19 CSR 30-86.042 - Administrative, Personnel and Resident Care Requirements for New and Existing Residential Care Facilities
PURPOSE: This rule establishes standards for administration, personnel and resident care in residential care facilities I and II.
(1) Definitions. For
the purpose of this rule, the following definitions shall apply:
(A) Department-Department of Health and
Senior Services;
(B) Outbreak-an
occurrence in a community or region of an illness(es) similar in nature,
clearly in excess of normal expectancy and derived from a common or a
propagated source; and
(C) Evacuate
the facility-moving to an area of refuge or from one (1) smoke section to
another or exiting the facility.
(2) For a residential care facility, a person
shall be designated as administrator/manager who is either currently licensed
as a nursing home administrator or is at least twenty-one (21) years of age,
has never been convicted of an offense involving the operation of a long-term
care or similar facility and who attends at least one (1) continuing education
workshop within each calendar year given by or approved by the department. When
used in this chapter of rules, the term manager shall mean that person who is
designated by the operator to be in general administrative charge of a
residential care facility. It shall be considered synonymous to "administrator"
as defined in section
198.006, RSMo and the
terms administrator and manager may be used interchangeably. II/III
(3) The administrator/manager of a
residential care facility shall have successfully completed the state approved
Level I Medication Aide course unless he or she is a physician, pharmacist,
licensed nurse or a certified medication technician, or if the facility is
operating in conjunction with a skilled nursing facility or intermediate care
facility on the same premises, or, for an assisted living facility, if the
facility employs on a full-time basis, a licensed nurse who is available seven
(7) days per week. II/III
(4) The
operator shall be responsible to assure compliance with all applicable laws and
regulations. The administrator/manager 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/manager's
responsibilities shall include oversight of residents to assure that they
receive care appropriate to their needs. II/III
(5) The administrator/manager shall devote
sufficient time and attention to the management of the facility as is necessary
for the health, safety and welfare of the residents. II
(6) The administrator/manager shall
designate, in writing, a staff member in charge in the administrator/manager's
absence. II/III
(7) The facility
shall not care for more residents than the number for which the facility is
licensed. If the facility operates a non-licensed adult day care program within
the licensed facility, the day care participants shall be counted in the
staffing determination during the hours the day care participants are in the
facility. II/III
(8) The facility's
current license shall be posted in a conspicuous place and notices provided to
the facility by the department granting exception(s) to regulatory requirements
shall be posted alongside of the facility's license. III
(9) All personnel responsible for resident
care shall have access to the legal name of each resident, name and telephone
number of resident's physician, resident's designee or legally authorized
representative in the event of emergency. II/III
(10) 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 residents. No person who is listed on the Employee
Disqualification List (EDL) maintained by the department as required by section
198.070,
RSMo shall work or volunteer in the facility in any capacity whether or not
employed by the operator. For the purpose of this rule, a volunteer is an
unpaid individual formally recognized by the facility as providing a direct
care service to residents. The facility is required to check the EDL for
individuals who volunteer to perform a service for which the facility might
otherwise have to hire an employee. The facility is not required to check the
EDL for individuals or groups such as scout groups, bingo or sing-along
leaders. The facility is not required to check the EDL for an individual such
as a priest, minister or rabbi visiting a resident who is a member of the
individual's congregation. However, if the minister, priest or rabbi serves as
a volunteer facility chaplain, the facility is required to check the EDL since
the individual would have potential contact with all residents. I/II
(11) Prior to allowing any person who has
been hired in a full-time, part-time or temporary position to have contact with
any residents the facility shall, or in the case of temporary employees hired
through or contracted for an employment agency, the employment agency shall
prior to sending a temporary employee to a provider:
(A) Request a criminal background check for
the person, as provided in section
43.540,
RSMo. Each facility must maintain in its record documents verification that the
background checks were requested and the nature of the response received for
each such request. II
1. The facility must
ensure that any applicant or person hired or retained who discloses prior to
the receipt of the criminal background check that he or she has been convicted
of, pled guilty or pled nolo contendere to in this state or
any other state or has been found guilty of a crime, which if committed in
Missouri would be a class A or B felony violation of Chapter 565, 566, or 569,
RSMo or any violation of subsection 198.070.3, RSMo or of section
568.020, RSMo,
will not have contact with residents. I/II
2. Upon receipt of the criminal background
check, the facility must ensure that if the criminal background check indicates
that the person hired or retained by the facility has been convicted of, pled
guilty or pled nolo contendere to in this state or any other
state or has been found guilty of a crime, which if committed in Missouri would
be a class A or B felony violation of Chapter 565, 566, or 569, RSMo or any
violation of subsection 198.070.3, RSMo or of section
568.020, RSMo,
the person will not have contact with residents unless the facility obtains
verification from the department that a good cause waiver has been granted and
maintains a copy of the verification in the individual's personnel file;
I/II
(B) Make an inquiry
to the department, whether the person is listed on the employee
disqualification list as provided in section
660.315,
RSMo. The inquiry may be made via Internet at
www.dhss.mo.gov/EDL/;
II/III
(C) If the person has
registered with the department's Family Care Safety Registry (FCSR), the
facility may utilize the Registry in order to meet the requirements of
subsections (1)(A) and (11)(B) of this rule. The FCSR is available via Internet
at www.dhss.mo.gov/EDL/; and
II/III
(D) For persons for whom the
facility has contracted for professional services (e.g., plumbing or air
conditioning repair) that will have contact with any resident, the facility
must either require a criminal background check or ensure that the individual
is sufficiently monitored by facility staff while in the facility to reasonably
ensure the safety of all residents. I/II
(12) A facility shall not employ as an agent
or employee who has access to controlled substances any person who has been
found guilty or entered a plea of guilty or nolo contendere in
a criminal prosecution under the laws of any state or of the United States for
any offense related to controlled substances. II
(A) A facility may apply in writing to the
department for a waiver of this section for a specific employee.
(B) The department may issue a written waiver
to a facility upon determination that a waiver would be consistent with the
public health and safety. In making this determination, the department shall
consider the duties of the employee, the circumstances surrounding the
conviction, the length of time since the conviction was entered, whether a
waiver has been granted by the department's Bureau of Narcotics and Dangerous
Drugs pursuant to
19 CSR
30-1.034 when the facility is registered with that
agency, whether a waiver has been granted by the federal Drug Enforcement
Administration (DEA) pursuant to
21 CFR
1301.76 when the facility is also registered
with that agency, the security measures taken by the facility to prevent the
theft and diversion of controlled substances, and any other factors consistent
with public health and safety. II/III
(13) The facility must develop and implement
written policies and procedures which require that persons hired for any
position which is to have contact with any patient or resident have been
informed of their responsibility to disclose their prior criminal history to
the facility as required by section 660.317.5, RSMo. The facility must also
develop and implement policies and procedures which ensure that the facility
does not knowingly hire, after August 28, 1997, any person who has or may have
contact with a patient or resident, who has been convicted of, plead guilty or
nolo con-tendere to, in this state or any other state, or has
been found guilty of any class A or B felony violation of Chapter 565, 566 or
569, RSMo, or any violation of subsection 3 of section
198.070,
RSMo, or of section
568.020, RSMo.
II/III
(14) All persons who have or
may have contact with residents shall at all time 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
(15) All personnel shall be able physically
and emotionally to work in a long-term care facility. I/II
(16) Personnel who have been diagnosed with a
communicable disease may begin work or return to duty only with written
approval by a physician or physician's designee which indicates any
limitations. II
(17) The
administrator/manager shall be responsible for preventing an employee known to
be diagnosed with communicable disease from exposing residents to such disease.
