Definition of Terms

PURPOSE: This rule defines terms used in the rules for long-term care facilities as set forth in chapters 19 CSR 30-85, 19 CSR 3086, 19 CSR 30-87, and 19 CSR 30-88. (1) Activities of daily living (ADL)—Shall mean one (1) or more of the following: (A) Eating; (B) Dressing; (C) Bathing; (D) Toileting; (E) Transferring; and (F) Walking. (2) Administrator—Shall mean an individual person who is in general administrative charge of a facility. (3) Assisted living facility (ALF)—Shall mean any premises, other than a residential care facility, intermediate care facility, or skilled nursing care facility, that is utilized by its owner, operator, or manager to provide twenty-four (24) hour care and services and protective oversight to three (3) or more residents who are provided with shelter, board, and who may need and are provided with the following: (A) Assistance with any activities of daily living and any instrumental activities of daily living; (B) Storage, distribution or administration of medications; and (C) Supervision of health care under the direction of a licensed physician, provided that such services are consistent with a social model of care. (D) The term “assisted living facility” does not include a facility where all of the residents are related within the fourth degree of consanguinity or affinity to the owner, operator, or manager of the facility. (4) Automated dispensing system—Shall mean a mechanical system that performs functions that may include, but are not limited to, storing, packaging or dispensing medications, and that collects, controls and maintains all transaction information. (5) Certified-medication technician—Shall mean a nursing assistant who has completed a course in medication administration approved by the Department of Health and Senior Services. (6) Chemical restraint—Shall mean a psychopharmacologic medication that is used for discipline or convenience and not required to treat medical symptoms. (7) Communicable disease—Any illness, disease or condition reportable to the Missouri Department of Health and Senior Services as required by 19 CSR 20-20.010 and 19 CSR 20-20.020 is considered, for the context of these rules, a communicable disease. (8) Community based assessment—Shall mean documented basic information and analysis provided by appropriately trained and qualified individuals describing an individual’s abilities and needs in activities of daily living, instrumental activities of daily living, vision/hearing, nutrition, social participation and support, and cognitive functioning using an assessment tool approved by the Department of Health and Senior Services (the department), that is designed for community based services and that is not the nursing home minimum data set. The assessment tool may be one developed by the department or one used by a facility which has been approved by the department. (9) Control of medication—Shall mean assuming responsibility by the facility for all facets of control of medication including, but not limited to, acquisition, storage, security and administration. (10) Convenience—Shall mean any action taken by the facility to control resident behavior or maintain residents with a lesser amount of effort by the facility and not in the resident’s best interest. (11) Dementia—Shall mean a general term for the loss of thinking, remembering, and reasoning so severe that it interferes with an individual’s daily functioning, and may cause symptoms that include changes in personality, mood, and behavior. (12) Designee—Shall mean an individual who has been designated in writing by a resident to handle matters and receive reports related to his/her personal possessions and property. (13) Discipline—Shall mean any action taken by the facility for the purpose of punishing or penalizing residents. (14) Emergency medical procedure—Shall mean those written policies and procedures which describe the types and degrees of accidents and injuries, how they will be treated, by whom, in which instances the resident’s physician will be notified and how quickly. (15) Emergency medication supply —Shall mean a limited number of dosage units of prescription medications that may be administered to a resident in an emergency situation or for initial doses of a necessary medication when a pharmacy cannot provide a prescription for a resident within a reasonable time based on the resident’s clinical needs at the time. (16) Existing or existing licensed facility— Shall mean a long-term care facility which was licensed and in operation or one whose plans were approved prior to June 10, 1981 for a skilled or intermediate care facility or prior to November 13, 1980 for residential care facilities and assisted living facilities except as otherwise indicated in 19 CSR 3086.012, 19 CSR 30-86.022 and 19 CSR 