19 CSR 30-85.042 - Administration and Resident Care Requirements for New and Existing Intermediate Care and Skilled Nursing Facilities
PURPOSE: This amendment clarifies and updates the requirements regarding the nursing assistant training program as a result of revisions made to regulation set in 19 CSR 30-84.010 Nursing Assistant Training Program.
(1) The operator
shall designate a person as administrator who holds a current license as a
nursing home administrator in Missouri. II
(2) The facility shall post the
administrator's license. III
(3)
The operator shall be responsible to assure compliance with all applicable laws
and rules. The administrator shall be fully authorized and empowered to make
decisions regarding the operation of the facility and shall be held responsible
for the actions of all employees. The administrator's responsibilities shall
include the oversight of residents to assure that they receive appropriate
nursing and medical care. II/III
(4) The administrator shall be employed in
the facility and serve in that capacity on a full-time basis. An administrator
cannot be listed or function as an administrator in more than one (1) licensed
facility at the same time, except that one (1) administrator may serve as the
administrator of more than one (1) licensed facility if all facilities are on
the same premises. II/III
(5) The
licensed administrator shall not leave the premises without delegating the
necessary authority in writing to a responsible individual. If the
administrator is absent from the facility for more than thirty (30) consecutive
days, the person designated to be in administrative charge shall be a currently
licensed nursing home administrator. Such thirty (30) consecutive-day absences
may only occur once within any consecutive twelve (12)-month period.
I/II
(6) The facility shall not
knowingly admit or continue to care for residents whose needs cannot be met by
the facility directly or in cooperation with outside resources. Facilities
which retain residents needing skilled nursing care shall provide licensed
nurses for these procedures. I/II
(7) When outside resources are used to
provide services to the resident, the facility shall enter into a written
agreement with each resource. III
(8) Persons under seventeen (17) years of age
shall not be admitted as residents to the facility unless the facility cares
primarily for residents under seventeen (17) years of age. III
(9) The facility shall not care for more
residents than the number for which the facility is licensed. II
(10) The facility's current license shall be
readily visible in a public area within the facility. Notices provided to the
facility by the Division of Aging granting exceptions to regulatory
requirements shall be posted with the facility's license. III
(11) Regular daily visiting hours shall be
established and posted. Relatives or guardians and clergy, if requested by the
resident or family, shall be allowed to see critically ill residents at any
time unless the physician orders otherwise in writing. II/III
(12) A supervising physician shall be
available to assist the facility in coordinating the overall program of medical
care offered in the facility. II
(13) The facility shall develop policies and
procedures applicable to its operation to insure the residents' health and
safety and to meet the residents' needs. At a minimum, there shall be policies
covering personnel practices, admission, discharge, payment, medical emergency
treatment procedures, nursing practices, pharmaceutical services, social
services, activities, dietary, housekeeping, infection control, disaster and
accident prevention, residents' rights and handling residents' property.
II/III
(14) A pharmacist currently
licensed in Missouri shall assist in the development of written policies and
procedures regarding pharmaceutical services in the facility. II/III
(15) All personnel shall be fully informed of
the policies of the facility and of their duties. II/III
(16) All persons who have any contact with
the residents in the facility shall not knowingly act or omit any duty in a
manner which would materially and adversely affect the health, safety, welfare
or property of a resident. I
(17)
Effective August 28, 1997, each facility shall, not later than two (2) working
days of the date an applicant for a position to have contact with residents is
hired, request a criminal background check, as provided in sections
43.530,
43.540 and
610.120, RSMo. Each facility
must maintain in its record documents verifying that the background checks were
requested and the nature of the response received for each such request. The
facility must ensure that any applicant who discloses prior to the check of
his/her criminal records that he/she has been convicted of, plead guilty or
nolo contendere to, or has been found guilty of any A or B
felony violation of Chapter 565, 566 or 569, RSMo, or any violation of
subsection 3 of section
198.070, RSMo, or of section
568.020, RSMo, will not be
allowed to work in contact with patients or residents until and unless a check
of the applicant's criminal record shows that no such conviction occurred.