The facility's policies and procedures must comply with the department's
regulations pertaining to communicable diseases, specifically
19
CSR 20-20.010 through
19
CSR 20-20.100. II/III
(18) The facility shall screen residents and
staff for tuberculosis as required for long-term care facilities by
19
CSR 20-20.100. II
(19) Prior to or on the first day that a new
employee works in the facility he or she shall receive orientation of at least
one (1) hour appropriate to his or her job function. This shall include at
least the following:
(A) Job
responsibilities;
(B) Emergency
response procedures;
(C) Infection
control and handwashing procedures and requirements;
(D) Confidentiality of resident
information;
(E) Preservation of
resident dignity;
(F) Information
regarding what constitutes abuse/neglect and how to report abuse/ neglect to
the department (1-800-392-0210);
(G) Information regarding the Employee
Disqualification List;
(H)
Instruction regarding the rights of residents and protection of property;
and
(I) Instruction regarding
working with residents with mental illness. II/III
(20) In addition to the orientation training
required in section (19) of this rule any facility that provides care to any
resident having Alzheimer's disease or related dementia shall provide
orientation training regarding mentally confused residents such as those with
Alzheimer's disease and related dementias as follows:
(A) For employees providing direct care to
such persons, the orientation training shall include at least three (3) hours
of training including at a minimum an overview of mentally confused residents
such as those having Alzheimer's disease and related dementias, communicating
with persons with dementia, behavior management, promoting independence in
activities of daily living, and understanding and dealing with family issues;
II/III
(B) For other employees who
do not provide direct care for, but may have daily contact with, such persons,
the orientation training shall include at least one (1) hour of training
including at a minimum an overview of mentally confused residents such as those
having dementias as well as communicating with persons with dementia; and
II/III
(C) For all employees
involved in the care of persons with dementia, dementia-specific training shall
be incorporated into ongoing in-service curricula. II/III
(21) The administrator/manager shall maintain
on the premises an individual personnel record on each facility employee, which
shall include the following:
(A) The
employee's name and address;
(B)
Social Security number;
(C) Date of
birth;
(D) Date of
employment;
(E) Documentation of
experience and education including for positions requiring licensure or
certification, documentation evidencing competency for the position held, which
includes copies of current licenses, transcripts when applicable, or for those
individuals requiring certification, such as level I medication aides (LIMA),
certified nurse aides, certified medication technicians (CMT) and insulin
administration aides; printing the We b Registry search results page available
at www.dhss.mo.gov/cnaregistry
shall meet the requirements of the employer's check regarding valid certification:
(F)
References, if available;
(G) The
results of background checks required by section
660.317,
RSMo; and a copy of any good cause waiver granted by the department, if
applicable;
(H) Position in the
facility;
(I) Written statement
signed by a licensed physician or physician's designee indicating the person
can work in a long-term care facility and indicating any limitations;
(J) Documentation of the employee's
tuber-cilin screening status;
(K)
Documentation of what the employee was instructed on during orientation
training; and
(L) Reason for
termination if the employee was terminated due to abuse or neglect of a
resident, residents' rights issues or resident injury. III
(22) Personnel records shall be maintained
for at least two (2) years following termination of employment. III
(23) There shall be written documentation
maintained in the facility showing actual hours worked by each employee.
III
(24) No one individual shall be
on duty with responsibility for oversight of residents longer than eighteen
(18) hours per day except in a residential care facility licensed for twelve
(12) or fewer residents. I/II
(25)
Employees who are counted in meeting the minimum staffing ratio and employees
who provide direct care to the residents shall be at least sixteen (16) years
of age. III
(26) One (1) employee
at least eighteen (18) years of age shall be on duty at all times.
I/II
(27) Staffing for Residential
Care Facility.
(A) The facility shall have an
adequate number and type of personnel on duty at all times for the proper care
of residents and upkeep of the facility. At a minimum, one (1) employee shall
be on duty for every forty (40) residents to provide protective oversight to
residents and for fire safety. I/II
| Staff | Residents |
| 1 | 1-40 |
| 2 | 41-80 |
| 3 | 81-120 |
| 4 | 121-160 |
(B)
The required staff person shall be in the facility awake, dressed and prepared
to assist residents in case of emergency, except that in a facility licensed
for twelve (12) or fewer residents, this person may be asleep during the night
hours. In a facility licensed for twenty (20) or fewer residents, the required
staff person may be asleep if there is a sprinkler system or if there is a
complete automatic fire detection system. I/II
(C) In a facility of more than one hundred
(100) residents, the administrator/manager shall not be counted when
determining the personnel required. II
(D) If the facility is opened in conjunction
with and is immediately adjacent to and contiguous to another licensed
long-term care facility and if-
1. The
resident bedrooms of the residential care facility are on the same floor or on
the ground floor immediately below that of the other licensed
facility;
2. There is an approved
call system in each resident's bedroom and bathroom or a patient-controlled
system connected to a nursing station of the other licensed facility;
3. There is a complete fire alarm system in
the residential care facility connected to the complete fire alarm system in
the other licensed facility;
4. The
staffing of the other licensed facility is greater than their minimum
requirements; and
5. Periodic
visits to the residential care facility are made by a staff person to determine
the welfare of the resident in the residential care facility; then, for a
facility serving twenty (20) or fewer residents, there need not be an attendant
on duty during the day and evening shifts and the attendant may be asleep
during the night shift; or if the facility is on the same floor as the other
licensed facility, there need not be an attendant at night. If there are more
than twenty (20) residents, there shall be at least one (1) staff person awake
and dressed at all times for every forty (40) residents or fraction of forty
(40). I/II
(E) Those
facilities which have only an asleep attendant during the night-time period and
those facilities which have only the minimum staff required by subsection
(27)(D) during the night-time period shall not accept residents who are blind,
use assistive devices, such as walkers or wheelchairs, or who need care greater
than can be provided with the staffing pattern in those facilities. Those
residents who were living in a residential care facility prior to July 11,
1980, may remain in that facility with an asleep attendant even though they may
be blind, deaf or use assistive devices provided they can demonstrate the
ability to reach safety unassisted or with assistive devices. II
(28) All residents shall be
physically and mentally capable of negotiating a normal path to safety
unassisted or with the use of assistive devices within five (5) minutes of
being alerted of the need to evacuate the facility as defined in subsection
(1)(C) of this rule. I/II
(29)
Residents suffering from short periods of incapacity due to illness, injury or
recuperation from surgery may be allowed to remain or be readmitted from a
hospital if the period of incapacity does not exceed forty-five (45) days and
written approval of a physician is obtained for the resident to remain in or be
readmitted to the facility. II/III
(30) The facility shall not admit or continue
to care for residents whose needs cannot be met. If necessary services cannot
be obtained in or by the facility, the resident shall be promptly referred to
appropriate outside resources or discharged from the facility. I/II
(31) In the event a resident is transferred
from the facility, staff shall forward a report of the resident's current
medical status, physician's orders/prescriptions, and if applicable, a copy of
the resident's advanced directives/living will to the facility to which the
resident is being transferred. If the resident is transferring to a private
residence, facility staff shall provide the reports to the resident or his or
her designee or legally authorized representative. II/III
(32) Residents admitted to a facility on
referral by the Department of Mental Health shall have an individual treatment
plan or individual habilitation plan on file prepared by the Department of
Mental Health, updated annually. II
(33) Placement of residents in the building
shall be determined by their abilities. Those residents who require the use of
a walker or who are blind shall be housed on a floor which has direct exits at
grade, a ramp or no more than two (2) steps to grade with a handrail unless an
area of refuge as defined in
19
CSR 30-86.022 is provided. Those residents who use a
wheelchair shall be able to demonstrate the ability to transfer to and from the
wheelchair unassisted. They shall be housed near an exit and there shall be a
direct exit at grade or a ramp or an area of refuge as defined in
19
CSR 30-86.022. II
(34) Requirements for facilities which admit
or retain residents with mental illness or mental retardation diagnosis and
residents with assaultive or disruptive behaviors:
(A) Each resident who exhibits mental and
psychosocial adjustment difficulty(ies) shall receive treatment and services to
address the resident's needs and behaviors as stated in the individual service
plan; I/II
(B) If specialized
rehabilitative services for mental illness or mental retardation are required
to enable a resident to reach and to comply with the individualized service
plan, the facility must ensure the required services are provided; and
II
(C) The facility shall maintain
in the resident's record the most recent progress notes and personal plan
developed and provided by the Department of Mental Health or designated
administrative agent for each resident whose care is funded by the Department
of Mental Health or designated administrative agent. III
(35) The use of interventions to manage
disruptive or assaultive resident behaviors shall be employed with sufficient
safeguards to ensure the safety, welfare and rights of the resident and shall
be in accordance with the therapeutic goals for the resident. I/II
(36) Residents under sixteen (16) years of
age shall not be admitted. III
(37)
Residents admitted or readmitted to the facility shall have an admission
physical examination by a licensed physician. Documentation should be obtained
prior to admission but shall be on file not later than ten (10) days after
admission and shall contain information regarding the resident's current
medical status and any special orders or procedures which should be followed.
If the resident is admitted directly from a hospital or another long-term care
facility and is accompanied on admission by a report which reflects his/her
current medical status, an admission physical will not be required.
