Administration and Resident Care Requirements for New and Existing Intermediate Care and Skilled Nursing Facilities

PURPOSE: This rule establishes standards for administration and resident care in an intermediate care or skilled nursing facility. Editor’s Note: All rules relating to long-term care facilities licensed by the Department of Health and Senior Services 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) The operator shall designate a person as administrator who holds a current license as a nursing home administrator in Missouri. II (2) The facility shall post the administrator’s license. III (3) The operator shall be responsible to assure compliance with all applicable laws and rules. 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 the oversight of residents to assure that they receive appropriate nursing and medical care. II/III (4) The administrator shall be employed in the facility and serve in that capacity on a full-time basis. An administrator cannot be listed or function as an administrator in more than one (1) licensed facility at the same time, except that 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 (5) The licensed administrator shall not leave the premises without delegating the necessary authority in writing to a responsible individual. If the administrator is absent from the facility for more than thirty (30) consecutive days, the person designated to be in administrative charge shall be a currently licensed nursing home administrator. Such thirty (30) consecutive-day absences may only occur once within any consecutive twelve (12)- month period. I/II (6) The facility shall not knowingly admit or continue to care for residents whose needs cannot be met by the facility directly or in cooperation with outside resources. Facilities which retain residents needing skilled nursing care shall provide licensed nurses for these procedures. I/II (7) When outside resources are used to provide services to the resident, the facility shall enter into a written agreement with each resource. III (8) Persons under seventeen (17) years of age shall not be admitted as residents to the facility unless the facility cares primarily for residents under seventeen (17) years of age. III (9) The facility shall not care for more residents than the number for which the facility is licensed. II (10) The facility’s current license shall be readily visible in a public area within the facility. Notices provided to the facility by the Division of Aging granting exceptions to regulatory requirements shall be posted with the facility’s license. III (11) Regular daily visiting hours shall be established and posted. Relatives or guardians and clergy, if requested by the resident or family, shall be allowed to see critically ill residents at any time unless the physician orders otherwise in writing. II/III (12) A supervising physician shall be available to assist the facility in coordinating the overall program of medical care offered in the facility. II (13) The facility shall develop policies and procedures applicable to its operation to insure the residents’ health and safety and to meet the residents’ needs. At a minimum, there shall be policies covering personnel practices, admission, discharge, payment, medical emergency treatment procedures, nursing practices, pharmaceutical services, social services, activities, dietary, housekeeping, infection control, disaster and accident prevention, residents’ rights and handling residents’ property. II/III (14) A pharmacist currently licensed in Missouri shall assist in the development of written policies and procedures regarding pharmaceutical services in the facility. II/III (15) All personnel shall be fully informed of the policies of the facility and of their duties. II/III (16) 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 a resident. I (17) Effective August 28, 1997, each facility shall, not later than two (2) working days of the date an applicant for a position to have contact with residents is hired, request a criminal background check, as provided in sections 43.530, 43.540 and 610.120, RSMo. Each facility must maintain in its record documents verifying that the background checks were requested and the nature of the response received for each such request. The facility must ensure that any applicant who discloses prior to the check of his/her criminal records that he/she has been convicted of, plead guilty or nolo contendere to, or has been found guilty of any 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, will not be allowed to work in contact with patients or residents until and unless a check of the applicant’s criminal record shows that no such conviction occurred. II/III (18) 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— (A) Shall 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 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, unless the person has been granted a good cause waiver by the division; (B) May consider for employment, in positions which have contact with resident or patients, any person who has been granted a good cause waiver by the division in accordance with the provisions of section 660.317, RSMo Supp. 1999 and 13 CSR 15-10.060; and; (C) Shall contact the division to confirm the validity of an applicant’s good cause waiver prior to hiring the applicant. II/III (19) No person who is listed on the employee disqualification list maintained by the division as required by section 198.070, RSMo shall work or volunteer in the facility in any capacity whether or not employed by the operator. II (20) The facility shall develop and offer an in-service orientation and continuing educational program for the development and improvement of skills of all the facility’s personnel, appropriate for their job function. Facilities shall begin providing orientation on the first day of employment for all personnel including licensed nurses and other professionals. At a minimum, this shall cover prevention and control of infection, facility policies and procedures including emergency