is operated in conjunc- (34) Protective oversight shall be provided tion with and is immediately adjacent to and (27) The facility shall not admit or continue twenty-four (24) hours a day. For residents contiguous to another licensed long-term care to care for residents whose needs cannot be departing the premises on voluntary leave, facility and if the resident bedrooms of the met. If necessary services cannot be obtained the facility shall have, at a minimum, a pro- facility are on the same floor as at least a por- in or by the facility, the resident shall be cedure to inquire of the resident or resident’s tion of a licensed intermediate care or skilled promptly referred to appropriate outside guardian of the resident’s departure, of the nursing facility; there is an approved call sys- resources or transferred to a facility providing resident’s estimated length of absence from tem in each resident’s bedroom and bathroom the appropriate level of care. I/II the facility, and of the resident’s whereabouts or a patient-controlled call system; and there is a complete fire alarm system in the facility while on voluntary leave. I/II (28) In the event a resident is transferred tied into the complete fire alarm system in the other licensed facility, then the following from the facility, a report of the resident’s (35) Residents shall receive proper care to minimum staffing for oversight and care of current medical status shall accompany meet their needs. Physician orders shall be residents, for upkeep of the facility and for him/her. III followed. I/II fire safety shall be one (1) staff person for every eighteen (18) residents or major frac- (29) Residents admitted to a facility on refer- (36) In case of serious illness, accident or tion of residents during the day shift, one (1) ral by the Department of Mental Health shall death, appropriate action shall be taken and person for every twenty-five (25) residents or have an individual treatment plan or individ- the person designated in the resident’s record major fraction of residents during the evening ual habilitation plan on file prepared by the as the responsible party and, if applicable, shift and one (1) person for every thirty (30) Department of Mental Health, updated annu- the guardian shall be immediately notified. residents or major fraction of residents dur- ally. III II/III ing the night shift. I/II (30) Residents under sixteen (16) years of age (37) Every resident shall be clean, dry and Time Personnel Residents shall not be admitted. III free of offensive body and mouth odor. I/II 7 a.m. to 3 p.m. (Day)* 1 3–18 (31) Placement of residents in the building (38) Except in the case of emergency, the res- 3 p.m. to 9 p.m. shall be determined by their abilities. Those ident shall not be inhibited by chemical (Evening)* 1 3–25 residents who require the use of a walker or and/or physical restraints that would limit 9 p.m. to 7 a.m. who are blind shall be housed on a floor self-care or ability to negotiate a path to safe- (Night)* 1 3–30 which has direct exits at grade, a ramp or no ty unassisted or with assistive devices. I/II more than two (2) steps to grade with a *If the shift hours vary from those indicated, handrail. Those residents who use a (39) A supply of clean linen shall be available the hours of the shifts shall show on the work wheelchair shall be able to demonstrate the in the facility and provided to residents to schedules of the facility and shall not be less ability to transfer to and from the wheelchair meet their daily needs. II/III

JOHN R. ASHCROFT (5/31/20) CODE OF STATE REGULATIONS 21 Secretary of State 19 CSR 30-86—DEPARTMENT OF HEALTH AND SENIOR SERVICES Division 30—Division of Regulation and Licensure

(40) Beds shall be made daily and linen (48) Injections shall be administered only by (A) Physician’s instructions, as evidenced changed at least weekly or more often if a physician or licensed nurse, except that res- by the prescription label or by signed order of needed to maintain a clean, dry bed. II/III idents who require insulin, upon written a physician, shall be accurately followed. If order of their physician, may administer their the physician changes the order which is des- (41) The resident’s unit shall be thoroughly own insulin or the insulin may be adminis- ignated on a prescription label, there shall be cleaned and disinfected following a resident’s tered by a person trained to do so by a on file in the resident’s record a signed physi- death, discharge or transfer. II/III licensed nurse or physician and the resident’s cian’s order to that effect with the amended condition shall be monitored by his/her physi- instructions for use or until the prescription (42) Commodes and urinals, if used, shall be cian. After December 31, 1990, unless label is changed by the pharmacy to reflect kept at the bedside of the residents. They insulin is self-administered or it is adminis- the new order. II/III shall not be left open and the container shall tered only by a physician or licensed nurse, (B) Physician’s written and signed orders be emptied promptly and thoroughly cleaned it shall be administered by a certified medica- are not required, but if it is the facility’s or after each use. III tion technician or a level I medication aide physician’s policy to use the orders, they shall who has successfully completed the state- include: name of medication, dosage and fre- (43) Cuspidors shall be emptied and cleaned approved course for insulin administration, quency of administration and the orders shall daily or disposable cartons shall be provided taught by an approved instructor and who was be renewed at least every three (3) months. daily. III recommended for training by an administra- II/III tor or nurse with whom he or she works. (C) Verbal and telephone orders shall be (44) Self-control of prescription medication Anyone trained prior to December 31, 1990, taken only by a licensed nurse, medication by a resident may be allowed only if approved who completed the state-approved insulin technician, level I medication aide or phar- in writing by the resident’s physician and administration course taught by an approved macist and shall be immediately reduced to allowed by facility policy. If a resident is not instructor shall be considered qualified to writing and signed by that individual. If a taking any prescription medication, the resi- administer insulin in a facility. Anyone telephone order is given to a medication tech- dent may be permitted to control the storage trained prior to December 31, 1990, to nician or level I medication aide, an initial and use of nonprescription medication unless administer insulin by a licensed nurse or dosage of a new prescription shall not be ini- there is a physician’s written order or facility physician not using the state-approved course tiated until the order has been reviewed by policy to the contrary. If not permitted, all may qualify by challenging the final examina- telephone or in person by a licensed nurse or medications for that resident, including over- tion of the insulin administration course. I/II pharmacist. II the-counter medications, shall be controlled (D) The review shall be documented by the by the administrator unless the physician (49) The administrator shall develop and nurse’s or pharmacist’s signature within specifies otherwise. II/III implement a safe and effective system of seven (7) days. III medication control and use which assures that (E) The physician shall sign all verbal and (45) Written approval for self-control of pre- all residents’ medications are administered or telephone orders within seven (7) days. III scription medication shall be rewritten as distributed by personnel at least eighteen (18) (F) The administration or distribution of needed but at least annually and after any years of age, in accordance with physicians’ medication shall be recorded on a medication period of hospitalization. III instructions using acceptable nursing tech- sheet or directly in the resident’s record and, niques. Until January 1, 1991, those facilities if recorded on a medication sheet, shall be (46) All medication shall be safely stored at administering medications shall utilize per- made part of the resident’s record. The proper temperature and shall be kept in a sonnel trained in medication administration administration or distribution shall be record- secured location behind at least one (1) (a licensed nurse, certified medication techni- ed by the same person who prepares the med- locked door or cabinet. If access is controlled cian or level I medication aide) and shall ication and who distributes or administers it. by the resident, a secured location shall mean employ a licensed nurse eight (8) hours per II/III in a locked container, a locked drawer in a week for every thirty (30) residents to moni- bedside table or dresser or in a resident’s pri- tor each resident’s condition. Distribution (51) A stock supply of prescription medica- vate room if locked in his/her absence, shall mean delivering to a resident his/her tion may be kept in the facility. An emergency although this does not preclude access by a prescription medication either in the original drug supply as recommended by a pharmacist responsible employee of the facility. II/III pharmacy container, or for internal medica- or physician may be kept if approved by the tion, removing an individual dose from the department. Storage and use of medications (47) All prescription medications shall be pharmacy container and placing it in a small in the emergency drug supply shall assure supplied as individual prescriptions. All med- container or liquid medium for the resident to accountability. II/III ications, including over-the-counter medica- remove from the container and self-adminis- tions shall be packaged and labeled in accor- ter. External prescription medication may be (52) Stock supplies of nonprescription medi- dance with applicable professional pharmacy applied by facility personnel if the resident is cation may be kept for pro re nata (PRN) use standards, state and federal drug laws and unable to do so and the resident’s physician in facilities as long as the particular medica- regulations and the United States Pharma- so authorizes. After December 31, 1990, all tions are approved in writing by a consulting copeia (USP). Labeling shall include acces- persons who administer or distribute medica- physician, a registered nurse or a pharmacist. sory and cautionary instructions as well as tion shall be trained in medication adminis- II/III the expiration date, when applicable, and the tration and, if not a physician or a licensed name of the medication as specified in the nurse, shall be a certified medication techni- (53) All controlled substances shall be han- physician’s order. Over-the-counter medica- cian or level I medication aide. I/II dled according to state laws and regulations tions for individual residents shall be labeled as given in and required by 19 CSR 30-1 and with at least the resident’s name. II/III (50) Medication Orders. Chapter 195, RSMo. II/III

22 CODE OF STATE REGULATIONS (5/31/20) JOHN R. ASHCROFT Secretary of State Chapter 86—Residential Care Facilities and Assisted Living Facilities 19 CSR 30-86