II/III
(18) The facility must
develop and implement written policies and procedures which require that
persons hired for any position which is to have contact with any patient or
resident have been informed of their responsibility to disclose their prior
criminal history to the facility as required by section 660.317.5, RSMo. The
facility-
(A) Shall also develop and implement
policies and procedures which ensure that the facility does not knowingly hire,
after August 28, 1997, any person who has or may have contact with a patient or
resident, who has been convicted of, plead guilty or nolo
contendere to, in this state or any other state, or has been found
guilty of any A or B felony violation of Chapter 565, 566 or 569, RSMo, or any
violation of subsection 3 of section
198.070, RSMo, or of section
568.020, RSMo, unless the person
has been granted a good cause waiver by the division;
(B) May consider for employment, in positions
which have contact with resident or patients, any person who has been granted a
good cause waiver by the division in accordance with the provisions of section
660.317, RSMo Supp. 1999 and
13 CSR
15-10.060; and;
(C) Shall contact the division to confirm the
validity of an applicant's good cause waiver prior to hiring the applicant.
II/III
(19) No person
who is listed on the employee disqualification list maintained by the division
as required by section
198.070, RSMo shall work or
volunteer in the facility in any capacity whether or not employed by the
operator. II
(20) The facility
shall develop and offer an in-service orientation and continuing educational
program for the development and improvement of skills of all the facility's
personnel, appropriate for their job function. Facilities shall begin providing
orientation on the first day of employment for all personnel including licensed
nurses and other professionals. At a minimum, this shall cover prevention and
control of infection, facility policies and procedures including emergency
protocol, job responsibilities and lines of authority, confidentiality of
resident information, and preservation of resident dignity including protection
of the resident's privacy and instruction regarding the property rights of
residents. II/III
(21) Nursing
Assistant Training Program.
(A) All nursing
assistants shall successfully complete the entire basic course (including
passing the final examination) of the nursing assistant training program and be
certified within four (4) months of employment. II/III
(B) Nursing assistants who have not
successfully completed the nursing assistant training program prior to
employment may begin duties as a nursing assistant and may provide direct
resident care only if under the direct supervision of a licensed nurse prior to
the completion of the seventy-five (75) classroom hours of the training
program. For the purpose of this rule, direct supervision shall mean close
contact whereby the licensed nurse is able to respond quickly to the needs of
the resident. The nursing assistant shall not perform any care or services for
which he or she has not been trained nor found proficient by a licensed nurse.
II/III
(C) Prior to any direct
resident contact, an individual enrolled in the nursing assistant training
program's basic course in a Medicare or Medicaid certified facility shall
complete at least a total of sixteen (16) of the required seventy-five (75)
hours of instructional training in communication and interpersonal skills;
infection control; safety/emergency procedures, including the Heimlich
maneuver; promoting residents' independence; and respecting residents' rights.
II/III
(22) The facility
must ensure there is a system of in-service training for nursing personnel
which identifies training needs related to problems, needs, care of residents
and infection control and is sufficient to ensure staff's continuing
competency. II/III
(23) Facilities
shall conduct at least annual in-service education for nursing personnel
including training in restorative nursing. This training by a registered nurse
or qualified therapist shall include: turning and positioning for the bedridden
resident, range of motion (ROM) exercises, ambulation assistance, transfer
procedures, bowel and bladder retraining and self-care activities of daily
living. II/III
(24) A registered
nurse shall be responsible for the planning and then assuring the
implementation of the in-service education program for nursing personnel.
II
(25) Facilities shall maintain
records which indicate the subject of, and attendance at, all in-service
sessions. III
(26) All authorized
personnel shall have access to the legal name of each resident, name and
telephone number of physician and next of kin or responsible party of each
resident to contact in the event of emergency. II/III
(27) The facility must develop and implement
policies and procedures which ensure employees are screened to identify
communicable diseases and ensure that employees diagnosed with communicable
diseases do not expose residents to such diseases. The facility's policies and
procedures must comply with the Missouri Department of Health's regulations
pertaining to communicable diseases, specifically
19 CSR
20-20.010 through
19 CSR
20-20.100, as amended. II
(28) The administrator shall maintain on the
premises an individual personnel record on each employee of the facility which
shall include: the employee's name and address; Social Security number; date of
birth; date of employment; experience and education; references, if available;
the result of background checks required by section
660.317, RSMo; a copy of any
good cause waiver, granted by the division, if applicable; position in the
facility; record that the employee was instructed on resident's rights; basic
orientation received; and reason for termination, if applicable. Documentation
shall be on file of all training received within the facility in addition to
current copies of licenses, transcripts, certificates or statements evidencing
competency for the position held. Facilities shall retain personnel records for
at least one (1) year following termination of employment. III
(29) Facilities shall maintain written
documentation on the premises showing actual hours worked by each employee.