3086.032. (17) Exit—Shall mean a door leading to the outside or through a horizontal exit in a fire wall to a fire-safe area in the building. (18) Facility—Shall mean any residential care facility, assisted living facility, intermediate care facility or skilled nursing facility licensed by the department. (19) Fire-resistant construction—For intermediate care facilities and skilled nursing facilities, fire-resistant construction shall mean that a facility meets the specifications for Type II (222) or Type II (111) construction as given in the National Fire Protection Association Code 220. Fire-resistant construction for residential care facilities and assisted living facilities is defined in 19 CSR 30-86.022. (20) Hazardous area—Shall mean furnace rooms other than electric forced air furnaces, laundries, kitchens, maintenance shops and storage rooms of over one hundred (100) square feet and any areas which contain combustible materials which will be either easily ignited, burn with an intense flame or result in the production of dense smoke and fumes. (21) Home-like—means a self-contained long-term care setting that integrates the psychosocial, organizational and environmental qualities that are associated with being at home. Home-like may include, but is not limited, to the following: (A) A living room and common use areas for social interactions and activities; (B) Kitchen and family style eating area for use by the residents; (C) Laundry area for use by residents; (D) A toilet room that contains a toilet, lavatory and bathing unit in each resident’s room; (E) Resident room preferences for residents who wish to share a room, and for residents who wish to have private bedrooms; (F) Outdoor area for outdoor activities and recreation; and (G) A place where residents can give and receive affection, explore their interests, exercise control over their environment, engage in interactions with others and have privacy, security, familiarity and a sense of belonging. (22) Individualized service plan (ISP)—Shall mean the planning document prepared by an assisted living facility which outlines a resident’s needs and preferences, services to be provided, and the goals expected by the resident or the resident’s legal representative in partnership with the facility. (23) Instrumental activities of daily living (IADL)—Shall mean one (1) or more of the following activities: (A) Preparing meals; (B) Shopping for personal items; (C) Medication management; (D) Managing money; (E) Using the telephone; (F) Housework; and (G) Transportation ability. (24) Intermediate care facility—Shall mean any premises, other than a residential care facility, assisted living facility, or skilled nursing facility, which is utilized by its owner, operator, or manager to provide twenty-four (24) hour accommodation, board, personal care, and basic health and nursing care services under the daily supervision of a licensed nurse and under the direction of a licensed physician to three (3) or more residents dependent for care and supervision and who are not related within the fourth degree of consanguinity or affinity to the owner, operator or manager of the facility. (25) Involuntary seclusion—Shall mean separation of a resident from other residents or from her/his room or confinement to her/his room (with or without roommates) against the resident’s will, or the will of the resident’s legal representative. Emergency or short term monitored separation from other residents will not be considered involuntary seclusion and may be permitted if used for a limited period of time as a therapeutic intervention to reduce agitation until professional staff can develop a plan of care to meet the resident’s needs. (26) Keeping residents in place—Shall mean maintaining residents in place during a fire in lieu of evacuation where a building’s occupants are not capable of evacuation, where evacuation has a low likelihood of success, or where it is recommended in writing by local fire officials as having a better likelihood of success and/or lower risk of injury. (27) Level I medication aide—Shall mean an individual who has completed a course approved by the department in medication administration in a residential care facility or assisted living facility. (28) Long-term care facility—Shall mean a facility that is licensed either solely or in combination as a skilled nursing facility, an intermediate care facility, a residential care facility, or assisted living facility. (29) Long-term care services—Shall mean the assistance and support that a resident receives in a residential care facility, assisted living facility, intermediate care facility, and skilled nursing care facility, to meet the resident’s individual need for nursing care, protective oversight, monitoring, medication management, social interactions, cooking, housekeeping, laundry, and