(54) A pharmacist or registered nurse shall (B) A resident’s record, including a review pursuant to sections 198.005 and 198.073, review the drug regimen of each resident. monthly or more frequently, if indicated, of RSMo (CCS HCS SCS SB 616, 93rd General This shall be done at least every other month the resident’s general condition and needs; a Assembly, Second Regular Session (2006)) in a facility. The review shall be performed in monthly review of medication consumption and complying with sections 198.073.4 and the facility and shall include, but shall not be of any resident controlling his/her own medi- 198.073.6, RSMo (CCS HCS SCS SB 616, limited to, possible drug and food interac- cation, noting if prescription medications are 93rd General Assembly, Second Regular Ses- tions, contraindications, adverse reactions being used in appropriate quantities; a daily sion (2006)) and 19 CSR 30-86.047 that and a review of the medication system uti- record of distribution or administration of choose to admit or continue to care for any lized by the facility. Irregularities and con- medication; any physician’s orders; a logging individual having a physical, cognitive or cerns shall be reported in writing to the resi- of the drug regimen review process; a month- other impairment that prevents the individual dent’s physician and to the administrator. If ly weight; a record of each referral of a resi- from safely evacuating the facility with mini- after thirty (30) days, there is no action taken dent for services from an outside service; and mal assistance. by a resident’s physician and significant con- a record of any patient incidents and acci- cerns continue regarding a resident’s or residents involving the resident. III (2) Definitions. For the purposes of this rule, dents’ medication order(s), the administrator the following definitions shall apply: shall contact or recontact the physician to (59) A record of the resident census as well (A) Area of refuge—A space located in or determine if he or she received the informa- as records regarding discharge, transfer or immediately adjacent to a path of travel lead- tion and if there are any new instructions. death of residents shall be kept in the facility. ing to an exit that is protected from the II/III III effects of fire, either by means of separation from other spaces in the same building or its (55) Medications controlled by the facility (60) Resident records shall be maintained by location, permitting a delay in evacuation. shall be disposed of either by destroying, the operator for at least five (5) years after An area of refuge may be temporarily used as returning to the pharmacy or sending with the resident leaves the facility or after the res- a staging area that provides some relative residents on discharge. The following shall be ident reaches the age of twenty-one (21), safety to its occupants while potential emer- destroyed within the facility within ninety whichever is longer. III gencies are assessed, decisions are made, and (90) days: discontinued medication not evacuation has begun; returnable to the pharmacy, all discontinued AUTHORITY: sections 198.073 and 198.076, (B) Evacuating the facility—The act of the controlled substances, outdated or deteriorat- RSMo Supp. 2011.* Original rule filed Aug. resident going from one (1) smoke section to ed medication, medication of expired resi- 23, 2006, effective April 30, 2007. Amended: another within the facility, going to an area of dents not returnable to the pharmacy and Filed March 1, 2012, effective Sept. 30, 2012. refuge within the facility, or going out of the medications not sent with the resident on dis- ** facility; charge. II/III (C) Individualized evacuation plan—A plan *Original authority: 198.073, RSMo 1979, amended to remove the resident from the facility, to an 1984, 1992, 1999, 2006, 2007 and 198.076, RSMo 1979, area of refuge within the facility or from one (56) Disposition of medication controlled by amended 1984, 2007. the facility shall be recorded listing the resi- (1) smoke section to another within the facil- dent’s name, the date and the name, strength **Pursuant to Executive Orders 20-04 and 20-10, 19 CSR 30- ity. The plan is specific to the resident’s and quantity of the drug and the signature(s) 86.043, sections (19), (48), and (49) was suspended from April 15, needs and abilities based on the current com- 2020 through June 15, 2020 and sections (8) and (54) was suspend- of the person(s) involved. Medication ed from April 17, 2020 through June 15, 2020. munity based assessment; destruction shall involve two (2) persons, one (D) Minimal assistance— (1) of whom shall be a pharmacist, a nurse or 1. Is the criterion which determines a state inspector. III 19 CSR 30-86.045 Standards and Require- whether or not staff must develop and include ments for Assisted Living Facilities Which an individualized evacuation plan as part of (57) Residents shall be encouraged to be Provide Services to Residents with a Phys- the resident’s service plan; active and to participate in activities. In a ical, Cognitive, or Other Impairment that 2. Minimal assistance may be the verbal facility licensed for more than twelve (12) Prevents the Individual from Safely Evacu- intervention that staff must provide for a res- residents, a method for informing the resi- ating the Facility with Minimal Assistance ident to initiate evacuating the facility; dents in advance of what activities are avail- 3. Minimal assistance may be the physi- able, where they will be held and at what PURPOSE: This rule establishes the addi- cal intervention that staff must provide, such times they will be held shall be developed, tional standards for those assisted living as turning a resident in the correct direction, maintained and used. II/III facilities which provide services to residents for a resident to initiate evacuating the facili- with a physical, cognitive, or other impair- ty; (58) A record shall be maintained in the facil- ment that prevents the individual from safely 4. A resident needing minimal assis- ity for each resident which shall include: evacuating the facility with minimal assistance is one who is able to prepare to leave (A) Admission information including the tance. and then evacuate the facility within five (5) resident’s name; admission date; confiden- minutes of being alerted of the need to evac- tiality number; previous address; birth date; AGENCY NOTE: All rules relating to uate and requires no more than one (1) phys- sex; marital status; Social Security number; long-term care facilities licensed by the ical intervention and no more than three (3) Medicare and Medicaid number; name, department are followed by a Roman Numeral verbal interventions of staff to complete evac- address and telephone number of physician notation which refers to the class (either uation from the facility; and alternate; name, address and telephone Class I, II or III) of standard as designated in 5. The following actions required of number of resident’s next of kin, legal section 198.085.1, RSMo. staff are considered to be more than minimal guardian, designee or person to be notified in assistance: case of emergency; and preferred dentist, (1) This rule contains the additional standards A. Assistance to traverse down stair- pharmacist and funeral director; and III for those assisted living facilities licensed ways;

JOHN R. ASHCROFT (5/31/20) CODE OF STATE REGULATIONS 23 Secretary of State 19 CSR 30-86—DEPARTMENT OF HEALTH AND SENIOR SERVICES Division 30—Division of Regulation and Licensure

B. Assistance to open a door; and 10. Comply with all requirements of this AUTHORITY: sections 198.073 and 198.076, C. Assistance to propel a wheelchair; rule. I/II RSMo Supp. 2007.* This rule originally filed (E) Resident, only for the purpose of this as 13 CSR 15-15.045. Emergency rule filed rule, means any individual having a physical, (4) Staffing Requirements. Dec. 14, 2000, effective Jan. 2, 2001, expired cognitive or other impairment that prevents (A) The facility shall have an adequate June 30, 2001. Original rule filed Dec. 14, the individual from safely evacuating the number and type of personnel for the proper 2000, effective June 30, 2001. Moved to 19 facility with minimal assistance who is admit- care of residents and upkeep of the facility. At CSR 30-86.045, effective Aug. 28, 2001. ted to or continues to be cared for in the facil- a minimum, the staffing pattern for fire safe- Amended: Filed Aug. 23, 2006, effective ity under the provisions of this rule; and ty and care of residents shall be one (1) staff April 30, 2007. Amended: Filed March 13, (F) Smoke section—A fire-rated separation person for every fifteen (15) residents or 2008, effective Oct. 30, 2008. of one (1) section of the building from the major fraction of fifteen (15) during the day rest of the building. shift, one (1) person for every fifteen (15) *Original authority: 198.073, RSMo 1979, amended residents or major fraction of fifteen (15) 1984, 1992, 1999, 2006, 2007 and 198.076, RSMo 1979, (3) General Requirements. I/II during the evening shift, and one (1) person amended 1984, 2007. (A) If the facility admits or retains any for every twenty (20) residents or major frac- individual needing more than minimal assis- tion of twenty (20) during the night shift. I/II tance due to having a physical, cognitive or 19 CSR 30-86.047 Administrative, Person- nel, and Resident Care Requirements for other impairment that prevents the individual Time Personnel Residents Assisted Living Facilities from safely evacuating the facility, the facility 7 a.m. to 3 p.m. shall: (Day)* 1 3–15 PURPOSE: This rule establishes standards 1. Meet the fire safety requirements of 3 p.m. to 9 p.m. for all assisted living facilities licensed pur- 19 CSR 30-86.022(16); I/II (Evening)* 1 3–15 suant to sections 198.005 and 198.073, 2. Take necessary measures to provide 9 p.m. to 7 a.m. RSMo (CCS HCS SCS SB 616, 93rd General residents with the opportunity to explore the (Night)* 1 3–20 facility and, if appropriate, its grounds; II Assembly, Second Regular Session (2006)) 3. Use a personal electronic monitoring *If the shift hours vary from those indicated, and required to meet assisted living facility device for any resident whose physician rec- the hours of the shifts shall show on the work standards pursuant to section 198.073.3, ommends the use of such device; II schedules of the facility and shall not be less RSMo (CCS HCS SCS SB 616, 93rd General 4. Have sufficient staff present and than six (6) hours. III Assembly, Second Regular Session (2006)) awake twenty-four (24) hours a day to assist (B) The required staff shall be in the facil- and section 198.076, RSMo 2000. in the evacuation of all residents; I/II ity awake, dressed, and prepared to assist res- 5. Include an individualized evacuation idents in case of emergency. I/II PUBLISHER’S NOTE: The secretary of state plan in the resident’s individual service plan; (C) The administrator shall count toward has determined that the publication of the II staffing when physically present at the facili- entire text of the material which is incorpo- 6. At a minimum the evacuation plan ty. II rated by reference as a portion of this rule shall include the following components: (D) These staffing requirements are appli- would be unduly cumbersome or expensive. A. The responsibilities of specific This material as incorporated by reference in staff positions in an emergency specific to the cable only when the facility actually has in residence one (1) or more residents who this rule shall be maintained by the agency at individual; II its headquarters and shall be made available B. The fire protection interventions require more than minimal assistance in evacuating the facility. II to the public for inspection and copying at no needed to ensure the safety of the resident; more than the actual cost of reproduction. and II (E) At a minimum there shall be a licensed This note applies only to the reference mate- C. The plan shall evaluate the resident nurse employed by the facility to work at least rial. The entire text of the rule is printed for his or her location within the facility and the following hours per week: here. the proximity to exits and areas of refuge. 3–30 Residents—8 hours The plan shall evaluate the resident, as appli- 31–60 Residents—16 hours AGENCY NOTE: All rules relating to long- cable, for his or her risk of resistance, mobil- 61–90 Residents—24 hours term care facilities licensed by the depart- ity, the need for additional staff support, con- 91 or more Residents—40 hours. II ment are followed by a Roman Numeral nota- sciousness, response to instructions, response (F) The licensed nurse shall be available to tion which refers to the class (either Class I, to alarms, and fire drills; II assess residents for pain and significant and 7. The resident’s evacuation plan shall acute changes in condition. The nurse’s II, or III) of standard as designated in section be amended or revised based on the ongoing duties shall include, but shall not be limited 198.085.1., RSMo. assessment of the needs of the resident; II to, review of residents’ records, medications, 8. Those employees with specific and special diets or other orders, review of (1) Facilities licensed as assisted living facil- responsibilities shall be instructed and each resident’s adjustment to the facility, and ities shall be inspected pursuant to the stan- informed regarding their duties and responsi- observation of each individual resident’s gen- dards outlined herein beginning April 1, bilities under the resident’s evacuation plan at eral physical, psychosocial, and mental sta- 2007. An assisted living facility may request, least every six (6) months and upon any sig- tus. The nurse shall inform the administrator in writing to the department, to comply with nificant change in the plan; II of any problems noted and these shall be these standards prior to April 1, 2007. Upon 9. A copy of the resident’s evacuation brought to the attention of the resident’s receipt of the request, the department shall plan shall be readily available to all staff; and physician and legally authorized representa- conduct an inspection to determine compli- II tive or designee. II/III ance with the standards outlined herein prior