III
(30) All persons who have or may
have contact with residents shall at all times when on duty or delivering
services wear an identification badge. The badge shall give their name, title
and, if applicable the status of their license or certification as any kind of
health care professional. This rule shall apply to all personnel who provide
services to any resident directly or indirectly. III
(31) Employees other than nursing personnel
shall be at least sixteen (16) years of age.II/III
(32) Nursing personnel shall be at least
eighteen (18) years of age except that a person between the ages of seventeen
(17) years of age and eighteen (18) years of age may provide direct resident
care if the individual is listed as a certified nursing assistant with an
active status on the department 's certified nursing assistant registry. The
individual shall work under the direct supervision of a licensed nurse and
shall never be left responsible for a nursing unit. II/III
(33) All nurses employed by the facility
shall be currently licensed in Missouri. II
(34) All facilities shall employ a director
of nursing on a full-time basis who shall be responsible for the quality of
patient care and supervision of personnel rendering patient care. II
(35) Licensed Nursing Requirements; Skilled
Nursing Facility.
(A) The director of nursing
shall be a registered nurse. II
(B)
A registered nurse shall be on duty in the facility on the day shift. Either a
licensed practical nurse (LPN) or a registered professional nurse (RN) shall be
on duty in the facility on both the evening and night shifts. II
(C) A registered nurse shall be on call
during the time when only an LPN is on duty. II
(36) Licensed Nursing Requirements;
Intermediate Care Facilities.
(A) The director
of nursing shall be either an RN or an LPN. II
(B) When the director of nursing is an LPN,
an RN shall be employed as consultant a minimum of four (4) hours per week to
provide consultation to the administrator and the director of nursing in
matters relating to nursing care in the facility. II
(C) An LPN or RN shall be on duty and in the
facility on the day shift. II
(D) An
LPN or RN shall be on call twenty-four (24) hours a day, seven (7) days a week.
I/II
(37) All facilities
shall employ nursing personnel in sufficient numbers and with sufficient
qualifications to provide nursing and related services which enable each
resident to attain or maintain the highest practicable level of physical,
mental and psychosocial well-being. Each facility shall have a licensed nurse
in charge who is responsible for evaluating the needs of the residents on a
daily and continuous basis to ensure there are sufficient, trained staff
present to meet those needs. I/II
(38) Nursing personnel shall be on duty at
all times on each resident-occupied floor. II
(39) Nursing personnel in any facility with more than
twenty (20) residents shall not routinely perform non-nursing duties.
II/III
(40) Nursing personnel in
facilities with twenty (20) residents or less shall perform non-nursing duties
only if acceptable infection control measures are maintained. II/III
(41) Each facility resident shall be under
the medical supervision of a Missouri-licensed physician who has been informed
of the facility's emergency medical procedures and is kept informed of
treatments or medications prescribed by any other professional lawfully
authorized to prescribe medications. I/II
(42) Facilities shall ensure that at the time the
resident is admitted, the facility obtains from a physician the resident's
primary diagnosis along with current medical findings and the written orders
for the immediate care of the resident. II/III
(43) The facility shall ensure that the resident's
private physician, the physician's designee, the facility's supervising
physician, or an alternate physician shall examine the resident at least
annually, and shall examine the resident as often as necessary to ensure proper
medical care. I/II
(44) For each
medical examination, the physician must review the resident's care, including
medications and treatments; write, sign, and date progress notes; and sign and
date all orders. The facility shall establish a policy requiring the physician
to sign orders and to complete all other documentation required if the
physician does not visit the resident routinely. II/III
(45) No medication, treatment, or diet shall be given
without a written order from a person lawfully authorized to prescribe such and
the order shall be followed. No restraint shall be applied except as provided
in 13 CSR
15-18.010, Resident Rights. I/II
(46) There shall be a safe and effective system of
medication distribution, administration, control, and use. I/II
(47) Verbal and telephone orders for
medication or treatment shall be given only to those individuals licensed or
certified to accept orders. Orders shall be immediately reduced to writing and
signed by that individual. If a telephone order is given to a certified
medication technician, an initial dose of medication or treatment shall not be
given until the order has been reviewed by telephone or in person by a licensed
nurse or pharmacist. The review shall be documented by the reviewer co-signing
the telephone order. II
(48)
Medications shall be administered only by a licensed physician, a licensed
nurse, or a medication technician who has successfully completed the
state-approved course for medication administration. II
(49) Injectable medication, other than insulin, shall
be administered only by a licensed physician or a licensed nurse. Insulin
injections may be administered by a certified medication technician who has
successfully completed the state-approved course for insulin administration.