II/III
(38) The facility shall
follow appropriate infection control procedures. The administrator or his or
her designee shall make a report to the local health authority or the
department of the presence or suspected presence of any diseases or findings
listed in
19
CSR 20-20.020, sections (1)-(3) according to the
specified time frames as follows:
(A)
Category I diseases or findings shall be reported to the local health authority
or to the department within twenty-four (24) hours of first knowledge or
suspicion by telephone, facsimile, or other rapid communication; I/II
(B) Category II diseases or findings shall be
reported to the local health authority or the department within three (3) days
of first knowledge or suspicion; I/II
(C) Category III. The occurrence of an
outbreak or epidemic of any illness, disease or condition which may be of
public health concern, including any illness in a food handler that is
potentially transmissible through food. This also includes public health
threats such as clusters of unusual diseases or manifestations of illness and
clusters of unexplained deaths. Such incidents shall be reported to the local
authority or to the department by telephone, facsimile, or other rapid
communication within twenty-four (24) hours of first knowledge or suspicion.
I/II
(39) Protective
oversight shall be provided twenty-four (24) hours a day. For residents
departing the premises on voluntary leave, the facility shall have, at a
minimum, a procedure to inquire of the resident or resident's guardian of the
resident's departure, of the resident's estimated length of absence from the
facility, and of the resident's whereabouts while on voluntary leave.
I/II
(40) Residents shall receive
proper care to meet their needs. Physician orders shall be followed.
I/II
(41) In case of behaviors that
present a reasonable likelihood of serious harm to himself or herself or
others, serious illness, significant change in condition, injury or death,
staff shall take appropriate action and shall promptly attempt to contact the
individual listed in the resident's record as the legally authorized
representative, designee or placement authority. The facility shall contact the
attending physician or designee and notify the local coroner or medical
examiner immediately upon the death of any resident of the facility prior to
transferring the deceased resident to a funeral home. II/III
(42) The facility shall encourage and assist
each resident based on his or her individual preferences and needs, to be clean
and free of body and mouth odor. II
(43) Except in the case of emergency, the
resident shall not be inhibited by chemical and/or physical restraints that
would limit self-care or ability to negotiate a path to safety unassisted or
with assistive devices. I/II
(44)
If the resident brings unsealed medications to the facility, the medications
shall not be used unless a pharmacist, physician or nurse examines, identifies
and determines the contents to be suitable for use. The individual performing
the identification shall document his or her review. II/III
(45) Self-control of prescription medication
by a resident may be allowed only if approved in writing by the resident's
physician and allowed by facility policy. A resident may be permitted to
control the storage and use of nonprescription medication unless there is a
physician's written order or facility policy to the contrary. Written approval
for self-control of prescription medication shall be rewritten as needed but at
least annually and after any period of hospitalization. II/III
(46) All medication shall be safely stored at
proper temperature and shall be kept in a secured location behind at least one
(1) locked door or cabinet. Medication shall be accessible only to persons
authorized to administer medications. II/III
(A) If access is controlled by the resident,
a secured location shall mean in a locked container, a locked drawer in a
bedside table or dresser or in a resident's private room if locked in his or
her absence, although this does not preclude access by a responsible employee
of the facility. II/III
(B)
Schedule II controlled substances shall be stored in locked compartments
separate from non-controlled medications, except that single doses of Schedule
II controlled substances may be controlled by a resident in compliance with the
requirements for self-control of medication of this rule. II/III
(C) Medication that is not in current use and
is not destroyed shall be stored separately from medication that is in current
use. II/III
(47) All
prescription medications shall be supplied as individual prescriptions except
where an emergency medication supply is allowed. All medications, including
over-the-counter medications shall be packaged and labeled in accordance with
applicable professional pharmacy standards and state and federal drug laws.
Labeling shall include accessory and cautionary instructions as well as the
expiration date, when applicable, and the name of the medication as specified
in the physician's order. Medication labels shall not be altered by facility
staff and medications shall not be repackaged by facility staff except as
allowed by section (48) of this rule. Over-the-counter medications for
individual residents shall be labeled with at least the resident's name.
II/III
(48) Controlled substances
and other prescription and non-prescription medications for administration when
a resident temporarily leaves a facility shall be provided as follows:
(A) Separate containers of medications for
the leave period may be prepared by the pharmacy. The facility shall have a
policy and procedure for families to provide adequate advance notice so that
medications can be obtained from the pharmacy; II/III
(B) Prescription medication cards or other
multiple-dose prescription containers currently in use in the facility may be
provided by any authorized facility medication staff member if the containers
are labeled by the pharmacy with complete pharmacy prescription labeling for
use. Original manufacturer containers of non-prescription medications, along
with instructions for administration, may be provided by any authorized
facility medication staff member; II/III
(C) When medications are supplied by the
pharmacy in customized patient medication packages that allow separation of
individual dose containers, the required number of containers may be provided
by any authorized facility medication staff member. The individual dose
containers shall be placed in an outer container that is labeled with the name
and address of the facility and the date; II/III
(D) When multiple doses of a medication are
required and it is not reasonably possible to obtain prescription medication
labeled by the pharmacy, and it is not appropriate to send a container of
medication currently in use in the facility, up to a twenty-four (24)-hour
supply of each prescription or non-prescription medication may be provided by a
licensed nurse in United States Pharmacopeia (USP) approved containers labeled
with the facility name and address, resident's name, medication name and
strength, quantity, instructions for use, date, initials of individual
providing, and other appropriate information; II/III
(E) When no more than a single dose of a
medication is required, any authorized facility medication staff member may
prepare the dose as for in-facility administration in a USP approved container
labeled with the facility name and address, resident's name, medication name
and strength, quantity, instructions for use, date, initials of person
providing, and other appropriate information;
(F) The facility may have a policy that
limits the quantity of medication sent with a resident without prior approval
of the prescriber; II/III
(G)
Returned containers shall be identified as having been sent with the resident,
and shall not later be returned to the pharmacy for reuse; and II/III
(H) The facility shall maintain accurate
records of medications provided to and returned by the resident.
II/III
(49) Upon
discharge or transfer of a resident, the facility shall release prescription
medications, including controlled substances, held by the facility for the
resident when the physician writes an order for each medication to be released.
Medications shall be labeled by the pharmacy with current instructions for use.
Prescription medication cards or other containers may be released if the
containers are labeled by the pharmacy with complete pharmacy prescription
labeling. II/III
(50) Injections
shall be administered only by a physician or licensed nurse, except that
insulin injections may be administered by a CMT or LIMA who has successfully
completed the state-approved course for insulin administration, taught by a
department-approved instructor. A resident who requires insulin, may administer
his or her own insulin if approved in writing by the resident's physician and
trained to do so by a licensed nurse or physician. The facility is responsible
to monitor the resident's condition and continued ability for
self-administration. I/II
(51) The
administrator/manager shall develop and implement a safe and effective system
of medication control and use, which assures that all residents' medications
are administered by personnel at least eighteen (18) years of age, in
accordance with physicians' instructions using acceptable nursing techniques.
The facility shall employ a licensed nurse eight (8) hours per week for every
thirty (30) residents to monitor each resident's condition and medication.
Administration of medication shall mean delivering to a resident his or her
prescription medication either in the original pharmacy container, or for
internal medication, removing an individual dose from the pharmacy container
and placing it in a small container or liquid medium for the resident to remove
from the container and self-administer. External prescription medication may be
applied by facility personnel if the resident is unable to do so and the
resident's physician so authorizes. All individuals who administer medication
shall be trained in medication administration and, if not a physician or a
licensed nurse, shall be a certified medication technician or level I
medication aide. I/II
(52)
Medication Orders.
(A) Physician's
instructions, as evidenced by the prescription label or by signed order of a
physician, shall be accurately followed. If the physician changes the order
which is designated on a prescription label, there shall be on file in the
resident's record a signed physician's order to that effect with the amended
instructions for use or until the prescription label is changed by the pharmacy
to reflect the new order. II/III
(B) Physician's written and signed orders are
not required, but if it is the facility's or physician's policy to use the
orders, they shall include: name of the medication, dosage, frequency and route
of administration and the orders shall be renewed at least every three (3)
months. Computer generated signatures may be used if safeguards are in place to
prevent their misuse. Computer identification codes shall be accessible to and
used only by the individuals whose signatures they represent. Orders that
include optional doses or include pro re nata (PRN)
administration frequencies shall specify a maximum frequency and the reason for
administration. II/III
(C)
Telephone and other verbal orders shall be received only by a licensed nurse,
medication technician, level I medication aide or pharmacist and shall be
immediately reduced to writing and signed by that individual. If a telephone or
other verbal order is given to a medication technician or level I medication
aide, an initial dosage shall not be administered until the order has been
reviewed by telephone, facsimile or in person by a licensed nurse or
pharmacist. II
(D) The review shall
be documented by the licensed nurse's or pharmacist's signature within seven
(7) days. III
(E) The physician
shall sign all telephone and other verbal orders within seven (7) days.