24 CODE OF STATE REGULATIONS (5/31/20) JOHN R. ASHCROFT Secretary of State Chapter 86—Residential Care Facilities and Assisted Living Facilities 19 CSR 30-86

to issuing a license indicating such compli- individuals describing an individual’s abili- 2. Minimal assistance may be the verbal ance. ties and needs in activities of daily living, intervention that staff must provide for a res- instrumental activities of daily living, ident to initiate evacuating the facility; (2) Consumer Education Requirements. The vision/hearing, nutrition, social participation 3. Minimal assistance may be the physi- facility shall disclose to a prospective resi- and support, and cognitive functioning using cal intervention that staff must provide, such dent, or legal representative of the resident, an assessment tool approved by the depart- as turning a resident in the correct direction, information regarding the services the facility ment, that is designed for community based for a resident to initiate evacuating the facili- is able to provide or coordinate, the cost of services and that is not the nursing home ty; such services to the resident, and the grounds minimum data set. The assessment tool may 4. A resident needing minimal assis- for discharge or transfer as permitted or be one developed by the department or one tance is one who is able to prepare to leave required by the Omnibus Nursing Home Act, used by a facility which has been approved by and then evacuate the facility within five (5) Chapter 198, RSMo and the department’s the department; minutes of being alerted of the need to evac- regulations, including the provisions set forth (F) Evacuating the facility—For the pur- uate and requires no more than one (1) phys- in section (29) of this rule. II pose of this rule, evacuating the facility shall ical intervention and no more than three (3) mean moving to an area of refuge or from one verbal interventions of staff to complete evac- (3) Nothing in this rule shall be construed to smoke section to another or exiting the facil- uation from the facility; allow any facility that has not met the require- ity; 5. The following actions required of ments of 198.073(4) and (6), RSMo, (CCS (G) Home-like—Means a self-contained staff are considered to be more than minimal HCS SCS SB 616, 93rd General Assembly, long-term care setting that integrates the psy- assistance: Second Regular Session (2006)) and 19 CSR chosocial, organizational and environmental A. Assistance to traverse down stair- 30-86.045 to care for any individual with a qualities that are associated with being at ways; physical, cognitive or other impairment that home. Home-like may include, but is not B. Assistance to open a door; and prevents the individual from safely evacuating limited to the following: C. Assistance to propel a wheelchair; the facility with minimal assistance. I/II 1. A living room and common use areas (K) Physical restraint—any manual method for social interactions and activities; or physical or mechanical device, material, (4) Definitions. For the purpose of this rule, 2. Kitchen and family style eating area or equipment attached to or adjacent to the the following definitions shall apply: for use by the residents; resident’s body that the individual cannot (A) Appropriately trained and qualified 3. Laundry area for use by residents; remove easily which restricts freedom of individual means an individual who is 4. A toilet room that contains a toilet, movement or normal access to one’s body. licensed or registered with the state of Mis- lavatory and bathing unit in each resident’s Physical restraints include, but are not limited souri in a health care related field or an indi- room; to, leg restraints, arm restraints, hand mitts, vidual with a degree in a health care related 5. Resident room preferences for resi- soft ties or vests, lap cushions, and lap trays field or an individual with a degree in a dents who wish to share a room, and for res- the resident cannot remove easily. Physical health care, social services, or human ser- idents who wish to have private bedrooms; restraints also include facility practices that vices field or an individual licensed under 6. Outdoor area for outdoor activities meet the definition of a restraint, such as the Chapter 344, RSMo, and who has received and recreation; and following: facility orientation training under 19 CSR 30- 7. A place where residents can give and 1. Using side rails that keep a resident 86.042(18), and dementia training under sec- receive affection, explore their interests, from voluntarily getting out of bed; tion 660.050, RSMo, and twenty-four (24) exercise control over their environment, 2. Tucking in or using Velcro to hold a hours of additional training, approved by the engage in interactions with others and have sheet, fabric, or clothing tightly so that a res- department, consisting of definition and privacy, security, familiarity and a sense of ident’s movement is restricted; assessment of activities of daily living, belonging; 3. Using devices in conjunction with a assessment of cognitive ability, service plan- (H) Individualized service plan (ISP)— chair, such as trays, tables, bars, or belts, that ning, and interview skills; Shall mean the planning document prepared the resident cannot remove easily, that pre- (B) Area of refuge—A space located in or by an assisted living facility, which outlines a vent the resident from rising; immediately adjacent to a path of travel lead- resident’s needs and preferences, services to 4. Placing the resident in a chair that ing to an exit that is protected from the be provided, and the goals expected by the prevents a resident from rising; and effects of fire, either by means of separation resident or the resident’s legal representative 5. Placing a chair or bed so close to a from other spaces in the same building or its in partnership with the facility; wall that the wall prevents the resident from location, permitting a delay in evacuation. (I) Keeping residents in place—Means rising out of the chair or voluntarily getting An area of refuge may be temporarily used as maintaining residents in place during a fire in out of bed; a staging area that provides relative safety to lieu of evacuation where a building’s occu- (L) Significant change—means any change its occupants while potential emergencies are pants are not capable of evacuation, where in the resident’s physical, emotional or psy- assessed, decisions are made, and evacuation evacuation has a low likelihood of success, or chosocial condition or behavior that will not is begun; where it is recommended in writing by local normally resolve itself without further inter- (C) Assisted living facility (ALF)—Is as fire officials as having a better likelihood of vention by staff or by implementing standard defined in 19 CSR 30-83.010; success and/or a lower risk of injury; disease-related clinical interventions, that has (D) Chemical restraint—Is as defined in 19 (J) Minimal assistance— an impact on more than one (1) area of the CSR 30-83.010; 1. Is the criterion which determines resident’s health status, and requires interdis- (E) Community based assessment—Docu- whether or not staff must develop and include ciplinary review or revision of the individual- mented basic information and analysis pro- an individualized evacuation plan as part of ized service plan, or both; vided by appropriately trained and qualified the resident’s service plan; (M) Skilled nursing facility—Means any

