PURPOSE: This rule establishes requirements for
administration, personnel and resident care requirements for facilities
licensed pursuant to section
198.005, RSMo that continue to
comply with residential care facilities (RCF) II standards in effect on August
27, 2006.
AGENCY NOTE: All rules relating to long-term care
facilities licensed by the department are followed by a Roman Numeral notation
which refers to the class (either Class I, II, or III) of standard as
designated in section 198.085.1., RSMo.
(1) This rule contains the administrative,
personnel and resident care standards in effect on August 27, 2006 for
residential care facility IIs (formerly published at
19 CSR
30-86.042 (effective 12/31/05)). These standards apply
to facilities that were licensed as residential care facility IIs on August 27,
2006 and that choose to be inspected under these standards rather than the
standards published at
19 CSR
30-86.047.
(2) A person shall be designated to be an
administrator who is currently licensed as an administrator by the Missouri
Board of Nursing Home Administrators, in accordance with Chapter 344, RSMo.
II
(3) By January 1, 1991, the
administrator of a facility shall have successfully completed the state
approved Level I Medication Aide course unless s/he 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 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
shall be fully authorized and empowered to make decisions regarding the
operation of the facility and shall be held responsible for the actions of all
employees. The administrator's responsibilities shall include oversight of
residents to assure that they receive appropriate care. II/III
(5) The administrator 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 cannot be listed or
function in more than one (1) facility at the same time unless s/he serves no
more than four (4) facilities which are within a thirty (30)-mile radius and
licensed to serve in total no more than one hundred (100) residents. However,
one (1) administrator may serve as the administrator of more than one (1)
licensed facility if all facilities are on the same premises. II/III
(7) The administrator shall designate, in
writing, a staff person in charge in his/her absence. If the administrator is
absent for more than thirty (30) consecutive days, during which time s/he is
not readily accessible for consultation by telephone with the person in charge
or if the administrator is absent from the facility for more than sixty (60)
working days during the course of a calendar year the person designated to be
in charge shall be an administrator currently licensed by the Missouri Board of
Nursing Home Administrators, in accordance with Chapter 344, RSMo.
II/III
(8) The facility shall not
care for more residents than the number for which the facility is licensed.
II/III
(9) The facility's current
license shall be posted in a conspicuous place and notices provided to the
facility by the Department of Health and Senior Services (the department)
granting exception(s) to regulatory requirements shall be posted alongside of
the facility's license. III
(10)
All personnel responsible for resident care shall have access to the legal name
of each resident, name and telephone number of physician and next of kin or
responsible party in the event of emergency. II/III
(11) 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 leaders, or sing-along leaders. The
facility is not required to check the EDL for an individual such as a priest,
minister, or rabbi visiting a resident who is a member of the individual's
congregation. However, if 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
(12) Prior to allowing any
person who has
been hired in a full-time, part-time, or temporary
position to have contact
with any resident, the facility shall, or in the case of temporary employees
hired through or contracted for an employment agency, the employment agency
shall, prior to sending a temporary employee to a facility:
(A) Request a criminal background check for
the
person, as provided in section
660.317, RSMo. Each facility
shall maintain documents verifying that the background checks were requested,
the date of each such request, and the nature of the response received for each
such request. II
1. The facility shall ensure
that any person hired or retained to have contact with any resident who
discloses that he or she has been convicted of, found guilty of, pled guilty
to, or pled nolo contendere to a crime, in this state or any
other state, which if committed in Missouri would be a class A or B felony
violation of Chapter 565, 566, or 569, RSMo, or any violation of section
198.070.3., RSMo, or section
568.020, RSMo, shall not be
retained in such a position. I/II
2. Upon receipt of the criminal background
check, the facility shall ensure that if the criminal background check
indicates that the person hired or retained by the facility has been convicted
of, found guilty of, pled guilty to, or pled nolo contendere
to a crime, in this state or any other state, which if committed in Missouri
would be a class A or B felony violation of Chapter 565, 566, or 569, RSMo, or
any violation of section 198.070.3., RSMo, or section
568.020, RSMo, the person shall
not have contact with any resident unless and until the facility obtains
verification from the department that a good cause waiver has been granted for
each qualifying offense and maintains a copy of the verification in the
individual's personnel file; I/II
(B) Make an inquiry to the
department, as
provided in section
660.315, RSMo, as to whether the
person is listed on the EDL.
