19 CSR 30-86.043 - Administrative, Personnel, and Resident Care Requirements for Facilities Licensed as a Residential Care Facility II on August 27, 2006 that Will Comply with Residential Care Facility II Standards

Current through Register Vol. 47, No. 7, April 1, 2022

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


19 CSR 30-86.043
AUTHORITY: sections 198.073 and 198.076, RSMo Supp. 2011.* Original rule filed Aug. 23, 2006, effective April 30, 2007. Amended: Filed March 1, 2012, effective Sept. 30, 2012.

*Original authority: 198.073, RSMo 1979, amended 1984, 1992, 1999, 2006, 2007 and 198.076, RSMo 1979, amended 1984, 2007.

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