JOHN R. ASHCROFT (5/31/20) CODE OF STATE REGULATIONS 25 Secretary of State 19 CSR 30-86—DEPARTMENT OF HEALTH AND SENIOR SERVICES Division 30—Division of Regulation and Licensure

premises, other than a residential care facili- trator of more than one (1) licensed facility if such as scout groups, bingo leaders, or sing- ty, assisted living facility or an intermediate all facilities are on the same premises. II along leaders. The facility is not required to care facility, which is utilized by its owner, check the EDL for an individual such as a operator or manager to provide for twenty- (8) The administrator shall designate, in writ- priest, minister, or rabbi visiting a resident four (24) hour accommodation, board and ing, a staff member in charge in the adminis- who is a member of the individual’s congre- skilled nursing care and treatment services to trator’s absence. If the administrator is absent gation. However, if a minister, priest, or at least three (3) residents who are not related for more than thirty (30) consecutive days, rabbi serves as a volunteer facility chaplain, within the fourth degree of consanguinity or during which time he or she is not readily the facility is required to check the EDL affinity to the owner, operator or manager of accessible for consultation by telephone with since the individual would have potential con- the facility. Skilled nursing care and treat- the delegated individual, the individual desig- tact with all residents. I/II ment services are those services commonly nated to be in charge shall be an administrator performed by or under the supervision of a currently licensed by the Missouri Board of (13) Prior to allowing any person who has registered professional nurse for individuals Nursing Home Administrators, in accordance been hired in a full-time, part-time, or tem- requiring twenty-four (24)-hours-a-day care with Chapter 344, RSMo. Such thirty- (30-) porary position to have contact with any res- by licensed nursing personnel including acts consecutive day absences may only occur ident, the facility shall, or in the case of tem- of observation, care and counsel of the aged, once within any consecutive twelve- (12-) porary employees hired through or contracted ill, injured or infirm, the administration of month period. II/III from an employment agency, the employment medications and treatments as prescribed by a agency shall, prior to sending a temporary licensed physician or dentist, and other nurs- (9) The facility shall not care for more resi- employee to a facility: ing functions requiring substantial specialized dents than the number for which the facility (A) Request a criminal background check judgment and skill; is licensed. However, if the facility operates a for the person, as provided in section 660.317, RSMo. Each facility shall maintain (N) Skilled nursing placement—Means non-licensed adult day care program for four (4) or fewer participants within the licensed documents verifying that the background placement in a skilled nursing facility as facility, the day care participants shall not be checks were requested, the date of each such defined in subsection (4)(M) of this rule; and included in the total facility census. Adult request, and the nature of the response (O) Social model of care—Means long- day care participants shall be counted in received for each such request. II term care services based on the abilities, staffing determination during the hours the 1. The facility shall ensure that any per- desires, and functional needs of the individu- day care participants are in the facility. II/III son hired or retained to have contact with any al delivered in a setting that is more home- resident who discloses that he or she has been like than institutional, that promote the digni- (10) The facility shall not admit or continue convicted of, found guilty of, pled guilty to, ty, individuality, privacy, independence and to care for residents whose needs cannot be or pled nolo contendere to a crime, in this autonomy of the individual, that respects res- met. If necessary services cannot be obtained state or any other state, which if committed in idents’ differences and promotes residents’ in or by the facility, the resident shall be Missouri would be a class A or B felony vio- choices. promptly referred to appropriate outside lation of Chapter 565, 566, or 569, RSMo, or resources or discharged from the facility. I/II any violation of section 198.070.3., RSMo, or (5) The operator shall designate an individual section 568.020, RSMo, shall not be retained for administrator who is currently licensed as (11) All personnel responsible for resident in such a position. I/II an administrator by the Missouri Board of care shall have access to the legal name of 2. Upon receipt of the criminal back- Nursing Home Administrators, in accordance each resident, name and telephone number of ground check, the facility shall ensure that if with Chapter 344, RSMo. II resident’s physician, resident’s designee or the criminal background check indicates that legally authorized representative in the event the person hired or retained by the facility has (6) The operator shall be responsible to of emergency. II/III been convicted of, found guilty of, pled assure compliance with all applicable laws guilty to, or pled nolo contendere to a crime, and regulations. The administrator shall be (12) All persons who have any contact with in this state or any other state, which if com- fully authorized and empowered to make the residents in the facility shall not knowing- mitted in Missouri would be a class A or B decisions regarding the operation of the facil- ly act or omit any duty in a manner that felony violation of Chapter 565, 566, or 569, ity and shall be held responsible for the would materially and adversely affect the RSMo, or any violation of section actions of all employees. The administrator’s health, safety, welfare, or property of resi- 198.070.3., RSMo, or section 568.020, responsibilities shall include oversight of res- dents. No person who is listed on the RSMo, the person shall not have contact with idents to assure that they receive care as Employee Disqualification List (EDL) main- any resident unless and until the facility defined in the individualized service plan. tained by the department as required by sec- obtains verification from the department that II/III tion 198.070, RSMo, shall work or volunteer a good cause waiver has been granted for in the facility in any capacity whether or not each qualifying offense and maintains a copy (7) The administrator cannot be listed or func- employed by the operator. For the purpose of of the verification in the individual’s person- tion in more than one (1) licensed facility at this rule, a volunteer is an unpaid individual nel file; I/II the same time unless he or she serves no more formally recognized by the facility as provid- (B) Make an inquiry to the department, as than five (5) facilities within a thirty (30)-mile ing a direct care service to residents. The provided in section 660.315, RSMo, as to radius and licensed to serve in total no more facility is required to check the EDL for indi- whether the person is listed on the EDL. than one hundred (100) residents, and the viduals who volunteer to perform a service Each facility shall maintain documents veri- administrator has an individual designated as for which the facility might otherwise have to fying that the EDL checks were requested, the daily manager of each facility. However, hire an employee. The facility is not required the date of each such request, and the nature the administrator may serve as the adminis- to check the EDL for individuals or groups of the response received for each such

26 CODE OF STATE REGULATIONS (5/31/20) JOHN R. ASHCROFT Secretary of State Chapter 86—Residential Care Facilities and Assisted Living Facilities 19 CSR 30-86

request. The inquiry may be made through contact with a patient or resident, who has department, if applicable; the department’s website; II/III been convicted of, plead guilty or nolo con- (H) Position in the facility; (C) If the person has registered with the tendere to, in this state or any other state, or (I) Written statement signed by a licensed department’s Family Care Safety Registry has been found guilty of any Class A or B physician or physician’s designee indicating (FCSR), the facility may utilize the FCSR in felony violation of Chapter 565, 566 or 569, the person can work in a long-term care facil- order to meet the requirements of subsections RSMo, or any violation of subsection 3 of ity and indicating any limitations; (13)(A) and (13)(B) of this rule. The FCSR is section 198.070, RSMo, or of section (J) Documentation of the employee’s tuber- available through the department’s website; 568.020, RSMo. II/III culin screening status; and (K) Documentation of what the employee (D) For persons for whom the facility has (16) All persons who have or may have con- was instructed on during orientation training; contracted for professional services (e.g., tact with residents shall at all times when on and plumbing or air conditioning repair) that will duty or delivering services wear an identifi- (L) Reason for termination if the employee have contact with any resident, the facility cation badge. The badge shall give their was terminated due to abuse or neglect of a shall either require a criminal background name, title and, if applicable, the status of resident, residents’ rights issues or resident their license or certification as any kind of check or ensure that the individual is suffi- injury. III ciently monitored by facility staff while in the health care professional. This rule shall apply to all personnel who provide services to any facility to reasonably ensure the safety of all (21) Personnel records shall be maintained resident directly or indirectly. III residents. I/II for at least two (2) years following termination of employment. III (14) A facility shall not employ, as an agent (17) Personnel who have been diagnosed with a communicable disease may begin work or or employee who has access to controlled (22) There shall be written documentation substances, any person who has been found return to duty only with written approval by a physician or physician’s designee, which maintained in the facility showing actual guilty or entered a plea of guilty or nolo con- hours worked by each employee. III tendere in a criminal prosecution under the indicates any limitations. II laws of any state or of the United States for (23) No one individual shall be on duty with any offense related to controlled substances. (18) The administrator shall be responsible to prevent an employee known to be diagnosed responsibility for oversight of residents longer II than eighteen (18) hours per day. I/II (A) A facility may apply in writing to the with communicable disease from exposing department for a waiver of this section of this residents to such disease. The facility’s policies and procedures must comply with the (24) Employees who are counted in meeting rule for a specific employee. the minimum staffing ratio and employees (B) The department may issue a written department’s regulations pertaining to com- who provide direct care to the residents shall waiver to a facility upon determination that a municable diseases, specifically 19 CSR 20- be at least sixteen (16) years of age. One waiver would be consistent with the public 20.010 through 19 CSR 20-20.100. II /III employee at least eighteen (18) years of age health and safety. In making this determina- (19) The facility shall screen residents and shall be on duty at all times. II tion, the department shall consider the duties staff for tuberculosis as required for long- of the employee, the circumstances surround- term care facilities by 19 CSR 20-20.100. II (25) Each facility resident shall be under the ing the conviction, the length of time since medical supervision of a physician licensed to the conviction was entered, whether a waiver (20) The administrator shall maintain on the practice in Missouri who has been informed has been granted by the department’s Bureau premises an individual personnel record on of the facility’s emergency medical proce- of Narcotics and Dangerous Drugs pursuant each facility employee, which shall include dures and is kept informed of treatments or to 19 CSR 30-1.034 when the facility is reg- the following: medications prescribed by any other profes- istered with that agency, whether a waiver has (A) The employee’s name and address; sional lawfully authorized to prescribe medi- been granted by the federal Drug Enforce- (B) Social Security number; cations. III ment Administration (DEA) pursuant to 21 (C) Date of birth; CFR 1301.76 when the facility is also regis- (D) Date of employment; (26) The facility shall ensure that each resi- tered with that agency, the security measures (E) Documentation of experience and edu- dent being admitted or readmitted to the facil- taken by the facility to prevent the theft and cation including for positions requiring licen- diversion of controlled substances, and any sure or certification, documentation evidenc- ity receives an admission physical examina- other factors consistent with public health ing competency for the position held, which tion by a licensed physician. The facility shall and safety. II includes copies of current licenses, tran- request documentation of the physical exami- scripts when applicable, or for those individ- nation prior to admission but must have doc- (15) The facility must develop and implement uals requiring certification, such as certified umentation of the physical examination on written policies and procedures which require medication technicians, level I medication file no later than ten (10) days after admis- that persons hired for any position which is to aides and insulin administration aides; print- sion. The physical examination shall contain have contact with any patient or resident have ing the Web Registry search results page documentation regarding the individual’s cur- been informed of their responsibility to dis- available at www.dhss.mo.gov/cnaregistry rent medical status and any special orders or close their prior criminal history to the facil- shall meet the requirements of the employer’s procedures to be followed. If the resident is ity as required by section 660.317.5, RSMo. check regarding valid certification; admitted directly from an acute care or The facility must also develop and implement (F) References, if available; another long-term care facility and is accom- policies and procedures which ensure that the (G) The results of background checks panied on admission by a report that reflects facility does not knowingly hire, after August required by section 660.317, RSMo; and a his or her current medical status, an admis- 28, 1997, any person who has or may have copy of any good cause waiver granted by the sion physical shall not be required. III

