Standards for the Operation of Long-Term Care Units

PURPOSE: This rule establishes standards for the administration, nursing staff, and overall operation of long-term care units in hospitals to provide a high level of care. (1) Swing beds located in the hospital which may be used intermittently for long-term care are exempt from the requirements of this rule. (2) Administration. (A) A long-term care unit shall be licensed as part of the hospital in which it is located or attached. The hospital governing body shall be the legal authority for the long-term care unit and shall be responsible for the overall planning, directing, control, and management of the activities and functions of the long-term care unit. (B) The administration of the long-term care unit shall be the responsibility of the chief executive officer of the hospital. This authority may be delegated to a qualified assistant in accordance with the governing body bylaws of the hospital. (C) Visiting Hours. 1. Regular daily visiting hours shall be established. 2. Relatives or guardians and clergy, if requested by the resident or family, shall be allowed to see critically-ill residents at any time in keeping with the orders of the physician. (D) Medical records shall comply with 19 CSR 30-20.015. All medical orders shall be renewed at least monthly. (E) All residents shall have a comprehensive, accurate, standardized assessment completed within fourteen (14) days of admission utilizing the resident assessment instrument developed by the Centers for Medicare and Medicaid Services (CMS) for use in long-term care facilities. The assessment shall be documented and become the basis for the care and treatment to be provided. (3) The hospital shall assure that individuals who are employed as nursing assistants in the long-term care unit are trained and tested, including successful completion of a final examination, pursuant to the provisions of 19 CSR 30-84.010. (4) Orientation In-Service Training and Continuing Education. (A) The chief executive officer of the hospital shall assure the development of an in-service orientation and continuing education program offered by qualified instructors for the development of all personnel in the long-term care unit that is appropriate to their job functions. Orientation for all new personnel shall begin the first day of employment in the longterm care unit and shall cover, at a minimum, prevention SENIOR SERVICES and control of infection and hospital policies and procedures, including emergency protocol, job responsibilities, lines of authority, confidentiality of patient information, resident’s rights, and preservation of patient dignity. (B) The continuing education program for nursing assistants shall focus on basic nursing skills, personal care skills, mental health and social service needs, and basic restorative services. (5) Training Record. Written records of the employee’s training and testing shall be maintained in the employee’s personnel file. (6) Medical Care. (A) Medical care in long-term care units shall be under the direction of a physician member of the medical staff and appointed by the governing body. (B) Each resident shall have the privilege of selecting his/her own physician consistent with hospital medical staff bylaws. (C) Each resident shall be visited by the attending physician as often as medically necessary but no less than every thirty (30) days for the first ninety (90) days and every sixty (60) days thereafter. (D) There shall be a process for the review and evaluation on a regular basis of the quality and appropriateness of medical care in the long-term care unit. (7) Long-Term Care Unit. (A) A long-term care unit as defined in 19 CSR 30-20.011 shall have a registered professional nurse on duty eight (8) hours a day and seven (7) days a week. (B) The nursing service administrator shall be responsible for the quality of nursing care supervision of personnel providing nursing care and for a program of in-service education for nursing personnel. (C) Skilled nursing units shall employ nursing personnel in sufficient numbers and sufficiently qualified to meet the needs of the residents. Exclusive of supervisory staff, the minimum ratio of nursing staff engaged in direct patient care and treatment to residents shall be as follows: Time Ratio of Staff to Residents* 7 a.m. to 3 p.m. 1 staff person for each 10 residents plus 1 (day) additional staff person for any remainder of 6 or more residents 3 p.m. to 11 p.m. 1 staff person for each 15 residents plus 1 (evening) additional staff person for any remainder of 8 or more residents 11 p.m. to 7 a.m. 1 staff person for each 20 residents plus 1 (night) additional staff person for any remainder of 11 or more residents. *The number of residents is based on occupied beds. (D) On every shift there shall be a registered professional nurse or a licensed practical nurse on duty. (E) A registered professional nurse shall be available in the hospital to assist during the time a licensed practical nurse is in charge. (F) In a multi-story long-term care unit, at least one (1) directcare staff person shall be on duty at all times for each occupied floor. (G) All medications shall be administered in accordance with state law and the provisions of 42 CFR 482.23 (2017), Condition of Participation for Nursing Services. The Code of Federal Regulations is published by the U.S. Government and is available by calling toll-free (866) 512-1800 or going to https:// bookstore.gpo.gov/. The address is: U.S. Government Publishing Office, U.S. Superintendent of Documents, Washington, DC 20402-0001. This rule incorporates later amendments and additions to 42 CFR Part 482.23 (2017). (H) A physical examination by a licensed physician shall be completed and recorded on the clinical record of each resident, preferably before admission, but not later than seven (7) days after admission, unless the resident is accompanied on admission from a hospital or long-term care unit by a record of a physical examination completed within the past six (6) months. Physical examinations shall be performed at least annually. (I) The unit shall not knowingly admit or continue to care for residents whose needs cannot be met by the unit directly or in cooperation with community resources or other providers of care with which it is affiliated or has contracts. (J) Provision shall be made for the care of residents with a communicable disease either in the hospital or in a suitable room in the unit. Infection control policies and procedures shall be followed. (8) Resident’s Rights and Grievance Procedures for Long-Term Care Units. (A) A complete copy of each official notification from the Department of Health and Senior Services of violations, deficiencies, licensure approvals, disapprovals, and responses shall be retained and made available at the unit for inspection when requested by staff, residents, families or legal representatives of the residents, and the public. (B) Each resident shall be