III
(F) Medication staff shall
record administration of medication on a medication sheet or directly in the
resident's record. If administration of medication is recorded on a medication
sheet, the medication sheet shall be made part of the resident's medical
record. The same individual who prepares and administers the medication shall
record the administration. II/III
(53) Influenza and pneumococcal
polysaccha-ride immunizations may be administered per physician-approved
facility policy after assessment for contraindications.
(A) The facility shall develop a policy that
provides recommendations and assessment parameters for the administration of
such immunizations. The policy shall be approved by the facility medical
director for facilities having a medical director, or by each resident's
attending physician for facilities that do not have a medical director, and
shall include the requirements to:
1. Provide
education regarding the potential benefits and side effects of the immunization
to each resident or the resident's designee or legally authorized
representative; II/III
2. Offer the
immunization to the resident or obtain permission from the resident's designee
or legally authorized representative when it is medically indicated, unless the
resident has already been immunized as recommended by the policy;
II/III
3. Provide the opportunity
to refuse the immunization; and II/III
4. Perform an assessment for
contraindications. II/III
(B) The assessment for contraindications and
documentation of the education and opportunity to refuse the immunization shall
be dated and signed by the nurse performing the assessment and placed in the
medical record. II/III
(C) The
facility shall with the approval of each resident's physician, access screening
and immunization through outside sources, such as county or city health
departments, and the facility shall document in the medical record that the
requirements in subsection (53)(B) were performed by outside sources.
II/III
(54) Stock
supplies of nonprescription medication may be kept when specific medications
are approved in writing by a consulting physician, a registered nurse or a
pharmacist. No stock supply of prescription medication may be kept in the
facility. II/III
(55) Records shall
be maintained upon receipt and disposition of all controlled substances and
shall be maintained separately from other records, for two (2) years.
(A) Inventories of controlled substances
shall be reconciled as follows: II/III
1.
Controlled Substance Schedule II medications shall be reconciled each shift;
and II
2. Controlled Substance
Schedule III-V medications shall be reconciled at least weekly and as needed to
ensure accountability. II/III
(B) Inventories of controlled substances
shall be reconciled by the following:
1. Two
(2) medication personnel, one of whom is a licensed nurse; or
2. Two (2) medication personnel, one of whom
is the administrator/manager when no nurse is available on staff; or
3. Two (2) medication personnel either
medication technicians or level I medication aides when neither a licensed
nurse nor the administrator/manager is available. II/III
(C) Receipt records shall include the date,
source of supply, resident name and prescription number when applicable,
medication name and strength, quantity and signature of the supplier and
receiver. Administration records shall include the date, time, resident name,
medication name, dose administered and the initials of the individual
administering. The signature and initials of each medication staff documenting
on the medication administration record must be signed in the signature area of
the medication record. II/III
(D)
When self-control of medication is approved a record shall be made of all
controlled substances transferred to and administered from the resident's room.
Inventory reconciliation shall include controlled substances transferred to the
resident's room. I/II
(56) Documentation of the wasting of
controlled substances at the time of administration shall include the reason
for the waste and the signature of another medication staff member or the
administrator who witnesses the waste. If no medication staff member or the
administrator is available at the time of administration, the controlled
substance shall be properly labeled, clearly identified as unusable, stored in
a locked area, and destroyed as soon as a medication staff member or the
administrator is available to witness the waste. When no medication staff
member or the administrator is available and the controlled substance is
contaminated by patient body fluids, the controlled substance shall be
destroyed immediately and the circumstances documented. II/III
(57) At least every three (3) months in a
residential care facility, a pharmacist or registered nurse shall review the
controlled substance record keeping including reconciling the inventories of
controlled substances. This shall be done at the time of the drug regimen
review of each resident. All discrepancies in controlled substance records
shall be reported to the administrator or manager for review and investigation.
The theft or loss of controlled substances shall be reported as follows: II/III
(A) The facility shall notify the
department's Section for Long Term Care (SLTC) and other appropriate
authorities of any theft or significant loss of any controlled substance
medication written as an individual prescription for a specific resident upon
the discovery of the theft or loss. The facility shall consider at least the
following factors in determining if a loss is significant:
1. The actual quantity lost in relation to
the total quantity;
2. The specific
controlled substance lost;
3.
Whether the loss can be associated with access by specific
individuals;
4. Whether there is a
pattern of losses, and if the losses appear to be random or not;
5. Whether the controlled substance is a
likely candidate for diversion; and
6. Local trends and other indicators of
diversion potential; II/III
(B) If an insignificant amount of such
controlled substance is lost during lawful activities, which includes but are
not limited to receiving, record keeping, access auditing, administration,
destruction and returning to the pharmacy, a description of the occurrence
shall be documented in writing and maintained with the facility's controlled
substance records. The documentation shall include the reason for determining
that the loss was insignificant. II/III
(58) A pharmacist or registered nurse shall
review the medication regimen of each resident. This shall be done at least
every three (3) months in a residential care facility. The review shall be
performed in the facility and shall include, but shall not be limited to,
indication for use, dose, possible medication interactions and medication/food
interactions, contraindications, adverse reactions and a review of the
medication system utilized by the facility. Irregularities and concerns shall
be reported in writing to the resident's physician and to the
administrator/manager. If after thirty (30) days, there is no action taken by a
resident's physician and significant concerns continue regarding a resident's
or residents' medication order(s), the administrator/manager shall contact or
recontact the physician to determine if he or she received the information and
if there are any new instructions. II/III
(59) All medication errors and adverse
reactions shall be promptly documented and reported to the
administrator/manager and the resident's physician. If the pharmacy made a
dispensing error, it shall also be reported to the issuing pharmacy.
II/III
(60) Medications that are
not in current use shall be disposed of as follows:
(A) Single doses of contaminated, refused, or
otherwise unusable non-controlled substance medications may be destroyed by any
authorized medication staff member at the time of administration. Single doses
of unusable controlled substance medications shall be destroyed according to
section (56) of this rule;
(B)
Discontinued medications may be retained up to one hundred twenty (120) days
prior to other disposition if there is reason to believe, based on clinical
assessment of the resident, that the medication might be reordered;
(C) Medications may be released to the
resident or family upon discharge according to section (49) of this
rule;
(D) After a resident has
expired, medications, except for controlled substances, may be released to the
resident's legal representative upon written request of the legal
representative that includes the name of the medication and the reason for the
request;
(E) Medications may be
returned to the pharmacy that dispensed the medications pursuant to 4 CSR
220-3.040 or returned pursuant to the Prescription Drug Repository Program,
19
CSR 20-50.020;
(F) All other medications, including all
controlled substances and all expired or otherwise unusable medications, shall
be destroyed within thirty (30) days as follows: II/III
1. Medications shall be destroyed within the
facility by a pharmacist and a licensed nurse or by two (2) licensed nurses or
when two (2) licensed nurses are not available on staff by two (2) individuals
who have authority to administer medications, one (1) of whom shall be a
licensed nurse or a pharmacist; and II/III
2. A record of medication destroyed shall be
maintained and shall include the resident's name, date, medication name and
strength, quantity, prescription number, and signatures of the individuals
destroying the medications; and II/III
(G) A record of medication released or
returned to the pharmacy shall be maintained and shall include the resident's
name, date, medication name and strength, quantity, prescription number, and
signatures of the individuals releasing and receiving the medications.
III
(61) Residents shall
be encouraged to be active and to participate in activities. In a residential
care facility licensed for more than twelve (12) residents, a method for
informing the residents in advance of what activities are available, where they
will be held and at what times they will be held shall be developed, maintained
and used. II/III
(62) The facility
shall maintain a record in the facility for each resident which shall include
the following:
(A) Admission information
including the resident's name; admission date; confidentiality number; previous
address; birth date; sex; marital status; Social Security number; Medicare and
Medicaid numbers (if applicable); name, address and telephone number of the
resident's physician and alternate; diagnosis; name, address and telephone
number of the resident's legally authorized representative or designee to be
notified in case of emergency; and preferred dentist, pharmacist and funeral
director; III
(B) A review monthly
or more frequently, if indicated, of the resident's general condition and
needs; a monthly review of medication consumption of any resident controlling
his or her own medication, noting if prescription medications are being used in
appropriate quantities; a daily record of administration of medication; a
logging of the medication regimen review process; a monthly weight; a record of
each referral of a resident for services from an outside service; and a record
of any resident incidents including behaviors that present a reasonable
likelihood of serious harm to himself or herself or others and accidents that
potentially could result in injury or did result in injuries involving the
resident; and III
(C) Any
Physician's Orders. Except as allowed by section (52) of this rule, the
facility shall submit to the physician written versions of any oral or
telephone orders within four (4) days of the giving of the oral or telephone
order. III
(63) A record
of the daily resident census shall be retained in the facility. III
(64) Resident records shall be maintained by
the operator for at least five (5) years after a resident leaves the facility
or after the resident reaches the age of twenty-one (21), whichever is longer
and must include reason for discharge or transfer from the facility and cause
of death, if applicable. III
Notes
All rules relating to long-term care facilities licensed by the department are followed by a Roman Numeral notation which refers to the class (either class I, II or III) of standard as designated in section 198.085.1, RSMo 1986.