JOHN R. ASHCROFT (5/31/20) CODE OF STATE REGULATIONS 27 Secretary of State 19 CSR 30-86—DEPARTMENT OF HEALTH AND SENIOR SERVICES Division 30—Division of Regulation and Licensure

(27) Residents under sixteen (16) years of age www.dhss.mo.gov or by telephone at (573) agree that such program of care is appropriate shall not be admitted. III 526-8548. This rule does not incorporate any for the resident. II subsequent amendments or additions; or II (28) The facility may admit or retain an indi- 3. The facility may use another assess- (31) Programs and Services Requirements for vidual for residency in an assisted living facil- ment form if approved in advance by the Residents. ity only if the individual does not require hos- department; II (A) The facility shall designate a staff pitalization or skilled nursing placement as (G) Develops an individualized service member to be responsible for leisure activity defined in this rule, and only if the facility: plan (ISP), which means the planning docu- coordination and for promoting the social (A) Provides for or coordinates oversight ment prepared by an assisted living facility model, multiple staff role directing all staff to and services to meet the needs, the social and which outlines a resident’s needs and prefer- provide routine care in a manner that empha- recreational preferences in accordance with ences, services to be provided, and goals sizes the opportunity for the resident and the the individualized service plan of the resident expected by the resident or the resident’s staff member to enjoy a visit rather than sim- as documented in a written contract signed by legal representative in partnership with the ply perform a procedure. II/III the resident, or legal representative of the facility; II (B) The facility shall make available and resident; II (H) Reviews the ISP with the resident, or implement self-care, productive and leisure (B) Has twenty-four (24) hour staff appro- legal representative of the resident, at least activity programs which maximize and priate in numbers and with appropriate skills annually or when there is a significant change encourage the resident’s optimal functional to provide such services; II in the resident’s condition which may require ability for residents. The facility shall pro- (C) Has a written plan for the protection of a change in services; II vide person-centered activities appropriate to all residents in the event of a disaster such as (I) Includes the signatures of an authorized the resident’s individual needs, preferences, tornado, fire, bomb threat or severe weather, representative of the facility and the resident background and culture. Individual or group including: or the resident’s legal representative in the activity programs may consist of the follow- 1. Keeping residents in place; individualized service plan to acknowledge ing: 2. Evacuating residents to areas of that the service plan has been reviewed and 1. Gross motor activities, such as exer- refuge; understood by the resident or legal represen- cise, dancing, gardening, cooking and other 3. Evacuating residents from the build- tative; II routine tasks; ing if necessary; or (J) Develops and implements a plan to pro- 2. Self-care activities, such as dressing, 4. Other methods of protection based on tect the rights, privacy, and safety of all resi- grooming and personal hygiene; the disaster and the individual building dents and to protect against the financial 3. Social and leisure activities, such as design; I/II exploitation of all residents; and II games, music and reminiscing; (D) Completes a premove-in screening 4. Sensory enhancement activities, such conducted as required by section 198.073.4 (K) Complies with the dementia specific as auditory, olfactory, visual and tactile stim- (4), RSMo (CCS HCS SCS SB 616, 93rd training requirements of subsection 8 of sec- ulation; General Assembly, Second Regular Session tion 660.050, RSMo. II 5. Outdoor activities, such as walking (2006)). II (E) The premove-in screening shall be (29) The facility shall not admit or continue and field trips; completed prior to admission with the partic- to care for a resident who: 6. Creative arts; or ipation of the prospective resident and be (A) Has exhibited behaviors that present a 7. Other social, leisure or therapeutic designed to determine if the individual is eli- reasonable likelihood of serious harm to him- activities that encourage mental and physical gible for admission to the assisted living self or herself or others; I/II stimulation or enhance the resident’s well- facility and shall be based on the admission (B) Requires physical restraint as defined being. II/III restrictions listed at section (29) of this rule; in this rule; II (C) Staff shall inform residents in advance II (C) Requires chemical restraint as defined of any organized group activity including the (F) Completes a community based assess- in this rule; II time and place of the activity. II/III ment conducted by an appropriately trained (D) Requires skilled nursing services as and qualified individual as defined in section defined in section 198.073.4, RSMo for (32) Requirements for Facilities Providing (4) of this rule: which the facility is not licensed or able to Care to Residents Having Mental Illness or 1. Time frame requirements for assess- provide; II Mental Retardation diagnosis. ment shall be: (E) Requires more than one (1) person to (A) Each resident who exhibits mental and A. Within five (5) calendar days of simultaneously physically assist the resident psychosocial adjustment difficulty(ies) shall admission; II with any activity of daily living, with the receive treatment and services to address the B. At least semiannually; and II exception of bathing and transferring; or resident’s needs and behaviors as stated in the C. Whenever a significant change has II/III individualized service plan. I/II occurred in the resident’s condition, which (F) Is bed-bound or similarly immobilized (B) If specialized rehabilitative services for may require a change in services. II due to a debilitating or chronic condition. II mental illness or mental retardation are 2. The facility shall use form MO 580- required to enable a resident to reach and to 2835, Assessment for Admission To Assisted (30) The requirements of subsections comply with the individualized service plan, Living Facilities, (9-06), incorporated by ref- (29)(D), (E) and (F) shall not apply to a res- the facility shall ensure the required services erence, provided by the Department of Health ident receiving hospice care, provided the are provided. II and Senior Services, PO Box 570, Jefferson resident, his or her legally authorized repre- (C) The facility shall maintain in the resi- City, MO 65102-0570 and which is available sentative or designee, or both, and the facili- dent’s record the most recent progress notes to long-term care facilities at ty, physician and licensed hospice provider all and personal plan developed and provided by

28 CODE OF STATE REGULATIONS (5/31/20) JOHN R. ASHCROFT Secretary of State Chapter 86—Residential Care Facilities and Assisted Living Facilities 19 CSR 30-86