recreational activities. (30) Major fraction thereof—Shall mean anything over fifty percent (50%) of the number of occupied beds. (31) Major remodeling—Shall mean any remodeling of a long-term care facility which involves the addition of resident-use rooms, which affects fire safety or the structure of the building. (32) Multistory building—Shall mean any building with more than one (1) floor entirely above the grade. A floor that is partially below grade will be counted as the first story to determine sprinkler requirements only if it contains resident sleeping rooms. (33) New or newly licensed facility—Shall mean a long-term care facility whose plans are approved or which is licensed after June 10, 1981 for a skilled nursing or intermediate care facility or after November 13, 1980 for residential care facility or assisted living facility except as otherwise indicated in 19 CSR 30-86.012, 19 CSR 30-86.022, and 19 CSR 30-86.032. (34) Nursing personnel—Shall include any employee, including a nurse’s aide or an orderly, who provides or assists in the provision of direct resident health care services. (35) Operator—Shall mean any person licensed or required to be licensed under the provisions of sections 198.003–198.096, RSMo, in order to establish, conduct, or maintain a facility. The term person required to be licensed shall mean any person having the following, as determined by the department: (A) Ultimate responsibility for making and implementing decisions regarding the operation of the facility; (B) Ultimate financial control of the operation of a facility; and (C) Legal right to possession of the premises on which a facility is located. (36) Person—Shall mean any individual, or any entity, including, but not limited to, a corporation, limited liability company, partnership, association, nonprofit organization, fraternal organization, church, or political subdivision of the state of Missouri. (37) Physical restraint—Shall mean any manual method or physical or mechanical device, material or equipment attached to or adjacent to the resident’s body that the individual cannot remove easily which restricts freedom of movement or normal access to one’s body. Physical restraints include, but are not limited to, leg restraints, arm restraints, hand mitts, soft ties or vests, lap cushions, and lap trays the resident cannot remove easily. Physical restraints also include facility practices that meet the definition of a restraint, such as the following: (A) Using side rails that keep a resident from voluntarily getting out of bed; (B) Tucking in or using Velcro to hold a sheet, fabric, or clothing tightly so that a resident’s movement is restricted; (C) Using devices in conjunction with a chair, such as trays, tables, bars, or belts, that the resident cannot remove easily, that prevent the resident from rising; (D) Placing the resident in a chair that prevents a resident from rising; and (E) Placing a chair or bed so close to a wall that the wall prevents the resident from rising out of the chair or voluntarily getting out of bed. (38) Physician—Shall mean an individual licensed to practice medicine in the state of Missouri under Chapter 334, RSMo. (39) Premises—Shall mean any structures that are in close proximity one to the other and which are located on a single piece of property. (40) Protective oversight—Shall mean an awareness twenty-four (24) hours a day of the location of a resident, the ability to intervene on behalf of the resident, supervision of nutrition, medication, or actual provisions of care, and the responsibility for the welfare of the resident, except where the resident is on voluntary leave. (41) Qualified dietitian—Shall mean an individual who is registered by the American Dietetic Association or who is eligible for registration. (42) Qualified therapist—Shall mean an individual who is either registered or is eligible for registration by the national accrediting association for that therapy or, if applicable, is licensed by the state of Missouri for the practice of the profession in which s/he is engaged. (43) Qualified therapy assistant—Shall mean an individual who would be qualified as an occupational therapy or physical therapist assistant as outlined in 42 CFR 484.4. (44) Residential care facility (RCF)—Shall mean any premises, other than an assisted living facility, intermediate care facility, or skilled nursing facility, which is utilized by its owner, operator, or manager to provide twenty-four (24) hour care to three (3) or more residents, who are not related within the fourth degree of consanguinity or affinity to the owner, operator, or manager of the facility and who need or are provided with shelter, board, and with protective oversight, which may include storage and distribution or administration of medications and care