*Original authority: 198.005, RSMo 2006; 198.006, RSMo 1979, amended 1984, 1987, 2003, 2006; and 198.076, RSMo 1979, amended 1984.
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.
PURPOSE: This rule establishes standards for administration, personnel and resident care in residential care facilities I and II.
(1) Definitions. For the purpose of this rule, the following definitions shall apply:
(A) Department -Department of Health and Senior Services;
(B) Outbreak-an occurrence in a community or region of an illness(es) similar in nature, clearly in excess of normal expectancy and derived from a common or a propagated source; and
(C) Evacuate the facility-moving to an area of refuge or from one (1) smoke section to another or exiting the facility.
(2) For a residential care facility, a person shall be designated as administrator/manager who is either currently licensed as a nursing home administrator or is at least twenty-one (21) years of age, has never been convicted of an offense involving the operation of a long-term care or similar facility and who attends at least one (1) continuing education workshop within each calendar year given by or approved by the department . When used in this chapter of rules, the term manager shall mean that person who is designated by the operator to be in general administrative charge of a residential care facility. It shall be considered synonymous to "administrator" as defined in section 198.006, RSMo and the terms administrator and manager may be used interchangeably. II/III
(3) The administrator/manager of a residential care facility shall have successfully completed the state approved Level I Medication Aide course unless he or she is a physician, pharmacist, licensed nurse or a certified medication technician, or if the facility is operating in conjunction with a skilled nursing facility or intermediate care facility on the same premises, or, for an assisted living facility, if the facility employs on a full-time basis, a licensed nurse who is available seven (7) days per week. II/III
(4) The operator shall be responsible to assure compliance with all applicable laws and regulations. The administrator/manager 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/manager's responsibilities shall include oversight of residents to assure that they receive care appropriate to their needs. II/III
(5) The administrator/manager shall devote sufficient time and attention to the management of the facility as is necessary for the health, safety and welfare of the residents. II
(6) The administrator/manager shall designate, in writing, a staff member in charge in the administrator/manager's absence. II/III
(7) The facility shall not care for more residents than the number for which the facility is licensed. If the facility operates a non-licensed adult day care program within the licensed facility, the day care participants shall be counted in the staffing determination during the hours the day care participants are in the facility. II/III
(8) The facility's current license shall be posted in a conspicuous place and notices provided to the facility by the department granting exception(s) to regulatory requirements shall be posted alongside of the facility's license. III
(9) All personnel responsible for resident care shall have access to the legal name of each resident, name and telephone number of resident's physician, resident's designee or legally authorized representative in the event of emergency. II/III
(10) 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 residents. No person who is listed on the Employee Disqualification List (EDL) maintained by the department as required by section 198.070, RSMo shall work or volunteer in the facility in any capacity whether or not employed by the operator. For the purpose of this rule, a volunteer is an unpaid individual formally recognized by the facility as providing a direct care service to residents. The facility is required to check the EDL for individuals who volunteer to perform a service for which the facility might otherwise have to hire an employee. The facility is not required to check the EDL for individuals or groups such as scout groups, bingo or sing-along leaders. The facility is not required to check the EDL for an individual such as a priest, minister or rabbi visiting a resident who is a member of the individual's congregation. However, if the minister, priest or rabbi serves as a volunteer facility chaplain, the facility is required to check the EDL since the individual would have potential contact with all residents. I/II
(11) Prior to allowing any person who has been hired in a full-time, part-time or temporary position to have contact with any residents the facility shall, or in the case of temporary employees hired through or contracted for an employment agency, the employment agency shall prior to sending a temporary employee to a provider:
(A) Request a criminal background check for the person , as provided in section 43.540, RSMo. Each facility must maintain in its record documents verification that the background checks were requested and the nature of the response received for each such request. II
1. The facility must ensure that any applicant or person hired or retained who discloses prior to the receipt of the criminal background check that he or she has been convicted of, pled guilty or pled nolo contendere to in this state or any other state or has been found guilty of a crime, which if committed in Missouri would be a class A or B felony violation of Chapter 565, 566, or 569, RSMo or any violation of subsection 198.070.3, RSMo or of section 568.020, RSMo, will not have contact with residents. I/II
2. Upon receipt of the criminal background check, the facility must ensure that if the criminal background check indicates that the person hired or retained by the facility has been convicted of, pled guilty or pled nolo contendere to in this state or any other state or has been found guilty of a crime, which if committed in Missouri would be a class A or B felony violation of Chapter 565, 566, or 569, RSMo or any violation of subsection 198.070.3, RSMo or of section 568.020, RSMo, the person will not have contact with residents unless the facility obtains verification from the department that a good cause waiver has been granted and maintains a copy of the verification in the individual's personnel file; I/II
(B) Make an inquiry to the department , whether the person is listed on the employee disqualification list as provided in section 660.315, RSMo. The inquiry may be made via Internet at www.dhss.mo.gov/EDL/; II/III
(C) If the person has registered with the department 's Family Care Safety Registry (FCSR), the facility may utilize the Registry in order to meet the requirements of subsections (1)(A) and (11)(B) of this rule. The FCSR is available via Internet at www.dhss.mo.gov/EDL/; and II/III
(D) For persons for whom the facility has contracted for professional services (e.g., plumbing or air conditioning repair) that will have contact with any resident, the facility must either require a criminal background check or ensure that the individual is sufficiently monitored by facility staff while in the facility to reasonably ensure the safety of all residents. I/II
(12) A facility shall not employ as an agent or employee who has access to controlled substances any person who has been found guilty or entered a plea of guilty or nolo contendere in a criminal prosecution under the laws of any state or of the United States for any offense related to controlled substances. II
(A) A facility may apply in writing to the department for a waiver of this section for a specific employee.