the Department of Mental Health or designat- sonable likelihood of serious harm to himself (42) All prescription medications shall be ed administrative agent for each resident or herself or others, serious illness, signifi- supplied as individual prescriptions except whose care is funded by the Department of cant change in condition, injury or death, where an emergency medication supply is Mental Health or designated administrative staff shall take appropriate action and shall allowed. All medications, including over-the- agent. III promptly attempt to contact the person listed counter medications, shall be packaged and in the resident’s record as the legally autho- labeled in accordance with applicable profes- (33) No facility shall accept any individual rized representative, designee or placement sional pharmacy standards, and state and fed- authority. The facility shall contact the with a physical, cognitive, or other impair- eral drug laws. Labeling shall include acces- attending physician or designee and notify the ment that prevents the individual from safely sory and cautionary instructions as well as evacuating the facility with minimal assis- local coroner or medical examiner immedi- the expiration date, when applicable, and the tance unless the facility meets all require- ately upon the death of any resident of the name of the medication as specified in the ments of section 198.073, RSMo (CCS HCS facility prior to transferring the deceased res- physician’s order. Medication labels shall not SCS SB 616, 93rd General Assembly, Sec- ident to a funeral home. I/II ond Regular Session (2006)) and those stan- be altered by facility staff and medications dards set forth in 19 CSR 30-86.045. I/II (38) The facility shall encourage and assist shall not be repackaged by facility staff except each resident based on his or her individual as allowed by section (43) of this rule. Over- (34) The facility shall follow appropriate preferences and needs to be clean and free of the-counter medications for individual resi- infection control procedures. The administra- body and mouth odor. II dents shall be labeled with at least the resi- tor or his or her designee shall make a report dent’s name. II/III to the local health authority or the department (39) If the resident brings unsealed medica- of the presence or suspected presence of any tions to the facility, the medications shall not (43) Controlled substances and other pre- diseases or findings listed in 19 CSR 20- be used unless a pharmacist, physician or scription and non-prescription medications 20.020, sections (1)–(3) according to the nurse examines, identifies and determines the for administration when a resident temporar- specified time frames as follows: contents to be suitable for use. The person ily leaves a facility shall be provided as fol- (A) Category I diseases or findings shall be performing the identification shall document lows: his or her review. II/III reported to the local health authority or to the (A) Separate containers of medications for department within twenty-four (24) hours of the leave period may be prepared by the phar- first knowledge or suspicion by telephone, (40) Self-control of prescription medication by a resident may be allowed only if approved macy. The facility shall have a policy and pro- facsimile, or other rapid communication; cedure for families to provide adequate (B) Category II diseases or findings shall in writing by the resident’s physician and included in the resident’s individualized ser- advance notice so that medications can be be reported to the local health authority or vice plan. A resident may be permitted to obtained from the pharmacy. the department within three (3) days of first control the storage and use of nonprescription (B) Prescription medication cards or other knowledge or suspicion; medication unless there is a physician’s writ- multiple-dose prescription containers current- (C) Category III—The occurrence of an ten order or facility policy to the contrary. ly in use in the facility may be provided by outbreak or epidemic of any illness, disease Written approval for self-control of prescrip- or condition which may be of public health any authorized facility medication staff mem- tion medication shall be rewritten as needed concern, including any illness in a food han- ber if the containers are labeled by the phar- but at least annually and after any period of dler that is potentially transmissible through macy with complete pharmacy prescription hospitalization. II/III food. This also includes public health threats labeling for use. Original manufacturer containers of non-prescription medications, such as clusters of unusual diseases or mani- (41) All medication shall be safely stored at along with instructions for administration, festations of illness and clusters of unex- proper temperature and shall be kept in a plained deaths. Such incidents shall be secured location behind at least one (1) may be provided by any authorized facility reported to the local authority or to the locked door or cabinet. Medication shall be medication staff member. department by telephone, facsimile, or other accessible only to persons authorized to (C) When medications are supplied by the rapid communication within twenty-four (24) administer medications. II/III pharmacy in customized patient medication hours of first knowledge or suspicion. I/II (A) If access is controlled by the resident, packages that allow separation of individual a secured location shall mean in a locked dose containers, the required number of con- (35) Protective oversight shall be provided container, a locked drawer in a bedside table tainers may be provided by any authorized twenty-four (24) hours a day. For residents or dresser or in a resident’s private room if facility medication staff member. The indi- departing the premises on voluntary leave, locked in his or her absence, although this vidual dose containers shall be placed in an the facility shall have, at a minimum, a pro- does not preclude access by a responsible outer container that is labeled with the name cedure to inquire of the resident or resident’s employee of the facility. and address of the facility and the date. guardian of the resident’s departure, of the (B) Schedule II controlled substances shall (D) When multiple doses of a medication resident’s estimated length of absence from be stored in locked compartments separate are required and it is not reasonably possible the facility, and of the resident’s whereabouts from non-controlled medications, except that while on voluntary leave. I/II single doses of Schedule II controlled sub- to obtain prescription medication labeled by stances may be controlled by a resident in the pharmacy, and it is not appropriate to (36) Residents shall receive proper care as compliance with the requirements for self- send a container of medication currently in defined in the individualized service plan. control of medication of this rule. use in the facility, up to a twenty-four (24)- I/II (C) Medication that is not in current use hour supply of each prescription or non-pre- and is not destroyed shall be stored separately scription medication may be provided by a (37) In case of behaviors that present a rea- from medication that is in current use. II/III licensed nurse in United States Pharmacopeia

JOHN R. ASHCROFT (5/31/20) CODE OF STATE REGULATIONS 29 Secretary of State 19 CSR 30-86—DEPARTMENT OF HEALTH AND SENIOR SERVICES Division 30—Division of Regulation and Licensure

(USP) approved containers labeled with the personnel at least eighteen (18) years of age, licensed nurse’s or pharmacist’s signature facility name and address, resident’s name, in accordance with physicians’ instructions within seven (7) days. III medication name and strength, quantity, using acceptable nursing techniques. The (E) The facility shall submit to the physi- instructions for use, date, initials of individu- facility shall employ a licensed nurse eight (8) cian written versions of any oral or telephone al providing, and other appropriate informa- hours per week for every thirty (30) residents orders within four (4) days of the giving of tion. to monitor each resident’s condition and med- the oral or telephone order. III (E) When no more than a single dose of a ication. Administration of medication shall (F) Influenza and pneumococcal polysac- medication is required, any authorized facili- mean delivering to a resident his or her pre- charide immunizations may be administered ty medication staff member may prepare the scription medication either in the original per physician-approved facility policy after dose as for in-facility administration in a USP pharmacy container, or for internal medica- assessment for contraindications— approved container labeled with the facility tion, removing an individual dose from the 1. The facility shall develop a policy that name and address, resident’s name, medica- pharmacy container and placing it in a small provides recommendations and assessment tion name and strength, quantity, instructions cup container or liquid medium for the resi- parameters for the administration of such for use, date, initials of person providing, and dent to remove from the container and self- immunizations. The policy shall be approved other appropriate information. administer. External prescription medication by the facility medical director for facilities (F) The facility may have a policy that lim- may be applied by facility personnel if the having a medical director, or by each resi- its the quantity of medication sent with a res- resident is unable to do so and the resident’s dent’s attending physician for facilities that ident without prior approval of the prescriber. physician so authorizes. All individuals who do not have a medical director, and shall (G) Returned containers shall be identified administer medication shall be trained in include the requirements to: as having been sent with the resident, and medication administration and, if not a physi- A. Provide education to each resident shall not later be returned to the pharmacy for cian or a licensed nurse, shall be a certified or the resident’s designee or legally autho- reuse. medication technician or level I medication rized representative regarding the potential (H) The facility shall maintain accurate aide. I/II benefits and side effects of the immunization; records of medications provided to and II/III returned by the resident. II/III (47) Medication Orders. B. Offer the immunization to the res- (A) No medication, treatment or diet shall ident or obtain permission from the resident’s (44) Upon discharge or transfer of a resident, be administered without an order from an designee or legally authorized representative the facility shall release prescription medica- individual lawfully authorized to prescribe when the immunization is medically indicat- tions, including controlled substances, held such and the order shall be followed. II/III ed unless the resident has already been by the facility for the resident when the physi- (B) Physician’s written and signed orders immunized as recommended by the policy; cian writes an order for each medication to be shall include: name of medication, dosage, II/III released. Medications shall be labeled by the frequency and route of administration and the C. Provide the opportunity to refuse pharmacy with current instructions for use. orders shall be renewed at least every three the immunization; and II/III Prescription medication cards or other con- (3) months. Computer generated signatures D. Perform an assessment for containers may be released if the containers are may be used if safeguards are in place to pre- traindications; II/III labeled by the pharmacy with complete phar- vent their misuse. Computer identification 2. The assessment for contraindications macy prescription labeling. II/III codes shall be accessible to and used by only and documentation of the education and the individuals whose signatures they repre- opportunity to refuse the immunization shall (45) Injections shall be administered only by sent. Orders that include optional doses or be dated and signed by the nurse performing a physician or licensed nurse, except that include pro re nata (prn) administration fre- the assessment and placed in the medical insulin injections may also be administered quencies shall specify a maximum frequency record; or by a certified medication technician or level I and the reason for administration. II/III 3. The facility shall with the approval of medication aide who has successfully com- (C) Telephone and other verbal orders each resident’s physician, access screening pleted the state-approved course for insulin shall be received only by a licensed nurse, and immunization through outside sources administration, taught by a department- certified medication technician, level I medi- such as county or city health departments. approved instructor. Anyone trained prior to cation aide or pharmacist, and shall be imme- II/III December 31, 1990, who completed the diately reduced to writing and signed by that (G) The administration of medication shall state-approved insulin administration course individual. A certified medication technician be recorded on a medication sheet or directly taught by an approved instructor shall be con- or level I medication aide may receive a tele- in the resident’s record and, if recorded on a sidered qualified to administer insulin in an phone or other verbal order only for a medi- medication sheet, shall be made part of the assisted living facility. A resident who cation or treatment that the technician or level resident’s record. The administration shall be requires insulin, may administer his or her I medication aide is authorized to administer. recorded by the same individual who pre- own insulin if approved in writing by the res- If a telephone or other verbal order is given pares the medication and administers it. ident’s physician and trained to do so by a to a medication technician or level I medica- II/III licensed nurse or physician. The facility shall tion aide, an initial dosage shall not be monitor the resident’s condition and ability to administered until the order has been (48) The facility may keep an emergency continue self-administration. I/II reviewed by telephone, facsimile or in person medication supply if approved by a pharma- by a licensed nurse or pharmacist. The cist or physician. Storage and use of medica- (46) The administrator shall develop and review shall be documented by the reviewer tions in the emergency medication supply implement a safe and effective system of med- co-signing the telephone or other verbal shall assure accountability. When the emer- ication control and use, which assures that all order. II gency medication supply contains controlled residents’ medications are administered by (D) The review shall be documented by the substances, the facility shall be registered