informed of his/her rights and responsibilities as a resident and of all rules governing resident conduct and responsibilities. A copy of all the information shall be posted in a conspicuous location in the facility and copies shall be available to anyone requesting the information. Prior to or at the time of admission, a copy of the information shall be provided to each resident or his/her designee, next of kin, or legal guardian. (C) Each resident shall be informed in writing, prior to or at the time of admission and during his/her stay, of services available in the unit and of related charges, including any charges for services not covered under the federal or state programs or not covered by the facility’s per-diem rate. (D) Each resident shall be informed by a physician of his/her health and medical condition unless medically contraindicated (as documented by a physician in the resident’s record); shall be given the opportunity to participate in the planning of his/ her total care and medical treatment and to refuse treatment; and shall participate in experimental research only upon his/ her informed written consent. (E) Each resident shall be transferred or discharged only for medical reasons, for his/her welfare or that of other residents, or for nonpayment for his/her stay. (F) Each resident shall be encouraged and assisted, throughout his/her period of stay, to exercise his/her rights as a resident and as a citizen and to this end may voice grievances and recommend changes in policies and services to facility staff or to outside representatives of his/her choice and shall be free from restraint, interference, coercion, discrimination, or reprisal. (G) Each resident may manage his/her personal financial affairs and, to the extent that the facility assists in the management, may have his/her personal financial affairs managed in accordance with section (9) of this rule. (H) No resident shall be mentally or physically abused. Each resident shall be free from chemical and physical restraints except when the restraints are authorized in writing by a physician for a specific period of time or when the restraints are necessary in an emergency to protect the resident from injury to him/herself or others. In an emergency, physical restraints may be authorized by a registered professional nurse. This action shall be reported immediately to a physician to obtain an order. (I) Each resident shall be assured confidential treatment of all information contained in his/her records, including information contained in an automatic data bank; his/her written consent shall be required for the release of information to persons not otherwise authorized under law to receive it. (J) Each resident shall be treated with consideration, respect, and full recognition of his/her dignity and individuality, including privacy in treatment and in care for his/her personal needs. (K) No resident shall be required to perform services for the unit that are not included for therapeutic purposes in the plan of care. (L) Each resident may communicate, associate, and meet privately with persons of his/her choice, unless to do so would infringe upon the rights of other residents. Each resident may send and receive his/her personal mail unopened. (M) Each resident may participate in activities of social, religious, and community groups at his/her discretion, unless contraindicated for reasons documented by a physician in the resident’s medical record. (N) Each resident may retain and use his/her personal clothing and possessions as space permits. (O) If married, a resident shall be insured privacy for visits by his/her other spouse; if both are residents in the facility, they shall be permitted to share a room unless medically contraindicated. (P) Each resident shall be allowed to purchase or rent any goods or services not included in the per-diem or monthly rate as long as the quality and delivery of those goods or services conform with policies and procedures of the hospital. (9) Personal Funds and Property of Residents. (A) No hospital shall be required to hold any personal funds or money in trust unless some other governmental agency placing residents in the facility imposes this requirement. (B) Authorizations by the resident, his/her designee, or legal guardian for the hospital to use the personal funds of the resident shall be in writing and kept with the resident’s record or with the personal funds account. (C) When a resident is admitted, s/he and his/her next of kin or legal guardian shall be provided with a statement explaining the resident’s rights regarding personal funds. (D) Resident’s personal funds that are held in trust shall be kept separate from the hospital funds. (E) There shall be a written account for each resident showing receipts to and disbursements from the personal funds of each resident. (F) A written statement of all receipts and disbursements showing the current balance shall be given on a quarterly basis to the resident, his/her designee, or legal guardian. (G) When personal funds and possessions held in trust by the hospital are returned to the resident or his/her designee or guardian before or after the resident’s discharge, the resident or his/her designee or guardian shall give the hospital a receipt for the funds and possessions returned. (H) There is no duty on the part of the hospital to invest a resident’s funds held in trust or to increase the principal. (I) Any owner, manager, employee, or affiliate of an owner who receives any personal property or anything else with a value of ten dollars ($10) or more from a resident shall give the resident a written statement giving the date it was received, from whom it was received, and its estimated value. (J) No owner, manager, employee, or affiliate of an owner, in one (1) calendar year, shall receive any personal property or anything else with a total value exceeding one hundred dollars ($100) from a resident of any facility. This does not apply to bequests. (K) The recordkeeping and other requirements of section (9) of this rule apply only to those personal possessions and funds which the facility accepts to hold in trust for the resident and does not apply to other possessions residents have in their rooms or bring into the facility. AUTHORITY: sections 192.006 and 197.297, RSMo 2016, and section 197.080, RSMo Supp. 2019.* This rule was previously filed as 13 CSR 50-20.050 and 19 CSR 10-20.050. Original rule filed Nov. 29, 1982, effective March 11, 1983. Amended: Filed May 31, 1989, effective Aug. 24, 1989. Amended: Filed July 12, 1991, effective Feb. 6, 1992. Amended: Filed March 20, 2019, effective Nov. 30, 2019. ** *Original authority: 192.006, RSMo 1993, amended 1995; 197.080, RSMo 1953, amended 1993, 1995, 2017; and 197.297, RSMo 2000. **Pursuant to Executive Order 21-09, 19 CSR 30-20.050, subsection (2)(C) was suspended from March 19, 2020 through December 31, 2021 and 19 CSR 30-20.050 was suspended from March 20, 2020 through December 31, 2021.