Each facility shall maintain documents verifying that the EDL
checks were requested, the date of each such request, and the nature of the
response received for each such request. The inquiry may be made through the
department's website; II/III
(C) For persons for whom the facility has
contracted for professional services (e.g., plumbing or air conditioning
repair) that will have contact with any resident, the facility shall either
require a criminal background check or ensure that the individual is
sufficiently monitored by facility staff while in the facility to reasonably
ensure the safety of all residents; and I/II
(D) If the person has registered with the
department's Family Care Safety Registry (FCSR), the facility may utilize the
FCSR in order to meet the requirements of subsections (12)(A) and (12)(B) of
this rule. The FCSR is available through the department's website.
(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 contendere 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 times when on duty or delivering services wear an
identification badge. The badge shall give their name, title and, if
applicable, the status of their license or certification as any kind of health
care professional. This rule shall apply to all personnel who provide services
to any resident directly or indirectly. III
(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 shall be responsible for monitoring the health of the employees.
II/III
(18) Prior to or on the
first day that a new employee works in the facility s/he shall receive
orientation of at least one (1) hour appropriate to his/her job function. This
shall include, at a minimum, job responsibilities, how to handle emergency
situations, the importance of infection control and hand-washing,
confidentiality of resident information, preservation of resident dignity, how
to report abuse/neglect to the department (1-800-392-0210), information
regarding the Employee Disqualification List and instruction regarding the
rights of residents and protection of property. II/III
(19) The administrator shall maintain on the
premises an individual personnel record on each employee of the facility which
shall include: the employee's name and address; Social Security number; date of
birth; date of employment; experience and education including documentation of
specialized training on medication and/or insulin administration, or both;
references, if available; the results of background checks required by section
660.317, RSMo; position in the
facility; 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; record that the employee was instructed on
residents' rights, facility's policies, job duties and any other orientation
and reason for termination. Personnel records shall be maintained for at least
one (1) year following termination of employment. III
(20) There shall be written documentation
maintained in the facility showing actual hours worked by each employee.
III
(21) No one individual shall be
on duty with responsibility for oversight of residents longer than eighteen
(18) hours per day. I/II
(22)
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
(23) One (1) employee
at least eighteen (18) years of age shall be on duty at all times.
I/II
(24) Staffing.
(A) The facility shall have an adequate
number and type of personnel for the proper care of residents and upkeep of the
facility. At a minimum, the staffing pattern for fire safety and care of
residents shall be one (1) staff
person for every fifteen (15) residents or
major fraction of fifteen (15) during the day shift, one (1)
person for every
twenty (20) residents or major fraction of twenty (20) during the evening shift
and one (1)
person for every twenty-five (25) residents or major fraction of
twenty-five (25) during the night shift. I/II
Time
|
Personnel
|
Residents
|
7 a.m. to 3 p.m. (Day)* |
1 |
3-15 |
3 p.m. to 9 p.m. (Evening)* |
1 |
3-20 |
9 p.m. to 7 a.m. (Night)* |
1 |
3-25 |
*If the shift hours vary from those indicated, the hours of
the shifts shall show on the work schedules of the facility and shall not be
less than six (6) hours. III
(B) The required staff shall be in the
facility awake, dressed and prepared to assist residents in case of emergency.