30 CODE OF STATE REGULATIONS (5/31/20) JOHN R. ASHCROFT Secretary of State Chapter 86—Residential Care Facilities and Assisted Living Facilities 19 CSR 30-86

with the Bureau of Narcotics and Dangerous 2. Two (2) medication personnel, who 2. The specific controlled substance Drugs (BNDD) and shall be in compliance are certified medication technicians or level I lost; with 19 CSR 30-1.052 and other applicable medication aides, when a licensed nurse is 3. Whether the loss can be associated state and federal controlled substance laws not available. II with access by specific individuals; and regulations. II/III (C) Receipt records shall include the date, 4. Whether there is a pattern of losses, source of supply, resident name and prescrip- and if the losses appear to be random or not; (49) Automated dispensing systems may be tion number when applicable, medication 5. Whether the controlled substance is a controlled by the facility or may be controlled name and strength, quantity and signature of likely candidate for diversion; and on-site or remotely by a pharmacy. the supplier and receiver. Administration 6. Local trends and other indicators of (A) Automated dispensing systems may be records shall include the date, time, resident diversion potential; used for an emergency medication supply. name, medication name, dose administered (B) If an insignificant amount of such con- (B) Automated dispensing systems that are and the initials of the individual administer- trolled substance is lost during lawful activi- controlled by a pharmacy may be used for ing. The signature and initials of each medi- ties, which includes but are not limited to continuing doses of controlled substance and cation staff documenting on the medication receiving, record keeping, access auditing, non-controlled substance medications. When administration record must be signed in the administration, destruction and returning to continuing doses are administered from an signature area of the medication record. II the pharmacy, a description of the occurrence automated dispensing system that is con- (D) When self-control of medication is shall be documented in writing and main- trolled by a pharmacy, a pharmacist shall approved a record shall be made of all contained with the facility’s controlled substance review and approve each new medication trolled substances transferred to and adminis- records. The documentation shall include the order prior to releasing the medication from tered from the resident’s room. Inventory reason for determining that the loss was the system. The pharmacy and the facility reconciliation shall include controlled sub- insignificant; and may have a policy and procedure to allow the stances transferred to the resident’s room. II (C) When the facility is registered with the release of initial doses of approved medica- BNDD, the facility shall report to or docu- tions when a pharmacist is not available in (52) Documentation of waste of controlled ment for the BNDD any loss of any stock lieu of a separate emergency medication sup- substances at the time of administration shall supply controlled substance in compliance ply. When initial doses are used when a include the reason for the waste and the sig- with 19 CSR 30-1.034. II/III pharmacist is not available, a pharmacist shall nature of another facility medication staff review and approve the order within twenty- member who witnesses the waste. If a sec- (54) A physician, pharmacist or registered four (24) hours of administration of the first ond medication staff member is not available nurse shall review the medication regimen of dose. at the time of administration, the controlled each resident. This shall be done at least (C) Automated dispensing systems shall be substance shall be properly labeled, clearly every other month. The review shall be per- used in compliance with state and federal identified as unusable, stored in a locked formed in the facility and shall include, but laws and regulations. When an automated area, and destroyed as soon as a medication shall not be limited to, indication for use, dispensing system controlled by the facility staff member is available to witness the dose, possible medication interactions and medication/food interactions, contraindica- contains controlled substances for an emer- waste. When a second medication staff mem- tions, adverse reactions and a review of the gency medication supply, the facility shall be ber is not available and the controlled sub- medication system utilized by the facility. stance is contaminated by patient body fluids, registered with the BNDD. When an auto- Irregularities and concerns shall be reported mated dispensing system is controlled by a the controlled substance shall be destroyed in writing to the resident’s physician and to pharmacy, the facility shall use it in compli- immediately and the circumstances docu- the administrator/manager. If after thirty (30) ance with 20 CSR 2220-2.900. II/III mented. II/III days, there is no action taken by a resident’s physician and significant concerns continue (50) Stock supplies of nonprescription medi- (53) At least every other month, a pharmacist regarding a resident’s or residents’ medica- cation may be kept when specific medications or registered nurse shall review the controlled tion order(s), the administrator shall contact are approved in writing by a consulting physi- substance record keeping including reconcil- or recontact the physician to determine if he cian, a registered nurse or a pharmacist. II/III ing the inventories of controlled substances. or she received the information and if there This shall be done at the time of the drug reg- are any new instructions. II/III (51) Records shall be maintained upon receipt imen review of each resident. All discrepan- and disposition of all controlled substances cies in controlled substance records shall be (55) All medication errors and adverse reac- and shall be maintained separately from other reported to the administrator for review and tions shall be promptly documented and records, for two (2) years. investigation. The theft or loss of controlled reported to the administrator and the resi- (A) Inventories of controlled substances substances shall be reported as follows: dent’s physician. If the pharmacy made a dis- shall be reconciled as follows: (A) The facility shall notify the depart- pensing error, it shall also be reported to the 1. Controlled Substance Schedule II ment’s Section for Long Term Care (SLTC) issuing pharmacy. II/III medications shall be reconciled each shift; and other appropriate authorities of any theft and II or significant loss of any controlled substance (56) Medications that are not in current use 2. Controlled Substance Schedule III–V medication written as an individual prescrip- shall be disposed of as follows: medications shall be reconciled at least week- tion for a specific resident upon the discovery (A) Single doses of contaminated, refused, ly and as needed to ensure accountability. II of the theft or loss. The facility shall consider or otherwise unusable non-controlled sub- (B) Inventories of controlled substances at least the following factors in determining if stance medications may be destroyed by any shall be reconciled by the following: a loss is significant: authorized medication staff member at the 1. Two (2) medication personnel, one of 1. The actual quantity lost in relation to time of administration. Single doses of unus- whom is a licensed nurse; or the total quantity; able controlled substance medications may be

JOHN R. ASHCROFT (5/31/20) CODE OF STATE REGULATIONS 31 Secretary of State 19 CSR 30-86—DEPARTMENT OF HEALTH AND SENIOR SERVICES Division 30—Division of Regulation and Licensure

destroyed according to section (52) of this (A) Admission information including the Time Personnel Residents rule; resident’s name; admission date; confiden- 7 a.m. to 3 p.m. (B) Discontinued medications may be tiality number; previous address; birth date; (Day)* 1 3–15 retained up to one hundred twenty (120) days sex; marital status; Social Security number; 3 p.m. to 9 p.m. prior to other disposition if there is reason to Medicare and Medicaid numbers (if applica- (Evening)* 1 3–20 believe, based on clinical assessment of the ble); name, address and telephone number of 9 p.m. to 7 a.m. resident, that the medication might be the resident’s physician and alternate; diagno- (Night)* 1 3–25 reordered; sis, name, address and telephone number of (C) Medications may be released to the the resident’s legally authorized representa- *If the shift hours vary from those indicated, resident or family upon discharge according tive or designee to be notified in case of the hours of the shifts shall show on the work to section (44) of this rule; emergency; and preferred dentist, pharmacist schedules of the facility and shall not be less (D) After a resident has expired, medica- and funeral director; III than six (6) hours. III tions, except for controlled substances, may (B) A review monthly or more frequently, (B) The administrator shall count toward be released to the resident’s legal representa- if indicated, of the resident’s general condi- staffing when physically present in the facili- tive upon written request of the legal repre- tion and needs; a monthly review of medica- ty. II (C) The required staff shall be in the facil- sentative that includes the name of the medi- tion consumption of any resident controlling ity awake, dressed and prepared to assist res- cation and the reason for the request; his or her own medication, noting if prescrip- idents in case of emergency. I/II (E) Medications may be returned to the tion medications are being used in appropri- (D) Meeting these minimal staffing pharmacy that dispensed the medications pur- ate quantities; a daily record of administra- requirements may not meet the needs of resi- suant to 20 CSR 2220-3.040 or returned pur- tion of medication; a logging of the medication regimen review process; a month- dents as outlined in the residents’ assess- suant to the Prescription Drug Repository ments and individualized service plans. I/II Program, 19 CSR 20-50.020. All other med- ly weight; a record of each referral of a resident for services from an outside service; and (E) There shall be a licensed nurse ications, including all controlled substances a record of any resident incidents including employed by the facility to work at least eight and all expired or otherwise unusable medi- behaviors that present a reasonable likelihood (8) hours per week at the facility for every cations, shall be destroyed within thirty (30) of serious harm to himself or herself or oth- thirty (30) residents or additional major frac- days as follows: ers and accidents that potentially could result tion of thirty (30). The nurse’s duties shall 1. Medications shall be destroyed within in injury or did result in injuries involving the include, but shall not be limited to, review of the facility by a pharmacist and a licensed resident; and residents’ charts, medications, and special nurse or by two (2) licensed nurses or when (C) Any physician’s orders. The facility diets or other orders, review of each resi- two (2) licensed nurses are not available on shall submit to the physician written versions dent’s adjustment to the facility, and observa- staff by two (2) individuals who have author- of any oral or telephone orders within four tion of each individual resident’s general ity to administer medications, one (1) of (4) days of the giving of the oral or telephone physical and mental condition. The nurse whom shall be a licensed nurse or a pharma- order. III shall inform the administrator of any prob- cist; and lems noted, and these shall be brought to the 2. A record of medication destroyed attention of the resident’s physician. II/III (59) A record of the resident census shall be shall be maintained and shall include the res- retained in the facility. III ident’s name, date, medication name and (62) Prior to or on the first day that a new strength, quantity, prescription number, and employee works in the facility he or she shall (60) Resident records shall be maintained by signatures of the individuals destroying the receive orientation of at least two (2) hours the operator for at least five (5) years after a medications; and appropriate to his or her job function. This resident leaves the facility or after the resi- (F) A record of medication released or shall include at least the following: dent reaches the age of twenty-one (21), returned to the pharmacy shall be maintained (A) Job responsibilities; whichever is longer and must include reason and shall include the resident’s name, date, (B) Emergency response procedures; for discharge or transfer from the facility and (C) Infection control and handwashing pro- medication name and strength, quantity, pre- cause of death, as applicable. III scription number, and signatures of the indi- cedures and requirements; viduals releasing and receiving the medica- (D) Confidentiality of resident informa- (61) Staffing Requirements. tions. II/III tion; (A) The facility shall have an adequate (E) Preservation of resident dignity; number and type of personnel for the proper (F) Information regarding what constitutes (57) Residents experiencing short periods of care of residents, the residents’ social well abuse/neglect and how to report incapacity due to illness or injury or recuper- being, protective oversight of residents and abuse/neglect to the department (1-800-392- ation from surgery may be allowed to remain upkeep of the facility. At a minimum, the 0210); or be readmitted from a hospital if the period staffing pattern for fire safety and care of res- (G) Information regarding the Employee of incapacity does not exceed forty-five (45) idents shall be one (1) staff person for every Disqualification List; days and written approval of a physician is fifteen (15) residents or major fraction of fif- (H) Instruction regarding the rights of res- obtained for the resident to remain in or be teen (15) during the day shift, one (1) person idents and protection of property; readmitted to the facility. II for every twenty (20) residents or major frac- (I) Instruction regarding working with res- tion of twenty (20) during the evening shift idents with mental illness; and (58) The facility shall maintain a record in and one (1) person for every twenty-five (25) (J) Instruction regarding person-centered the facility for each resident, which shall residents or major fraction of twenty-five care and the concept of a social model of include the following: (25) during the night shift. I/II care, and techniques that are effective in