II
(50) Self-administration of
medication is permitted only if approved in writing by the resident's
physician, and it is in accordance with the facility's policy and procedures.
II
(51) All medication errors and
adverse reactions shall be reported immediately to the nursing supervisor and
the resident's physician and, if there was a dispensing error, to the issuing
pharmacist. II/III
(52) At least
monthly a pharmacist or a registered nurse shall review the drug regimen of
each resident. Irregularities shall be reported in writing to the resident's
physician, the administrator, and the director of nurses. There must be written
documentation which indicates how the reports were acted upon. II/III
(53) All prescription medications shall be
supplied as individual prescriptions. All medications, including
over-the-counter medications, shall be packaged and labeled in accordance with
applicable professional pharmacy standards and state and federal drug laws and
regulations. The United States Pharmacopoeia (USP) labeling shall include
accessory and cautionary instructions as well as the expiration date, when
applicable, and the name of the medication as specified in the physician's
order. Over-the-counter medications for individual residents shall be labeled
with at least the resident's name. II/III
(54) If the resident brings medications to the
facility, they shall not be used unless the contents have been examined,
identified, and documented by a pharmacist or a physician. II/III
(55) Facilities shall store all external and
internal medications at appropriate temperatures in a safe, clean place and in
an orderly manner apart from foodstuffs and dangerous chemicals. A facility
shall secure all medications, including those refrigerated, behind at least one
(1) locked door or cabinet. Facilities shall store containers of discontinued
medication separately from current medications. II/III
(56) Facilities shall store Schedule II medications,
including those in the emergency drug supply, under double lock separately from
noncontrolled medication. Schedule II medications may be stored and handled
with other noncontrolled medication if the facility has a single unit dose drug
distribution system in which the quantity stored is minimal and a missing dose
can be readily detected. II
(57)
Upon discharge or transfer, a resident may be given medications with a written
order from the physician. Instructions for the use of those medications will be
provided to the resident or the resident's designee. III
(58) All non-unit doses and all controlled substances
which have been discontinued must be destroyed on the premises within thirty
(30) days. Outdated, contaminated, or deteriorated medications and non-unit
dose medications of deceased residents shall be destroyed within thirty (30)
days. Unit dose medications returnable to the pharmacy shall be returned within
thirty (30) days. II/III
(59)
Medications shall be destroyed in the facility by a pharmacist and a licensed
nurse or by two (2) licensed nurses. III
(60) Facilities shall maintain records of medication
destroyed in the facility. Records shall include: the resident's name; the
date; the name, strength, and quantity of the medication; the prescription
number; and the signatures of the participating parties. III
(61) The facility shall maintain records of
medication released to the family or resident upon discharge or to the
pharmacy. Records shall include: the resident's name; the date; the name,
strength, and quantity of the medication; the prescription number; and the
signature of the persons releasing and receiving the medication. III
(62) The facility must establish a system of
records of receipt and disposition of all controlled drugs in sufficient detail
to enable an accurate reconciliation. The system must enable the facility to
determine that drug records are in order and that an account of all controlled
drugs is maintained and reconciled. II/III
(63) Facilities shall make available to all nursing
staff up-to-date reference material on all medications in use in the facility.