protocol, job responsibilities and lines of authority, confidentiality of resident information, and preservation of resident dignity including protection of the resident’s privacy and instruction regarding the property rights of residents. II/III (21) Nursing Assistant Training Program. (A) All nursing assistants shall successfully complete the entire basic course (including passing the final examination) of the nursing assistant training program and be certified within four (4) months of employment. II/III (B) Nursing assistants who have not successfully completed the nursing assistant training program prior to employment may begin duties as a nursing assistant and may provide direct resident care only if under the direct supervision of a licensed nurse prior to the completion of the seventy-five (75) classroom hours of the training program. For the purpose of this rule, direct supervision shall mean close contact whereby the licensed nurse is able to respond quickly to the needs of the resident. The nursing assistant shall not perform any care or services for which he or she has not been trained nor found proficient by a licensed nurse. II/III (C) Prior to any direct resident contact, an individual enrolled in the nursing assistant training program’s basic course in a Medicare or Medicaid certified facility shall complete at least a total of sixteen (16) of the required seventy-five (75) hours of instructional training in communication and interpersonal skills; infection control; safety/emergency procedures, including the Heimlich maneuver; promoting residents’ independence; and respecting residents’ rights. II/III (22) The facility must ensure there is a system of in-service training for nursing personnel which identifies training needs related to problems, needs, care of residents and infection control and is sufficient to ensure staff’s continuing competency. II/III (23) Facilities shall conduct at least annual in-service education for nursing personnel including training in restorative nursing. This training by a registered nurse or qualified therapist shall include: turning and positioning for the bedridden resident, range of motion (ROM) exercises, ambulation assistance, transfer procedures, bowel and bladder retraining and self-care activities of daily living. II/III (24) A registered nurse shall be responsible for the planning and then assuring the implementation of the in-service education program for nursing personnel. II (25) Facilities shall maintain records which indicate the subject of, and attendance at, all in-service sessions. III (26) All authorized personnel shall have access to the legal name of each resident, name and telephone number of physician and next of kin or responsible party of each resident to contact in the event of emergency. II/III (27) The facility must develop and implement policies and procedures which ensure employees are screened to identify communicable diseases and ensure that employees diagnosed with communicable diseases do not expose residents to such diseases. The facility’s policies and procedures must comply with the Missouri Department of Health’s regulations pertaining to communicable diseases, specifically 19 CSR 20-20.010 through 19 CSR 20-20.100, as amended. II (28) 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; references, if available; the result of background checks required by section 660.317, RSMo; a copy of any good cause waiver, granted by the division, if applicable; position in the facility; record that the employee was instructed on resident’s rights; basic orientation received; and reason for termination, if applicable. Documentation shall be on file of all training received within the facility in addition to current copies of licenses, transcripts, certificates or statements evidencing competency for the position held. Facilities shall retain personnel records for at least one (1) year following termination of employment. III (29) Facilities shall maintain written documentation on the premises showing actual hours worked by each employee. III (30) 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 (31) Employees other than nursing personnel shall be at least sixteen (16) years of age.II/III (32) Nursing personnel shall be at least eighteen (18) years of age except that a person between the ages of seventeen (17) years of age and eighteen (18) years of age may provide direct resident care if the individual is listed as a certified nursing assistant with an active status on the department’s certified nursing assistant registry. The individual shall work under the direct supervision of a licensed nurse and shall never be left responsible for a nursing unit. II/III (33) All nurses employed by the facility shall be currently licensed in Missouri. II (34) All facilities shall employ a director of nursing on a full-time basis who shall be responsible for the quality of patient care and supervision of personnel rendering patient care. II (35) Licensed Nursing Requirements; Skilled Nursing Facility. (A) The director of nursing shall be a registered nurse. II (B) A registered nurse shall be on duty in the facility on the day shift. Either a licensed practical nurse (LPN) or a registered professional nurse (RN) shall be on duty in the facility on both the evening and night shifts. II (C) A registered nurse shall be on call during the time when only an LPN is on duty. II (36) Licensed Nursing Requirements; Intermediate Care Facilities. (A) The director of nursing shall be either an RN or an LPN. II (B) When the director of nursing is an LPN, an RN shall be employed as consultant a minimum of four (4) hours per week to provide consultation to the administrator and the director of nursing in matters relating to nursing care in the facility. II (C) An LPN or RN shall be on duty and in the facility on the day shift. II (D) An LPN or RN shall be on call twenty-four (24) hours a day, seven (7) days a week. I/II (37) All facilities shall employ nursing personnel in sufficient numbers and with sufficient qualifications to provide nursing