32 CODE OF STATE REGULATIONS (5/31/20) JOHN R. ASHCROFT Secretary of State Chapter 86—Residential Care Facilities and Assisted Living Facilities 19 CSR 30-86

enhancing resident choice and control over and shall sign and maintain training docu- to sixteen (16) hours may elapse between a his or her own environment. II/III mentation. Initial training shall include a substantial evening meal and breakfast the minimum of two (2) classroom instruction following day if a resident group agrees to (63) In addition to the orientation training hours in addition to the on-the-job training this meal span, and a nourishing snack is required in section (62) of this rule any facil- related to safely transferring residents who served. III ity that provides care to any resident having need assistance with transfers. II/III Alzheimer’s disease or related dementia shall (B) The facility shall ensure that a mini- (4) Fresh water shall be available to the resi- provide orientation training regarding mental- mum of one (1) hour of transfer training is dent at all times. II/III ly confused residents such as those with provided by a licensed nurse annually regard- Alzheimer’s disease and related dementias as ing safe transfer skills. II/III (5) Dining room service for residents shall be follows: attractive and each resident shall receive (A) For employees providing direct care to AUTHORITY: sections 198.073 and 198.076, appropriate table service. III such persons, the orientation training shall RSMo Supp. 2011.* Original rule filed Aug. include at least three (3) hours of training 23, 2006, effective April 30, 2007. Amended: (6) Menus shall be planned in advance and including at a minimum an overview of men- Filed March 13, 2008, effective Oct. 30, shall be readily available for personnel tally confused residents such as those having 2008. Amended: Filed March 1, 2012, effec- involved in food purchase and preparation. Alzheimer’s disease and related dementias, tive Sept. 30, 2012. ** Food shall be served as planned although communicating with persons with dementia, substitutes of equal nutritional value and *Original authority: 198.073, RSMo 1979, amended complementary to the remainder of the meal behavior management, promoting indepen- 1984, 1992, 1999, 2006, 2007 and 198.076, RSMo 1979, dence in activities of daily living, techniques amended 1984, 2007. can be made if recorded. III for creating a safe, secure and socially orient- **Pursuant to Executive Orders 20-04 and 20-10, 19 CSR 30- (7) A three (3)-day supply of food shall be ed environment, provision of structure, sta- 86.047, subsection (20)(I), sections (3), (10), (45), (46), and section bility and a sense of routine for residents 198.073.4, RSMo was suspended from April 15, 2020 through June maintained in the facility. III 15, 2020 and sections (9), (18), (19), (26), (45), and (54) was sus- based on their needs, and understanding and pended from April 17, 2020 through June 15, 2020. dealing with family issues; and II/III (8) If a physician prescribes in writing a mod- (B) For other employees who do not pro- ified diet for a resident, the resident may be vide direct care for, but may have daily con- 19 CSR 30-86.052 Dietary Requirements accepted or remain in the facility if— tact with, such persons, the orientation train- for Residential Care Facilities and Assist- (A) The physician monitors the resident’s ing shall include at least one (1) hour of ed Living Facilities condition on a regular periodic basis and at training including at a minimum an overview least quarterly; II of mentally confused residents such as those PURPOSE: This rule establishes standards (B) The diet, food preparation and serving having dementias as well as communicating for meeting dietary needs of residents in resis reviewed at least quarterly by a consulting with persons with dementia; and II/III idential care facilities I and II. nutritionist, dietitian, registered nurse or (C) For all employees involved in the care Editor’s Note: All rules relating to long-term physician and there is written documentation of persons with dementia, dementia-specific care facilities licensed by the department are of the review; II/III training shall be incorporated into ongoing in- followed by a Roman Numeral notation which (C) The modified diet menu is posted in service curricula. II/III refers to the class (either class I, II or III) of the kitchen and includes portions to be standard as designated in section 198.085.1, served; III and (64) All in-service or orientation training RSMo 1986. (D) The facility has entered into a written relating to the special needs, care and safety agreement for dietary consultation with a of residents with Alzheimer’s disease and (1) Each resident shall be served food pre- nutritionist, dietitian registered nurse or other dementia shall be conducted, presented pared and served under safe, sanitary condi- physician. III or provided by an individual who is qualified tions that is prepared consistent with the preferences of the resident and in accordance by education, experience or knowledge in the (9) Nothing in this rule shall be construed as with attending physician’s orders. The nutri- care of individuals with Alzheimer’s disease taking precedence over the resident’s right to tional needs of the residents shall be met. or other dementia. II/III make decisions regarding his or her eating Balanced nutritious meals using a variety of and dining preferences. foods shall be served. Consideration shall be (A) In assisted living facilities, information (65) Requirements for training related to given to the food habits, preferences, medical about the resident’s eating and dining prefer- safely transferring residents. needs and physical abilities of the residents. ences shall be incorporated in his or her indi- (A) The facility shall ensure that all staff II/III responsible for transferring residents are vidualized service plan based on an assess- appropriately trained to transfer residents (2) Each resident shall receive and the facility ment that includes the resident’s culture, safely. Individuals authorized to provide this shall provide at least three (3) meals daily, at life-long routines, habits, patterns and prefer- training include a licensed nurse, a physical regular times comparable to normal meal- ences. III therapist, a physical therapy assistant, an times in the community. At least two (2) (B) In assisted living facilities, if the resi- occupational therapist or a certified occupa- meals daily shall be hot. II/III dent’s eating and dining preferences have a tional therapy assistant. The individual who potential health risk, staff shall inform the provides the transfer training shall observe (3) There shall be no more than fourteen (14) resident or his or her legally authorized rep- the caregiver’s skills when checking compe- hours between a substantial evening meal and resentative of the potential health risks and tency in completing safe transfers, shall doc- breakfast the following day, except when a document this in his or her individualized ument the date(s) of training and competency nourishing snack is provided at bedtime. Up service plan. III

JOHN R. ASHCROFT (5/31/20) CODE OF STATE REGULATIONS 33 Secretary of State 19 CSR 30-86—DEPARTMENT OF HEALTH AND SENIOR SERVICES Division 30—Division of Regulation and Licensure

AUTHORITY: sections 198.076, RSMo 2000 and 198.005 and 198.073, RSMo Supp. 2006.* This rule originally filed as 13 CSR 15-15.052. Original rule filed July 13, 1983, effective Oct. 13, 1983. Emergency amendment filed Aug. 1, 1984, effective Aug. 13, 1984, expired Dec. 10, 1984. Amended: Filed Sept. 12, 1984, effective Dec. 13, 1984. Amended: Filed Aug. 1, 1988, effective Nov. 10, 1988. Moved to 19 CSR 30-86.052, effective Aug. 28, 2001. Amended: Aug. 23, 2006, effective April 30, 2007.

*Original authority: 198.005, RSMo 2006; 198.073, RSMo 1979, amended 1984, 1992, 1999, 2006; and 198.076, RSMo 1979, amended 1984.

34 CODE OF STATE REGULATIONS (5/31/20) JOHN R. ASHCROFT Secretary of State