III
(64) The facility shall
develop policies to identify any emergency stock supply of prescription
medications to be kept in the facility for resident use only. This emergency
drug supply must be checked at least monthly by a pharmacist to ensure its
safety for use and compliance with facility policy. A facility shall have the
emergency drug supply readily available to medical personnel and use of
medications in the emergency drug supply shall assure accountability.
III
(65) Each resident shall
receive twenty-four- (24-) hour protective oversight and supervision. For
residents departing the premises on voluntary leave, the facility shall have,
at a minimum, a procedure to inquire of the resident or resident's guardian of
the resident's departure, of the resident's estimated length of absence from
the facility, and of the resident's whereabouts while on voluntary leave.
I/II
(66) Each resident shall
receive personal attention and nursisg care in accordance with his/her
condition and consistent with current acceptable nursing practice.
I/II
(67) Each resident shall be
clean, dry, and free of body and mouth odor that is offensive to others.
I/II
(68) Taking into
consideration the resident's preferences, residents shall be well-groomed and
dressed appropriately for the time of day, the environment and any identified
medical conditions. II/III
(69)
Residents who are physically or mentally incapable, or both, of changing their
own positions shall have their positions changed at least every two (2) hours
and shall be provided supportive devices to maintain good body alignment.
I/II
(70) The facility must
provide each resident the opportunity to access sufficient fluids to maintain
proper hydration in accordance with the resident's medical condition and goals
of treatment as documented in the medical record. I/II
(71) All residents who require assistance at
mealtimes, whether it be preparation of the food items or actual feeding, shall
be provided the assistance upon delivery of the tray. Facilities shall provide
dining room supervision during meals. II/III
(72) Facilities shall provide each resident, according
to his/her needs, with restorative nursing to encourage independence, activity
and self-help to maintain strength and mobility. Each resident shall be out of
bed as desired unless medically contraindicated. II
(73) Each resident shall have skin care including the
application of oil, lotion, and cream as needed to prevent dryness and scaling
of skin. II/III
(74) Facilities
shall keep residents free from avoidable pressure sores, taking measures toward
prevention. If sores exist, staff shall give adequate treatment. I/II
(75) Facility staff shall check residents
requiring restraints every thirty (30) minutes and exercise the residents every
two (2) hours. II/III
(76)
Facilities shall not use locked restraints. I
(77) Residents shall be cared for by using acceptable
infection control procedures to prevent the spread of infection. The facility
shall make a report to the division within seven (7) days if a resident is
diagnosed as having a communicable disease, as determined by the Missouri
Department of Health and listed in the Code of State Regulations pertaining to
communicable diseases, specifically
19 CSR
20-20.020, as amended. I/II
(78) In the event of accident, injury, or significant
change in the resident's condition, facility staff shall notify the resident's
physician in accordance with the facility's emergency treatment policies which
have been approved by the supervising physician. I/II
(79) In the event of accident, injury, or significant
change in the resident's conditions, facility staff shall immediately notify
the person designated in the resident's record as the designee or responsible
party. III
(80) Staff shall inform
the administrator of accidents, injuries, and unusual occurrences which
adversely affect, or could adversely affect, the resident. The facility shall
develop and implement responsive plans of action. III
(81) Facilities shall ensure that each resident is
provided individual personal care items necessary for good grooming. Items
shall be stored and maintained in a clean manner within the resident's room.
III
(82) Facilities shall provide
equipment and nursing supplies in sufficient number to meet the needs of the
residents. II/III
(83) Facilities
shall keep all utensils and equipment in good condition, effectively sanitized,
sterilized, or both, and stored to prevent contamination. II/III
(84) Staff shall ensure that bedpans,
commodes, and urinals are covered after use, emptied promptly, and thoroughly
cleaned after use. II/III
(85)
Facilities shall provide and use a sufficient supply of clean bed linen,
including sheets, pillow cases, blankets, and mattress pads to assure that
resident beds are kept clean, neat, dry, and odor free. II/III
(86) Staff shall use moisture proof covers
as necessary to keep mattresses and pillows clean, dry, and odor free.