I/II
(C) In a facility of more than
one hundred (100) residents, the administrator shall not be counted when
determining the personnel required. II
(D) If the facility is operated in
conjunction with and is immediately adjacent to and contiguous to another
licensed long-term care facility and if the resident bedrooms of the facility
are on the same floor as at least a portion of a licensed intermediate care or
skilled nursing facility; there is an approved call system in each resident's
bedroom and bathroom or a patient-controlled call system; and there is a
complete fire alarm system in the facility tied into the complete fire alarm
system in the other licensed facility, then the following minimum staffing for
oversight and care of residents, for upkeep of the facility and for fire safety
shall be one (1) staff
person for every eighteen (18) residents or major
fraction of residents during the day shift, one (1)
person for every
twenty-five (25) residents or major fraction of residents during the evening
shift and one (1)
person for every thirty (30) residents or major fraction of
residents during the night shift. I/II
Time
|
Personnel
|
Residents
|
7 a.m. to 3 p.m. (Day)* |
1 |
3-18 |
3 p.m. to 9 p.m. (Evening)* |
1 |
3-25 |
9 p.m. to 7 a.m. (Night)* |
1 |
3-30 |
*If the shift hours vary from those indicated, the hours of
the shifts shall show on the work schedules of the facility and shall not be
less than six (6) hours. III
(E) There shall be a licensed nurse employed
by the facility to work at least eight (8) hours per week at the facility for
every thirty (30) residents or additional major fraction of thirty (30). The
nurse's duties shall include, but shall not be limited to, review of residents'
charts, medications and special diets or other orders, review of each
resident's adjustment to the facility and observation of each individual
resident's general physical and mental condition. The nurse shall inform the
administrator of any problems noted and these shall be brought to the attention
of the resident's physician. II/III
(25) All residents shall be physically and
mentally capable of negotiating a normal path to safety unassisted or with the
use of assistive devices. I/II
(26)
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
(27) 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 transferred to a facility providing the
appropriate level of care. I/II
(28) In the event a resident is transferred
from the facility, a report of the resident's current medical status shall
accompany him/her. III
(29)
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. III
(30) Residents under sixteen (16) years of
age shall not be admitted. III
(31)
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. 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. II
(32)
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
(33) If at any time a
resident or prospective resident is diagnosed with a communicable disease, the
department shall be notified within seven (7) days and if the facility can meet
the resident's needs, the resident may be admitted or does not need to be
transferred. Appropriate infection control procedures shall be followed if the
resident remains in or is accepted by the facility. I/II
(34) 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
(35) Residents shall receive proper care to
meet their needs. Physician orders shall be followed. I/II
(36) In case of serious illness, accident or
death, appropriate action shall be taken and the person designated in the
resident's record as the responsible party and, if applicable, the guardian
shall be immediately notified. II/III
(37) Every resident shall be clean, dry and
free of offensive body and mouth odor. I/II
(38) 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
(39) A
supply of clean linen shall be available in the facility and provided to
residents to meet their daily needs. II/III
(40) Beds shall be made daily and linen
changed at least weekly or more often if needed to maintain a clean, dry bed.
II/III
(41) The resident's unit
shall be thoroughly cleaned and disinfected following a resident's death,
discharge or transfer. II/III
(42)
Commodes and urinals, if used, shall be kept at the bedside of the residents.
They shall not be left open and the container shall be emptied promptly and
thoroughly cleaned after each use. III
(43) Cuspidors shall be emptied and cleaned
daily or disposable cartons shall be provided daily. III
(44) 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. If a resident is not taking any
prescription medication, the 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. If not permitted, all medications for
that resident, including over-the-counter medications, shall be controlled by
the administrator unless the physician specifies otherwise. II/III
(45) Written approval for self-control of
prescription medication shall be rewritten as needed but at least annually and
after any period of hospitalization. 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. 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/her absence,
although this does not preclude access by a responsible employee of the
facility. II/III
(47) All
prescription medications shall be supplied as individual prescriptions. All
medications, including over-the-counter medications shall be packaged and
labeled in accordance with applicable professional pharmacy standards, state
and federal drug laws and regulations and the United States
Pharmacopeia (USP). Labeling shall include accessory and cautionary
instructions as well as the expiration date, when applicable, and the name of
the medication as specified in the physician's order. Over-the-counter
medications for individual residents shall be labeled with at least the
resident's name. II/III
(48)
Injections shall be administered only by a physician or licensed nurse, except
that residents who require insulin, upon written order of their physician, may
administer their own insulin or the insulin may be administered by a person
trained to do so by a licensed nurse or physician and the resident's condition
shall be monitored by his/her physician. After December 31, 1990, unless
insulin is self-administered or it is administered only by a physician or
licensed nurse, it shall be administered by a certified medication technician
or a level I medication aide who has successfully completed the state-approved
course for insulin administration, taught by an approved instructor and who was
recommended for training by an administrator or nurse with whom he or she
works. Anyone trained prior to December 31, 1990, who completed the
state-approved insulin administration course taught by an approved instructor
shall be considered qualified to administer insulin in a facility. Anyone
trained prior to December 31, 1990, to administer insulin by a licensed nurse
or physician not using the state-approved course may qualify by challenging the
final examination of the insulin administration course. I/II
(49) The administrator shall develop and
implement a safe and effective system of medication control and use which
assures that all residents' medications are administered or distributed by
personnel at least eighteen (18) years of age, in accordance with physicians'
instructions using acceptable nursing techniques. Until January 1, 1991, those
facilities administering medications shall utilize personnel trained in
medication administration (a licensed nurse, certified medication technician or
level I medication aide) and shall employ a licensed nurse eight (8) hours per
week for every thirty (30) residents to monitor each resident's condition.