and related services which enable each resident to attain or maintain the highest practicable level of physical, mental and psychosocial well-being. Each facility shall have a licensed nurse in charge who is responsible for evaluating the needs of the residents on a daily and continuous basis to ensure there are sufficient, trained staff present to meet those needs. I/II (38) Nursing personnel shall be on duty at all times on each resident-occupied floor. II (39) Nursing personnel in any facility with more than twenty (20) residents shall not routinely perform non-nursing duties. II/III (40) Nursing personnel in facilities with twenty (20) residents or less shall perform non-nursing duties only if acceptable infection control measures are maintained. II/III (41) Each facility resident shall be under the medical supervision of a Missouri-licensed physician who has been informed of the facility’s emergency medical procedures and is kept informed of treatments or medications prescribed by any other professional lawfully authorized to prescribe medications. I/II (42) Facilities shall ensure that at the time the resident is admitted, the facility obtains from a physician the resident’s primary diagnosis along with current medical findings and the written orders for the immediate care of the resident. II/III (43) The facility shall ensure that the resident’s private physician, the physician’s designee, the facility’s supervising physician, or an alternate physician shall examine the resident at least annually, and shall examine the resident as often as necessary to ensure proper medical care. I/II (44) For each medical examination, the physician must review the resident’s care, including medications and treatments; write, sign, and date progress notes; and sign and date all orders. The facility shall establish a policy requiring the physician to sign orders and to complete all other documentation required if the physician does not visit the resident routinely. II/III (45) No medication, treatment, or diet shall be given without a written order from a person lawfully authorized to prescribe such and the order shall be followed. No restraint shall be applied except as provided in 13 CSR 1518.010, Resident Rights. I/II (46) There shall be a safe and effective system of medication distribution, administration, control, and use. I/II (47) Verbal and telephone orders for medication or treatment shall be given only to those individuals licensed or certified to accept orders. Orders shall be immediately reduced to writing and signed by that individual. If a telephone order is given to a certified medication technician, an initial dose of medication or treatment shall not be given until the order has been reviewed by telephone or in person by a licensed nurse or pharmacist. The review shall be documented by the reviewer co-signing the telephone order. II (48) Medications shall be administered only by a licensed physician, a licensed nurse, or a medication technician who has successfully completed the state-approved course for medication administration. II (49) Injectable medication, other than insulin, shall be administered only by a licensed physician or a licensed nurse. Insulin injections may be administered by a certified medication technician who has successfully completed the state-approved course for insulin administration. II (50) Self-administration of medication is permitted only if approved in writing by the resident’s physician, and it is in accordance with the facility’s policy and procedures. II (51) All medication errors and adverse reactions shall be reported immediately to the nursing supervisor and the resident’s physician and, if there was a dispensing error, to the issuing pharmacist. II/III (52) At least monthly a pharmacist or a registered nurse shall review the drug regimen of each resident. Irregularities shall be reported in writing to the resident’s physician, the administrator, and the director of nurses. There must be written documentation which indicates how the reports were acted upon. II/III (53) 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 and state and federal drug laws and regulations. The United States Pharmacopoeia (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 (54) If the resident brings medications to the facility, they shall not be used unless the contents have been examined, identified, and documented by a pharmacist or a physician. II/III (55) Facilities shall store all external and internal medications at appropriate temperatures in a safe, clean place and in an orderly manner apart from foodstuffs and dangerous chemicals. A facility shall secure all medications, including those refrigerated, behind at least one (1) locked door or cabinet. Facilities shall store containers of discontinued medication separately from current medications. II/III (56) Facilities shall store Schedule II medications, including those in the emergency drug supply, under double lock separately from noncontrolled medication. Schedule II medications may be stored and handled with other noncontrolled medication if the facility has a single unit dose drug distribution system in which the quantity stored is minimal and a missing dose can be readily detected. II (57) Upon discharge or transfer, a resident may be given medications with a written order from the physician. Instructions for the use of those medications will be provided to the resident or the resident’s designee. III (58) All non-unit doses and all controlled substances which have been discontinued must be destroyed on the premises within thirty (30) days. Outdated, contaminated, or deteriorated medications and non-unit dose medications of deceased residents shall be destroyed within thirty (30) days. Unit dose medications returnable to the pharmacy shall be returned within thirty (30) days. II/III (59) Medications shall be destroyed in the facility by a pharmacist and a licensed nurse or by two (2) licensed nurses. III (60) Facilities shall maintain records of medication destroyed in the facility. Records