II/III
(87) Facilities shall
provide each resident with fresh bath towels, hand towels, and washcloths as
needed for individual usage. II/III
(88) In addition to rehabilitative or restorative
nursing, all facilities shall provide or make arrangements for providing
rehabilitation services to all residents according to their needs. If a
resident needs rehabilitation services, a qualified therapist shall perform an
evaluation on written order of the resident's physician. II/III
(89) Facilities shall ensure that
rehabilitation services are provided by or under the on-site supervision of a
qualified therapist or a qualified therapy assistant who works under the
general supervision of a qualified therapist. I/II
(90) Staff shall include the following in
documentation of rehabilitation services: physician's written approval for
proposed plan of care; progress notes at least every thirty (30) days by the
therapist; daily record of the procedure(s) performed; summary of therapy when
rehabilitation has been reached and, if applicable, recommendations for
maintenance procedures by restorative nursing. III
(91) The facility shall designate a staff member to be
responsible for the facility's social services program. The designated staff
person shall be capable of identifying social and emotional needs,
knowledgeable of methods or resources, or a combination of these to use to meet
them and services shall be provided to residents as needed. II/III
(92) The facility shall designate an
employee to be responsible for the activity program. The designated person
shall be capable of identifying activity needs of residents, designing and
implementing programs to maintain or increase, or both, the resident's
capability in activities of daily living. Facilities shall provide activity
programs on a regular basis. Each resident shall have a planned activity
program which includes individualized activities, group activities, and
activities outside the facility as appropriate to his/her needs and interests.
II/III
(93) The facility shall
provide and use adequate space and equipment within the facility for the
identified activity needs of residents. II/III
(94) The facility shall establish and maintain a
program for informing all residents in advance of available activities,
activity location and time. III
(95) Facility staff shall include the following
general information in admission records: resident's name; prior address; age
(birth date); sex; marital status; Social Security number; Medicare and
Medicaid numbers; date of admission; name, address, and telephone number of
responsible party; name, address, and telephone number of attending physician;
height and weight on admission; inventory of resident's personal possessions
upon admission; and names of preferred dentist, pharmacist, and funeral
director. II/III
(96) Facility
staff shall include physician entries in the medical record with the following
information: admission diagnosis, admission physical and findings of subsequent
examinations; progress notes; orders for all medications and treatment; orders
for extent of activity; orders for restraints including type and reason for
restraint; orders for diet; and discharge diagnosis or cause of death.
II/III
(97) Residents admitted to
a facility on referral by the Department of Mental Health shall have an
individualized treatment plan or individualized habilitation plan on file which
is updated annually. III
(98)
Facilities shall ensure that the clinical record contains sufficient
information to-
(A) Identify the
resident;
(B) Reflect the initial
and ongoing assessments and interventions by each discipline involved in the
care and treatment of the resident; and
(C) Identify the discharge or transfer
destination. II/III
(99) Facilities shall ensure that the resident's
clinical record must contain progress notes that include, but are not limited
to:
(A) Response to care and
treatment;
(B) Change(s) in
physical, mental, and psychosocial condition;
(C) Reasons for changes in treatment;
and
(D) Reasons for transfer or
discharge. II/III
(100)
The facility must safeguard clinical record information against loss,
destruction, or unauthorized use. III
(101) The facility must keep all information
confidential that is contained in the resident's records regardless of the form
or storage method of the records, including video-, audio-, or computer-stored
information. III
(102) The
facility must maintain clinical records on each resident in accordance with
accepted professional standards and practices. These records shall be complete,
accurately documented, readily accessible on each nursing unit, and
systematically organized. II/III
(103) Facilities must retain clinical records for the
period of time required by state law or five (5) years from the date of
discharge when there is no requirement in state law. III
(104) Facilities shall retain all financial records
related to the facility operation for seven (7) years from the end of the
facility's fiscal year. III
(105)
In the event the resident is transferred from the facility, the resident shall
be accompanied by a copy of the medical history, transfer forms which include
the physical exam report, nursing summary, and report of orders physicians
prescribed. II/III
Notes
All rules relating to long-term care facilities licensed by the Division of Aging are followed by a Roman Numeral notation which refers to the class (either Class I, II or III) of standard as designated in section 198.085.1, RSMo.
*Original authority: 198.006, RSMo 1979, amended 1984, 1987, 2003; 198.079, RSMo 1979.
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
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