Distribution shall mean delivering to a resident his/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. After December 31, 1990, all persons who administer or
distribute 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
(50)
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 medication, dosage and frequency of
administration and the orders shall be renewed at least every three (3) months.
II/III
(C) Verbal and telephone
orders shall be taken 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 order is given to a medication
technician or level I medication aide, an initial dosage of a new prescription
shall not be initiated until the order has been reviewed by telephone or in
person by a licensed nurse or pharmacist. II
(D) The review shall be documented by the
nurse's or pharmacist's signature within seven (7) days. III
(E) The physician shall sign all verbal and
telephone orders within seven (7) days. III
(F) The administration or distribution of
medication shall be recorded on a medication sheet or directly in the
resident's record and, if recorded on a medication sheet, shall be made part of
the resident's record. The administration or distribution shall be recorded by
the same person who prepares the medication and who distributes or administers
it. II/III
(51) A stock
supply of prescription medication may be kept in the facility. An emergency
drug supply as recommended by a pharmacist or physician may be kept if approved
by the department. Storage and use of medications in the emergency drug supply
shall assure accountability. II/III
(52) Stock supplies of nonprescription
medication may be kept for pro re nata (PRN) use in facilities
as long as the particular medications are approved in writing by a consulting
physician, a registered nurse or a pharmacist. II/III
(53) All controlled substances shall be
handled according to state laws and regulations as given in and required by 19
CSR
30-1 and Chapter 195, RSMo. II/III
(54) A pharmacist or registered nurse shall
review the drug regimen of each resident. This shall be done at least every
other month in a facility. The review shall be performed in the facility and
shall include, but shall not be limited to, possible drug and 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. If
after thirty (30) days, there is no action taken by a resident's physician and
significant concerns continue regarding a resident's or residents' medication
order(s), the administrator shall contact or recontact the physician to
determine if he or she received the information and if there are any new
instructions. II/III
(55)
Medications controlled by the facility shall be disposed of either by
destroying, returning to the pharmacy or sending with residents on discharge.
The following shall be destroyed within the facility within ninety (90) days:
discontinued medication not returnable to the pharmacy, all discontinued
controlled substances, outdated or deteriorated medication, medication of
expired residents not returnable to the pharmacy and medications not sent with
the resident on discharge. II/III
(56) Disposition of medication controlled by
the facility shall be recorded listing the resident's name, the date and the
name, strength and quantity of the drug and the signature(s) of the person(s)
involved. Medication destruction shall involve two (2) persons, one (1) of whom
shall be a pharmacist, a nurse or a state inspector. III
(57) Residents shall be encouraged to be
active and to participate in activities. In a 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
(58) A record shall be maintained in the
facility for each resident which shall include:
(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
number; name, address and telephone number of physician and alternate; name,
address and telephone number of resident's next of kin, legal guardian,
designee or person to be notified in case of emergency; and preferred dentist,
pharmacist and funeral director; and III
(B) A resident's record, including 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/her own medication, noting if prescription medications are
being used in appropriate quantities; a daily record of distribution or
administration of medication; any physician's orders; a logging of the drug
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 patient
incidents and accidents involving the resident. III
(59) A record of the resident census as well
as records regarding discharge, transfer or death of residents shall be kept in
the facility. III
(60) Resident
records shall be maintained by the operator for at least five (5) years after
the resident leaves the facility or after the resident reaches the age of
twenty-one (21), whichever is longer. III