(B) The department may issue a written waiver to a facility upon determination that a waiver would be consistent with the public health and safety. In making this determination, the department shall consider the duties of the employee, the circumstances surrounding the conviction, the length of time since the conviction was entered, whether a waiver has been granted by the department 's Bureau of Narcotics and Dangerous Drugs pursuant to 19 CSR 30-1.034 when the facility is registered with that agency, whether a waiver has been granted by the federal Drug Enforcement Administration (DEA) pursuant to 21 CFR 1301.76 when the facility is also registered with that agency, the security measures taken by the facility to prevent the theft and diversion of controlled substances, and any other factors consistent with public health and safety. II/III
(13) The facility must develop and implement written policies and procedures which require that persons hired for any position which is to have contact with any patient or resident have been informed of their responsibility to disclose their prior criminal history to the facility as required by section 660.317.5, RSMo. The facility must also develop and implement policies and procedures which ensure that the facility does not knowingly hire, after August 28, 1997, any person who has or may have contact with a patient or resident, who has been convicted of, plead guilty or nolo con-tendere to, in this state or any other state, or has been found guilty of any class A or B felony violation of Chapter 565, 566 or 569, RSMo, or any violation of subsection 3 of section 198.070, RSMo, or of section 568.020, RSMo. II/III
(14) All persons who have or may have contact with residents shall at all time 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
(15) All personnel shall be able physically and emotionally to work in a long-term care facility. I/II
(16) Personnel who have been diagnosed with a communicable disease may begin work or return to duty only with written approval by a physician or physician's designee which indicates any limitations. II
(17) The administrator/manager shall be responsible for preventing an employee known to be diagnosed with communicable disease from exposing residents to such disease. The facility's policies and procedures must comply with the department 's regulations pertaining to communicable diseases, specifically 19 CSR 20-20.010 through 19 CSR 20-20.100. II/III
(18) The facility shall screen residents and staff for tuberculosis as required for long-term care facilities by 19 CSR 20-20.100. II
(19) Prior to or on the first day that a new employee works in the facility he or she shall receive orientation of at least one (1) hour appropriate to his or her job function. This shall include at least the following:
(A) Job responsibilities;
(B) Emergency response procedures;
(C) Infection control and handwashing procedures and requirements;
(D) Confidentiality of resident information;
(E) Preservation of resident dignity;
(F) Information regarding what constitutes abuse/neglect and how to report abuse/ neglect to the department (1-800-392-0210);
(G) Information regarding the Employee Disqualification List;
(H) Instruction regarding the rights of residents and protection of property; and
(I) Instruction regarding working with residents with mental illness. II/III
(20) In addition to the orientation training required in section (19) of this rule any facility that provides care to any resident having Alzheimer's disease or related dementia shall provide orientation training regarding mentally confused residents such as those with Alzheimer's disease and related dementias as follows:
(A) For employees providing direct care to such persons, the orientation training shall include at least three (3) hours of training including at a minimum an overview of mentally confused residents such as those having Alzheimer's disease and related dementias, communicating with persons with dementia, behavior management, promoting independence in activities of daily living, and understanding and dealing with family issues; II/III
(B) For other employees who do not provide direct care for, but may have daily contact with, such persons, the orientation training shall include at least one (1) hour of training including at a minimum an overview of mentally confused residents such as those having dementias as well as communicating with persons with dementia; and II/III
(C) For all employees involved in the care of persons with dementia, dementia-specific training shall be incorporated into ongoing in-service curricula. II/III
(21) The administrator/manager shall maintain on the premises an individual personnel record on each facility employee, which shall include the following:
(A) The employee's name and address;
(B) Social Security number;
(C) Date of birth;
(D) Date of employment;
(E) Documentation of experience and education including for positions requiring licensure or certification, documentation evidencing competency for the position held, which includes copies of current licenses, transcripts when applicable, or for those individuals requiring certification, such as level I medication aides (LIMA), certified nurse aides, certified medication technicians (CMT) and insulin administration aides; printing the We b Registry search results page available at www.dhss.mo.gov/cnaregistry
shall meet the requirements of the employer's check regarding valid certification:
(F) References, if available;
(G) The results of background checks required by section 660.317, RSMo; and a copy of any good cause waiver granted by the department , if applicable;
(H) Position in the facility;
(I) Written statement signed by a licensed physician or physician's designee indicating the person can work in a long-term care facility and indicating any limitations;
(J) Documentation of the employee's tuber-cilin screening status;
(K) Documentation of what the employee was instructed on during orientation training; and
(L) Reason for termination if the employee was terminated due to abuse or neglect of a resident, residents' rights issues or resident injury. III
(22) Personnel records shall be maintained for at least two (2) years following termination of employment. III
(23) There shall be written documentation maintained in the facility showing actual hours worked by each employee. III
(24) No one individual shall be on duty with responsibility for oversight of residents longer than eighteen (18) hours per day except in a residential care facility licensed for twelve (12) or fewer residents. I/II
(25) Employees who are counted in meeting the minimum staffing ratio and employees who provide direct care to the residents shall be at least sixteen (16) years of age. III
(26) One (1) employee at least eighteen (18) years of age shall be on duty at all times. I/II
(27) Staffing for Residential Care Facility.
(A) The facility shall have an adequate number and type of personnel on duty at all times for the proper care of residents and upkeep of the facility. At a minimum, one (1) employee shall be on duty for every forty (40) residents to provide protective oversight to residents and for fire safety. I/II
| Staff | Residents |
| 1 | 1-40 |
| 2 | 41-80 |
| 3 | 81-120 |
| 4 | 121-160 |
(B) The required staff person shall be in the facility awake, dressed and prepared to assist residents in case of emergency, except that in a facility licensed for twelve (12) or fewer residents, this person may be asleep during the night hours. In a facility licensed for twenty (20) or fewer residents, the required staff person may be asleep if there is a sprinkler system or if there is a complete automatic fire detection system. I/II
(C) In a facility of more than one hundred (100) residents, the administrator/manager shall not be counted when determining the personnel required. II
(D) If the facility is opened in conjunction with and is immediately adjacent to and contiguous to another licensed long-term care facility and if-
1. The resident bedrooms of the residential care facility are on the same floor or on the ground floor immediately below that of the other licensed facility;
2. There is an approved call system in each resident's bedroom and bathroom or a patient-controlled system connected to a nursing station of the other licensed facility;
3. There is a complete fire alarm system in the residential care facility connected to the complete fire alarm system in the other licensed facility;
4. The staffing of the other licensed facility is greater than their minimum requirements; and
5. Periodic visits to the residential care facility are made by a staff person to determine the welfare of the resident in the residential care facility; then, for a facility serving twenty (20) or fewer residents, there need not be an attendant on duty during the day and evening shifts and the attendant may be asleep during the night shift; or if the facility is on the same floor as the other licensed facility, there need not be an attendant at night. If there are more than twenty (20) residents, there shall be at least one (1) staff person awake and dressed at all times for every forty (40) residents or fraction of forty (40). I/II
(E) Those facilities which have only an asleep attendant during the night-time period and those facilities which have only the minimum staff required by subsection (27)(D) during the night-time period shall not accept residents who are blind, use assistive devices, such as walkers or wheelchairs, or who need care greater than can be provided with the staffing pattern in those facilities. Those residents who were living in a residential care facility prior to July 11, 1980, may remain in that facility with an asleep attendant even though they may be blind, deaf or use assistive devices provided they can demonstrate the ability to reach safety unassisted or with assistive devices. II
(28) All residents shall be physically and mentally capable of negotiating a normal path to safety unassisted or with the use of assistive devices within five (5) minutes of being alerted of the need to evacuate the facility as defined in subsection (1)(C) of this rule. I/II
(29) Residents suffering from short periods of incapacity due to illness, injury or recuperation from surgery may be allowed to remain or be readmitted from a hospital if the period of incapacity does not exceed forty-five (45) days and written approval of a physician is obtained for the resident to remain in or be readmitted to the facility. II/III
(30) The facility shall not admit or continue to care for residents whose needs cannot be met. If necessary services cannot be obtained in or by the facility, the resident shall be promptly referred to appropriate outside resources or discharged from the facility. I/II
(31) In the event a resident is transferred from the facility, staff shall forward a report of the resident's current medical status, physician's orders/prescriptions, and if applicable, a copy of the resident's advanced directives/living will to the facility to which the resident is being transferred. If the resident is transferring to a private residence, facility staff shall provide the reports to the resident or his or her designee or legally authorized representative. II/III
(32) Residents admitted to a facility on referral by the Department of Mental Health shall have an individual treatment plan or individual habilitation plan on file prepared by the Department of Mental Health, updated annually. II
(33) Placement of residents in the building shall be determined by their abilities. Those residents who require the use of a walker or who are blind shall be housed on a floor which has direct exits at grade, a ramp or no more than two (2) steps to grade with a handrail unless an area of refuge as defined in 19 CSR 30-86.022 is provided. Those residents who use a wheelchair shall be able to demonstrate the ability to transfer to and from the wheelchair unassisted. They shall be housed near an exit and there shall be a direct exit at grade or a ramp or an area of refuge as defined in 19 CSR 30-86.022. II
(34) Requirements for facilities which admit or retain residents with mental illness or mental retardation diagnosis and residents with assaultive or disruptive behaviors:
(A) Each resident who exhibits mental and psychosocial adjustment difficulty(ies) shall receive treatment and services to address the resident's needs and behaviors as stated in the individual service plan; I/II
(B) If specialized rehabilitative services for mental illness or mental retardation are required to enable a resident to reach and to comply with the individualized service plan, the facility must ensure the required services are provided; and II
(C) The facility shall maintain in the resident's record the most recent progress notes and personal plan developed and provided by the Department of Mental Health or designated administrative agent for each resident whose care is funded by the Department of Mental Health or designated administrative agent. III
(35) The use of interventions to manage disruptive or assaultive resident behaviors shall be employed with sufficient safeguards to ensure the safety, welfare and rights of the resident and shall be in accordance with the therapeutic goals for the resident. I/II