shall include: the resident’s name; the date; the name, strength, and quantity of the medication; the prescription number; and the signatures of the participating parties. III (61) The facility shall maintain records of medication released to the family or resident upon discharge or to the pharmacy. Records shall include: the resident’s name; the date; the name, strength, and quantity of the medication; the prescription number; and the signature of the persons releasing and receiving the medication. III (62) The facility must establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation. The system must enable the facility to determine that drug records are in order and that an account of all controlled drugs is maintained and reconciled. II/III (63) Facilities shall make available to all nursing staff up-to-date reference material on all medications in use in the facility. III (64) The facility shall develop policies to identify any emergency stock supply of prescription medications to be kept in the facility for resident use only. This emergency drug supply must be checked at least monthly by a pharmacist to ensure its safety for use and compliance with facility policy. A facility shall have the emergency drug supply readily available to medical personnel and use of medications in the emergency drug supply shall assure accountability. III (65) Each resident shall receive twenty-four- (24-) hour protective oversight and supervision. 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 (66) Each resident shall receive personal attention and nursing care in accordance with his/her condition and consistent with current acceptable nursing practice. I/II (67) Each resident shall be clean, dry, and free of body and mouth odor that is offensive to others. I/II (68) Taking into consideration the resident’s preferences, residents shall be well-groomed and dressed appropriately for the time of day, the environment and any identified medical conditions. II/III (69) Residents who are physically or mentally incapable, or both, of changing their own positions shall have their positions changed at least every two (2) hours and shall be provided supportive devices to maintain good body alignment. I/II (70) The facility must provide each resident the opportunity to access sufficient fluids to maintain proper hydration in accordance with the resident’s medical condition and goals of treatment as documented in the medical record. I/II (71) All residents who require assistance at mealtimes, whether it be preparation of the food items or actual feeding, shall be provided the assistance upon delivery of the tray. Facilities shall provide dining room supervision during meals. II/III (72) Facilities shall provide each resident, according to his/her needs, with restorative nursing to encourage independence, activity and self-help to maintain strength and mobility. Each resident shall be out of bed as desired unless medically contraindicated. II (73) Each resident shall have skin care including the application of oil, lotion, and cream as needed to prevent dryness and scaling of skin. II/III (74) Facilities shall keep residents free from avoidable pressure sores, taking measures toward prevention. If sores exist, staff shall give adequate treatment. I/II (75) Facility staff shall check residents requiring restraints every thirty (30) minutes and exercise the residents every two (2) hours. II/III (76) Facilities shall not use locked restraints. I (77) Residents shall be cared for by using acceptable infection control procedures to prevent the spread of infection. The facility shall make a report to the division within seven (7) days if a resident is diagnosed as having a communicable disease, as determined by the Missouri Department of Health and listed in the Code of State Regulations pertaining to communicable diseases, specifically 19 CSR 20-20.020, as amended. I/II (78) In the event of accident, injury, or significant change in the resident’s condition, facility staff shall notify the resident’s physician in accordance with the facility’s emergency treatment policies which have been approved by the supervising physician. I/II (79) In the event of accident, injury, or significant change in the resident’s conditions, facility staff shall immediately notify the person designated in the resident’s record as the designee or responsible party. III (80) Staff shall inform the administrator of accidents, injuries, and unusual occurrences which adversely affect, or could adversely affect, the resident. The facility shall develop and implement responsive plans of action. III (81) Facilities shall ensure that each resident is provided individual personal care items necessary for good grooming. Items shall be stored and maintained in a clean manner within the resident’s room. III (82) Facilities shall provide equipment and nursing supplies in sufficient number to meet the needs of the residents. II/III (83) Facilities shall keep all utensils and equipment in good condition, effectively sanitized, sterilized, or both, and stored to prevent contamination. II/III (84) Staff shall ensure that bedpans, commodes, and urinals are covered after use, emptied promptly, and thoroughly cleaned after use. II/III (85) Facilities shall provide and use a sufficient supply of clean bed linen, including sheets, pillow cases, blankets, and mattress pads to assure that resident beds are kept clean, neat, dry, and odor free. II/III (86) Staff shall use moisture proof covers as necessary to keep mattresses and pillows clean, dry, and odor free. II/III (87) Facilities shall provide each resident with fresh bath towels, hand towels, and washcloths as needed for individual usage. II/III (88) In addition to rehabilitative or restorative nursing, all facilities shall provide or make arrangements for providing rehabilitation services to all residents according to their needs. If a resident needs rehabilitation services, a qualified therapist shall perform an evaluation on written order of the resident’s physician. II/III (89) Facilities shall