during short-term illness or recuperation, except that, for purposes of eligible residents of facilities formerly licensed as residential care facilities II receiving supplemental welfare assistance payments, any residential care facility that was licensed as a residential care facility II on or before August 27, 2006 that continues to meet the licensure standards for a residential care facility II in effect on August 27, 2006 shall be considered a residential care facility II for purposes of its eligible residents receiving the cash grant payment amount allocated immediately prior to August 28, 2006 for residents of a residential care facility II pursuant to section 208.030, RSMo. (45) Responsible party—Shall mean an individual who has been designated in writing by the resident to handle matters and receive reports related to his/her general condition. (46) Self-administration of medication—Shall mean the act of actually taking or applying medication to oneself. (47) Self-control of medication—Shall mean assuming immediate responsibility by a resident for the storage and administration of medication for oneself while the facility retains ultimate control of medication. (48) Skilled nursing care—Shall mean services furnished pursuant to physicians’ orders which require the skills of licensed nurses and which are provided directly by or under the on-site supervision of these personnel. Examples of skilled nursing care may include, but are not limited to: administration of levine tube or gastrostomy tube feedings; nasopharyngeal and tracheotomy aspiration; insertion of medicated or sterile irrigation solutions and replacement of catheters; administration of parenteral fluids; inhalation therapy treatments; administration of other treatments requiring aseptic technique; and administration of injectable medication other than insulin. (49) Skilled nursing facility—Shall mean any premises, other than a residential care facility, assisted living facility, or an intermediate care facility, which is utilized by its owner, operator, or manager to provide for twentyfour (24) hour accommodation, board and skilled nursing care and treatment services to at least three (3) residents who are not related within the fourth degree of consanguinity or affinity to the owner, operator, or manager of the facility. Skilled nursing care and treatment services are those services commonly performed by or under the supervision of a registered professional nurse for individuals requiring twenty-four (24) hours a day care by licensed nursing personnel including acts of observation, care, and counsel of the aged, ill, injured, or infirm, the administration of medications and treatments as prescribed by a licensed physician or dentist, and other nursing functions requiring substantial specialized judgment and skill. (50) Social model of care—means long-term care services based on the abilities, desires, and functional needs of the individual delivered in a setting that is more home-like than institutional, that promote the dignity, individuality, privacy, independence, and autonomy of the individual, that respects residents’ differences and promotes residents’ choices. (51) Voluntary leave—Shall mean an offpremises leave initiated by: a) a resident that has not been declared mentally incompetent or incapacitated by a court; or b) a legal guardian of a resident that has been declared mentally incompetent or incapacitated by a court. (52) Vulnerable person—Shall mean any person in the custody, care, or control of the Department of Mental Health that is receiving services from an operated, funded, licensed, or certified program. AUTHORITY: sections 198.009, RSMo 2000, and section 198.073, RSMo Supp. 2007.* Emergency rule filed Sept. 7, 1979, effective Sept. 28, 1979, expired Jan. 24, 1980. This rule originally filed as 13 CSR 15-11.010. Original rule filed Sept. 7, 1979, effective Jan. 12, 1980. Amended: Filed Dec. 10, 1980, effective June 11, 1981. Amended: Filed Dec. 10, 1981, effective May 11, 1982. Rescinded and readopted: Filed July 13, 1983, effective Oct. 13, 1983. Amended: Filed Nov. 9, 1983, effective Feb. 11, 1984. Emergency amendment filed Aug. 1, 1984, effective Aug. 13, 1984, expired Dec. 10, 1984. Amended: Filed Sept. 12, 1984, effective Dec. 13, 1984. Amended: Filed Aug. 1, 1988, effective Nov. 11, 1988. Moved to 19 CSR 30-83.010, effective Aug. 28, 2001. Emergency amendment filed Sept. 12, 2003, effective Sept. 22, 2003, expired March 19, 2004. Amended: Filed Sept. 12, 2003, effective Feb. 29, 2004. Amended: Filed Sept. 14, 2004, effective March 30, 2005. Amended: Filed Aug. 23, 2006, effective April 30, 2007. Amended: Filed March 13, 2008, effective Oct. 30, 2008. *Original authority: 198.009, RSMo 1979, amended 1993, 1995 and 198.073, RSMo 1979, amended 1984, 1992, 1999, 2006, 2007.