(36) Residents under sixteen (16) years of age shall not be admitted. III
(37) Residents admitted or readmitted to the facility shall have an admission physical examination by a licensed physician. Documentation should be obtained prior to admission but shall be on file not later than ten (10) days after admission and shall contain information regarding the resident's current medical status and any special orders or procedures which should be followed. If the resident is admitted directly from a hospital or another long-term care facility and is accompanied on admission by a report which reflects his/her current medical status, an admission physical will not be required. II/III
(38) The facility shall follow appropriate infection control procedures. The administrator or his or her designee shall make a report to the local health authority or the department of the presence or suspected presence of any diseases or findings listed in 19 CSR 20-20.020, sections (1)-(3) according to the specified time frames as follows:
(A) Category I diseases or findings shall be reported to the local health authority or to the department within twenty-four (24) hours of first knowledge or suspicion by telephone, facsimile, or other rapid communication; I/II
(B) Category II diseases or findings shall be reported to the local health authority or the department within three (3) days of first knowledge or suspicion; I/II
(C) Category III. The occurrence of an outbreak or epidemic of any illness, disease or condition which may be of public health concern, including any illness in a food handler that is potentially transmissible through food. This also includes public health threats such as clusters of unusual diseases or manifestations of illness and clusters of unexplained deaths. Such incidents shall be reported to the local authority or to the department by telephone, facsimile, or other rapid communication within twenty-four (24) hours of first knowledge or suspicion. I/II
(39) Protective oversight shall be provided twenty-four (24) hours a day. For residents departing the premises on voluntary leave, the facility shall have, at a minimum, a procedure to inquire of the resident or resident's guardian of the resident's departure, of the resident's estimated length of absence from the facility, and of the resident's whereabouts while on voluntary leave. I/II
(40) Residents shall receive proper care to meet their needs. Physician orders shall be followed. I/II
(41) In case of behaviors that present a reasonable likelihood of serious harm to himself or herself or others, serious illness, significant change in condition, injury or death, staff shall take appropriate action and shall promptly attempt to contact the individual listed in the resident's record as the legally authorized representative, designee or placement authority. The facility shall contact the attending physician or designee and notify the local coroner or medical examiner immediately upon the death of any resident of the facility prior to transferring the deceased resident to a funeral home. II/III
(42) The facility shall encourage and assist each resident based on his or her individual preferences and needs, to be clean and free of body and mouth odor. II
(43) Except in the case of emergency, the resident shall not be inhibited by chemical and/or physical restraints that would limit self-care or ability to negotiate a path to safety unassisted or with assistive devices. I/II
(44) If the resident brings unsealed medications to the facility, the medications shall not be used unless a pharmacist, physician or nurse examines, identifies and determines the contents to be suitable for use. The individual performing the identification shall document his or her review. II/III
(45) Self-control of prescription medication by a resident may be allowed only if approved in writing by the resident's physician and allowed by facility policy. A resident may be permitted to control the storage and use of nonprescription medication unless there is a physician's written order or facility policy to the contrary. Written approval for self-control of prescription medication shall be rewritten as needed but at least annually and after any period of hospitalization. II/III
(46) All medication shall be safely stored at proper temperature and shall be kept in a secured location behind at least one (1) locked door or cabinet. Medication shall be accessible only to persons authorized to administer medications. II/III
(A) If access is controlled by the resident, a secured location shall mean in a locked container, a locked drawer in a bedside table or dresser or in a resident's private room if locked in his or her absence, although this does not preclude access by a responsible employee of the facility. II/III
(B) Schedule II controlled substances shall be stored in locked compartments separate from non-controlled medications, except that single doses of Schedule II controlled substances may be controlled by a resident in compliance with the requirements for self-control of medication of this rule. II/III
(C) Medication that is not in current use and is not destroyed shall be stored separately from medication that is in current use. II/III
(47) All prescription medications shall be supplied as individual prescriptions except where an emergency medication supply is allowed. All medications, including over-the-counter medications shall be packaged and labeled in accordance with applicable professional pharmacy standards and state and federal drug laws. Labeling shall include accessory and cautionary instructions as well as the expiration date, when applicable, and the name of the medication as specified in the physician's order. Medication labels shall not be altered by facility staff and medications shall not be repackaged by facility staff except as allowed by section (48) of this rule. Over-the-counter medications for individual residents shall be labeled with at least the resident's name. II/III
(48) Controlled substances and other prescription and non-prescription medications for administration when a resident temporarily leaves a facility shall be provided as follows:
(A) Separate containers of medications for the leave period may be prepared by the pharmacy. The facility shall have a policy and procedure for families to provide adequate advance notice so that medications can be obtained from the pharmacy; II/III
(B) Prescription medication cards or other multiple-dose prescription containers currently in use in the facility may be provided by any authorized facility medication staff member if the containers are labeled by the pharmacy with complete pharmacy prescription labeling for use. Original manufacturer containers of non-prescription medications, along with instructions for administration, may be provided by any authorized facility medication staff member; II/III
(C) When medications are supplied by the pharmacy in customized patient medication packages that allow separation of individual dose containers, the required number of containers may be provided by any authorized facility medication staff member. The individual dose containers shall be placed in an outer container that is labeled with the name and address of the facility and the date; II/III
(D) When multiple doses of a medication are required and it is not reasonably possible to obtain prescription medication labeled by the pharmacy, and it is not appropriate to send a container of medication currently in use in the facility, up to a twenty-four (24)-hour supply of each prescription or non-prescription medication may be provided by a licensed nurse in United States Pharmacopeia (USP) approved containers labeled with the facility name and address, resident's name, medication name and strength, quantity, instructions for use, date, initials of individual providing, and other appropriate information; II/III
(E) When no more than a single dose of a medication is required, any authorized facility medication staff member may prepare the dose as for in-facility administration in a USP approved container labeled with the facility name and address, resident's name, medication name and strength, quantity, instructions for use, date, initials of person providing, and other appropriate information;
(F) The facility may have a policy that limits the quantity of medication sent with a resident without prior approval of the prescriber; II/III
(G) Returned containers shall be identified as having been sent with the resident, and shall not later be returned to the pharmacy for reuse; and II/III
(H) The facility shall maintain accurate records of medications provided to and returned by the resident. II/III
(49) Upon discharge or transfer of a resident, the facility shall release prescription medications, including controlled substances, held by the facility for the resident when the physician writes an order for each medication to be released. Medications shall be labeled by the pharmacy with current instructions for use. Prescription medication cards or other containers may be released if the containers are labeled by the pharmacy with complete pharmacy prescription labeling. II/III
(50) Injections shall be administered only by a physician or licensed nurse, except that insulin injections may be administered by a CMT or LIMA who has successfully completed the state-approved course for insulin administration, taught by a department -approved instructor. A resident who requires insulin, may administer his or her own insulin if approved in writing by the resident's physician and trained to do so by a licensed nurse or physician. The facility is responsible to monitor the resident's condition and continued ability for self-administration. I/II
(51) The administrator/manager shall develop and implement a safe and effective system of medication control and use, which assures that all residents' medications are administered by personnel at least eighteen (18) years of age, in accordance with physicians' instructions using acceptable nursing techniques. The facility shall employ a licensed nurse eight (8) hours per week for every thirty (30) residents to monitor each resident's condition and medication. Administration of medication shall mean delivering to a resident his or her prescription medication either in the original pharmacy container, or for internal medication, removing an individual dose from the pharmacy container and placing it in a small container or liquid medium for the resident to remove from the container and self-administer. External prescription medication may be applied by facility personnel if the resident is unable to do so and the resident's physician so authorizes. All individuals who administer medication shall be trained in medication administration and, if not a physician or a licensed nurse, shall be a certified medication technician or level I medication aide. I/II
(52) Medication Orders.
(A) Physician's instructions, as evidenced by the prescription label or by signed order of a physician, shall be accurately followed. If the physician changes the order which is designated on a prescription label, there shall be on file in the resident's record a signed physician's order to that effect with the amended instructions for use or until the prescription label is changed by the pharmacy to reflect the new order. II/III
(B) Physician's written and signed orders are not required, but if it is the facility's or physician's policy to use the orders, they shall include: name of the medication, dosage, frequency and route of administration and the orders shall be renewed at least every three (3) months. Computer generated signatures may be used if safeguards are in place to prevent their misuse. Computer identification codes shall be accessible to and used only by the individuals whose signatures they represent. Orders that include optional doses or include pro re nata (PRN) administration frequencies shall specify a maximum frequency and the reason for administration. II/III
(C) Telephone and other verbal orders shall be received only by a licensed nurse, medication technician, level I medication aide or pharmacist and shall be immediately reduced to writing and signed by that individual. If a telephone or other verbal order is given to a medication technician or level I medication aide, an initial dosage shall not be administered until the order has been reviewed by telephone, facsimile or in person by a licensed nurse or pharmacist. II
(D) The review shall be documented by the licensed nurse's or pharmacist's signature within seven (7) days. III
(E) The physician shall sign all telephone and other verbal orders within seven (7) days. III
(F) Medication staff shall record administration of medication on a medication sheet or directly in the resident's record. If administration of medication is recorded on a medication sheet, the medication sheet shall be made part of the resident's medical record. The same individual who prepares and administers the medication shall record the administration. II/III
(53) Influenza and pneumococcal polysaccha-ride immunizations may be administered per physician-approved facility policy after assessment for contraindications.