ensure that rehabilitation services are provided by or under the on-site supervision of a qualified therapist or a qualified therapy assistant who works under the general supervision of a qualified therapist. I/II (90) Staff shall include the following in documentation of rehabilitation services: physician’s written approval for proposed plan of care; progress notes at least every thirty (30) days by the therapist; daily record of the procedure(s) performed; summary of therapy when rehabilitation has been reached and, if applicable, recommendations for maintenance procedures by restorative nursing. III (91) The facility shall designate a staff member to be responsible for the facility’s social services program. The designated staff person shall be capable of identifying social and emotional needs, knowledgeable of methods or resources, or a combination of these to use to meet them and services shall be provided to residents as needed. II/III (92) The facility shall designate an employee to be responsible for the activity program. The designated person shall be capable of identifying activity needs of residents, designing and implementing programs to maintain or increase, or both, the resident’s capability in activities of daily living. Facilities shall provide activity programs on a regular basis. Each resident shall have a planned activity program which includes individualized activities, group activities, and activities outside the facility as appropriate to his/her needs and interests. II/III (93) The facility shall provide and use adequate space and equipment within the facility for the identified activity needs of residents. II/III (94) The facility shall establish and maintain a program for informing all residents in advance of available activities, activity location and time. III (95) Facility staff shall include the following general information in admission records: resident’s name; prior address; age (birth date); sex; marital status; Social Security number; Medicare and Medicaid numbers; date of admission; name, address, and telephone number of responsible party; name, address, and telephone number of attending physician; height and weight on admission; inventory of resident’s personal possessions upon admission; and names of preferred dentist, pharmacist, and funeral director. II/III (96) Facility staff shall include physician entries in the medical record with the following information: admission diagnosis, admission physical and findings of subsequent examinations; progress notes; orders for all medications and treatment; orders for extent of activity; orders for restraints including type and reason for restraint; orders for diet; and discharge diagnosis or cause of death. II/III (97) Residents admitted to a facility on referral by the Department of Mental Health shall have an individualized treatment plan or individualized habilitation plan on file which is updated annually. III (98) Facilities shall ensure that the clinical record contains sufficient information to— (A) Identify the resident; (B) Reflect the initial and ongoing assessments and interventions by each discipline involved in the care and treatment of the resident; and (C) Identify the discharge or transfer destination. II/III (99) Facilities shall ensure that the resident’s clinical record must contain progress notes that include, but are not limited to: (A) Response to care and treatment; (B) Change(s) in physical, mental, and psychosocial condition; (C) Reasons for changes in treatment; and (D) Reasons for transfer or discharge. II/III (100) The facility must safeguard clinical record information against loss, destruction, or unauthorized use. III (101) The facility must keep all information confidential that is contained in the resident’s records regardless of the form or storage method of the records, including video-, audio-, or computer-stored information. III (102) The facility must maintain clinical records on each resident in accordance with accepted professional standards and practices. These records shall be complete, accurately documented, readily accessible on each nursing unit, and systematically organized. II/III (103) Facilities must retain clinical records for the period of time required by state law or five (5) years from the date of discharge when there is no requirement in state law. III (104) Facilities shall retain all financial records related to the facility operation for seven (7) years from the end of the facility’s fiscal year. III (105) In the event the resident is transferred from the facility, the resident shall be accompanied by a copy of the medical history, transfer forms which include the physical exam report, nursing summary, and report of orders physicians prescribed. II/III AUTHORITY: sections 198.006, 198.009, 198.079, RSMo 2016.* This rule originally filed as 13 CSR 15-14.042. Original rule filed July 13, 1983, effective Oct. 13, 1983. Emergency amendment filed Nov. 9, 1983, effective Nov. 19, 1983, expired March 18, 1984. Amended: Filed Nov. 9, 1983, effective Feb. 11, 1984. Amended: Filed Sept. 12, 1984, effective Dec. 13, 1984. Amended: Filed Aug. 1, 1988, effective Nov. 10, 1988. Amended: Filed Jan. 3, 1992, effective Aug. 6, 1992. Amended: Feb. 13, 1998, effective Sept. 30, 1998. Amended: Filed Feb. 15, 2000, effective Aug. 30, 2000. Moved to 19 CSR 30-85.042, 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 June 14, 2021, effective Dec. 30, 2021. *Original authority: 198.006, RSMo 1979, amended 1984, 1987, 2003; 198.009, RSMo 2016; and 198.079, RSMo 1979. **Pursuant to Executive Order 21-07, 19 CSR 30-85.042, sections (7) and (21) was suspended from April 16, 2020 through May 1, 2021 and section (27) was suspended from April 23, 2020 through August 31, 2021. Pursuant to Executive Order 21-09, 19 CSR 3085.042, sections (11), (20), (33), (40), (49), and (50) was suspended from April 15, 2020 through December 31, 2021 and sections (9) and (11), subsection (35)(B), section (39), and section 198.082, RSMo was suspended from April 16, 2020 through December 31, 2021.