(A) The facility shall develop a policy that provides recommendations and assessment parameters for the administration of such immunizations. The policy shall be approved by the facility medical director for facilities having a medical director, or by each resident's attending physician for facilities that do not have a medical director, and shall include the requirements to:
1. Provide education regarding the potential benefits and side effects of the immunization to each resident or the resident's designee or legally authorized representative; II/III
2. Offer the immunization to the resident or obtain permission from the resident's designee or legally authorized representative when it is medically indicated, unless the resident has already been immunized as recommended by the policy; II/III
3. Provide the opportunity to refuse the immunization; and II/III
4. Perform an assessment for contraindications. II/III
(B) The assessment for contraindications and documentation of the education and opportunity to refuse the immunization shall be dated and signed by the nurse performing the assessment and placed in the medical record. II/III
(C) The facility shall with the approval of each resident's physician, access screening and immunization through outside sources, such as county or city health departments, and the facility shall document in the medical record that the requirements in subsection (53)(B) were performed by outside sources. II/III
(54) Stock supplies of nonprescription medication may be kept when specific medications are approved in writing by a consulting physician, a registered nurse or a pharmacist. No stock supply of prescription medication may be kept in the facility. II/III
(55) Records shall be maintained upon receipt and disposition of all controlled substances and shall be maintained separately from other records, for two (2) years.
(A) Inventories of controlled substances shall be reconciled as follows: II/III
1. Controlled Substance Schedule II medications shall be reconciled each shift; and II
2. Controlled Substance Schedule III-V medications shall be reconciled at least weekly and as needed to ensure accountability. II/III
(B) Inventories of controlled substances shall be reconciled by the following:
1. Two (2) medication personnel, one of whom is a licensed nurse; or
2. Two (2) medication personnel, one of whom is the administrator/manager when no nurse is available on staff; or
3. Two (2) medication personnel either medication technicians or level I medication aides when neither a licensed nurse nor the administrator/manager is available. II/III
(C) Receipt records shall include the date, source of supply, resident name and prescription number when applicable, medication name and strength, quantity and signature of the supplier and receiver. Administration records shall include the date, time, resident name, medication name, dose administered and the initials of the individual administering. The signature and initials of each medication staff documenting on the medication administration record must be signed in the signature area of the medication record. II/III
(D) When self-control of medication is approved a record shall be made of all controlled substances transferred to and administered from the resident's room. Inventory reconciliation shall include controlled substances transferred to the resident's room. I/II
(56) Documentation of the wasting of controlled substances at the time of administration shall include the reason for the waste and the signature of another medication staff member or the administrator who witnesses the waste. If no medication staff member or the administrator is available at the time of administration, the controlled substance shall be properly labeled, clearly identified as unusable, stored in a locked area, and destroyed as soon as a medication staff member or the administrator is available to witness the waste. When no medication staff member or the administrator is available and the controlled substance is contaminated by patient body fluids, the controlled substance shall be destroyed immediately and the circumstances documented. II/III
(57) At least every three (3) months in a residential care facility, a pharmacist or registered nurse shall review the controlled substance record keeping including reconciling the inventories of controlled substances. This shall be done at the time of the drug regimen review of each resident. All discrepancies in controlled substance records shall be reported to the administrator or manager for review and investigation. The theft or loss of controlled substances shall be reported as follows: II/III
(A) The facility shall notify the department 's Section for Long Term Care (SLTC) and other appropriate authorities of any theft or significant loss of any controlled substance medication written as an individual prescription for a specific resident upon the discovery of the theft or loss. The facility shall consider at least the following factors in determining if a loss is significant:
1. The actual quantity lost in relation to the total quantity;
2. The specific controlled substance lost;
3. Whether the loss can be associated with access by specific individuals;
4. Whether there is a pattern of losses, and if the losses appear to be random or not;
5. Whether the controlled substance is a likely candidate for diversion; and
6. Local trends and other indicators of diversion potential; II/III
(B) If an insignificant amount of such controlled substance is lost during lawful activities, which includes but are not limited to receiving, record keeping, access auditing, administration, destruction and returning to the pharmacy, a description of the occurrence shall be documented in writing and maintained with the facility's controlled substance records. The documentation shall include the reason for determining that the loss was insignificant. II/III
(58) A pharmacist or registered nurse shall review the medication regimen of each resident. This shall be done at least every three (3) months in a residential care facility. The review shall be performed in the facility and shall include, but shall not be limited to, indication for use, dose, possible medication interactions and medication/food interactions, contraindications, adverse reactions and a review of the medication system utilized by the facility. Irregularities and concerns shall be reported in writing to the resident's physician and to the administrator/manager. If after thirty (30) days, there is no action taken by a resident's physician and significant concerns continue regarding a resident's or residents' medication order(s), the administrator/manager shall contact or recontact the physician to determine if he or she received the information and if there are any new instructions. II/III
(59) All medication errors and adverse reactions shall be promptly documented and reported to the administrator/manager and the resident's physician. If the pharmacy made a dispensing error, it shall also be reported to the issuing pharmacy. II/III
(60) Medications that are not in current use shall be disposed of as follows:
(A) Single doses of contaminated, refused, or otherwise unusable non-controlled substance medications may be destroyed by any authorized medication staff member at the time of administration. Single doses of unusable controlled substance medications shall be destroyed according to section (56) of this rule;
(B) Discontinued medications may be retained up to one hundred twenty (120) days prior to other disposition if there is reason to believe, based on clinical assessment of the resident, that the medication might be reordered;
(C) Medications may be released to the resident or family upon discharge according to section (49) of this rule;
(D) After a resident has expired, medications, except for controlled substances, may be released to the resident's legal representative upon written request of the legal representative that includes the name of the medication and the reason for the request;
(E) Medications may be returned to the pharmacy that dispensed the medications pursuant to 4 CSR 220-3.040 or returned pursuant to the Prescription Drug Repository Program, 19 CSR 20-50.020;
(F) All other medications, including all controlled substances and all expired or otherwise unusable medications, shall be destroyed within thirty (30) days as follows: II/III
1. Medications shall be destroyed within the facility by a pharmacist and a licensed nurse or by two (2) licensed nurses or when two (2) licensed nurses are not available on staff by two (2) individuals who have authority to administer medications, one (1) of whom shall be a licensed nurse or a pharmacist; and II/III
2. A record of medication destroyed shall be maintained and shall include the resident's name, date, medication name and strength, quantity, prescription number, and signatures of the individuals destroying the medications; and II/III
(G) A record of medication released or returned to the pharmacy shall be maintained and shall include the resident's name, date, medication name and strength, quantity, prescription number, and signatures of the individuals releasing and receiving the medications. III
(61) Residents shall be encouraged to be active and to participate in activities. In a residential care facility licensed for more than twelve (12) residents, a method for informing the residents in advance of what activities are available, where they will be held and at what times they will be held shall be developed, maintained and used. II/III
(62) The facility shall maintain a record in the facility for each resident which shall include the following:
(A) Admission information including the resident's name; admission date; confidentiality number; previous address; birth date; sex; marital status; Social Security number; Medicare and Medicaid numbers (if applicable); name, address and telephone number of the resident's physician and alternate; diagnosis; name, address and telephone number of the resident's legally authorized representative or designee to be notified in case of emergency; and preferred dentist, pharmacist and funeral director; III
(B) A review monthly or more frequently, if indicated, of the resident's general condition and needs; a monthly review of medication consumption of any resident controlling his or her own medication, noting if prescription medications are being used in appropriate quantities; a daily record of administration of medication; a logging of the medication regimen review process; a monthly weight; a record of each referral of a resident for services from an outside service; and a record of any resident incidents including behaviors that present a reasonable likelihood of serious harm to himself or herself or others and accidents that potentially could result in injury or did result in injuries involving the resident; and III
(C) Any Physician's Orders. Except as allowed by section (52) of this rule, the facility shall submit to the physician written versions of any oral or telephone orders within four (4) days of the giving of the oral or telephone order. III
(63) A record of the daily resident census shall be retained in the facility. III
(64) Resident records shall be maintained by the operator for at least five (5) years after a resident leaves the facility or after the resident reaches the age of twenty-one (21), whichever is longer and must include reason for discharge or transfer from the facility and cause of death, if applicable. III
Notes
All rules relating to long-term care facilities licensed by the
*Original authority: 198.005, RSMo 2006; 198.006, RSMo 1979, amended 1984, 1987, 2003, 2006; and 198.076, RSMo 1979, amended 1984.