Administrative, Personnel, and Resident Care Requirements for New and Existing Residential Care Facilities

PURPOSE: This rule establishes standards for administration, personnel, and resident care in residential care facilities. Editor’s 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) Definitions. For the purpose of this rule, the following definitions shall apply: (A) Department—Department of Health and Senior Services; (B) Outbreak—an occurrence in a community or region of an illness(es) similar in nature, clearly in excess of normal expectancy and derived from a common or a propagated source; and (C) Evacuate the facility—moving to an area of refuge or from one (1) smoke section to another or exiting the facility. (2) For a residential care facility, a person shall be designated as administrator/manager who is either currently licensed as a nursing home administrator or is at least twenty-one (21) years of age, has never been convicted of an offense involving the operation of a long-term care or similar facility and who attends at least one (1) continuing education workshop within each calendar year given by or approved by the department. When used in this chapter of rules, the term manager shall mean that person who is designated by the operator to be in general administrative charge of a residential care facility. It shall be considered synonymous to “administrator” as defined in section 198.006, RSMo and the terms administrator and manager may be used interchangeably. II/III (3) The administrator/manager of a residential care facility shall have successfully completed the state approved Level I Medication Aide course unless he or she is a physician, phar macist, 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, for an assisted living facility, if the facility employs on a fulltime 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/manager 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/ manager’s responsibilities shall include oversight of residents to assure that they receive care appropriate to their needs. II/III (5) The administrator/manager 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/manager shall designate, in writing, a staff member in charge in the administrator/manager’s absence. II/III (7) The facility shall not care for more residents than the number for which the facility is licensed. If the facility operates a non-licensed adult day care program within the licensed facility, the day care participants shall be counted in the staffing determination during the hours the day care participants are in the facility. II/III (8) The facility’s current license shall be posted in a conspicuous place and notices provided to the facility by the department granting exception(s) to regulatory requirements shall be posted alongside of the facility’s license. III (9) All personnel responsible for resident care shall have access to the legal name of each resident, name and telephone number of resident’s physician, resident’s designee or legally authorized representative in the event of emergency. II/III (10) 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 SENIOR SERVICES to check the EDL for individuals or groups such as scout groups, bingo, 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 (11) Prior to allowing any person who has been hired in a fulltime, part-time, or temporary position to have contact with any residents, 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 provider— (A) Request a criminal background check for the person, as provided in section 43.540, RSMo. Each facility must maintain in its record documents verification that the background checks were requested and the nature of the response received for each such request. II 1. The facility must ensure that any applicant or person hired or retained who discloses prior to the receipt of the criminal background check that he or she has been found guilty in this state or any other state or has been found guilty of a crime, 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 subsection 198.070.3, RSMo, or of section 568.020, RSMo, will not have contact with residents. I/II 2. Upon receipt of the criminal background check, the facility must ensure that if the criminal background check indicates that the person hired or retained by the facility has been found guilty in this state or any other state or has been found guilty of a crime, 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 subsection 198.070.3, RSMo, or of section 568.020, RSMo, the person will not have contact with residents unless the facility obtains verification from the department that a good cause waiver has been granted and maintains a copy of the verification in the individual’s personnel file; I/II (B) Make an inquiry to the department, whether the person is listed on the employee disqualification list as provided in section 192.2490, RSMo. The inquiry may be made at www. health.mo.gov/safety/edl; II/III (C) If the person has registered with the department’s Family Care Safety Registry (FCSR), the facility may utilize the Registry in order to meet the requirements of subsections (11)(A) and (11) (B) of this rule. The FCSR is available at www.health.mo.gov/ safety/fcsr; and II/III (D) 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 must 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. I/II (12) A facility shall not employ as an agent or employee who has access to controlled substances any person who has been found guilty or entered a plea of guilty or nolo contendere in a criminal prosecution under the laws of any state or of the United States for any offense related to controlled substances. II (A) A facility may apply in writing to the department for a waiver of this section for a specific employee. (B) The department may issue a written waiver to a facility upon determination that a waiver would be consistent with the public health and safety. In making this determination, the department shall consider the duties of the employee, the circumstances surrounding the conviction, the length of time since the conviction was entered, whether a waiver has been granted by the department’s Bureau of Narcotics and Dangerous Drugs pursuant to 19 CSR 30-1.034 when the facility is registered with that agency, whether a waiver has been granted by the federal Drug Enforcement Administration (DEA) pursuant to 21 CFR 1301.76 when the facility is also registered with that agency, the security measures taken by the facility to prevent the theft and diversion of controlled substances, and any other factors consistent with public health and safety. II/III (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 resident have been informed of their responsibility to disclose their prior criminal history to the facility as required by section 192.2495, 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 resident who has been found guilty in this state or any other state or has been found guilty of a crime, 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 subsection 198.070.3, RSMo, or of section 568.020, RSMo. II/III (14) All persons who have or may have contact with residents shall at all time 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/manager shall be responsible for preventing an employee known to be diagnosed with communicable disease from exposing residents to such disease. The facility’s policies and procedures must comply with the department’s regulations pertaining to communicable diseases, specifically 19 CSR 20-20.010 through 19 CSR 20-20.100. II/III (18) The facility shall screen residents and staff for tuberculosis as required for long-term care facilities by 19 CSR 20-20.100. II (19) Prior to or on the first day that a new employee works in the facility he or she shall receive orientation of at least one (1) hour appropriate to his or her job function. This shall include at least the following: (A) Job responsibilities; (B) Emergency response procedures; (C) Infection control and handwashing procedures and requirements; (D) Confidentiality of resident information; (E) Preservation of resident dignity; (F) Information regarding what constitutes abuse/neglect and how to report abuse/neglect to the department (1-800-3920210); (G) Information regarding the Employee Disqualification List; (H) Instruction regarding the rights of residents and protec tion of property; and (I) Instruction regarding working with residents with mental illness. II/III (20) In addition to the orientation training required in section (19) of this rule any facility that provides care to any resident having Alzheimer’s disease or related dementia shall provide orientation training regarding mentally confused residents such as those with Alzheimer’s disease and related dementias as follows: (A) For employees providing direct care to such persons, the orientation training shall include at least three (3) hours of training including at a minimum an overview of mentally confused residents such as those having Alzheimer’s disease and related dementias, communicating with persons with dementia, behavior management, promoting independence in activities of daily living, and understanding and dealing with family issues; II/III (B) For other employees who do not provide direct care for, but may have daily contact with, such persons, the orientation training shall include at least one (1) hour of training including at a minimum an overview of mentally confused residents such as those having dementias as well as communicating with persons with dementia; and II/III (C) For all employees involved in the care of persons with dementia, dementia-specific training shall be incorporated into ongoing in-service curricula. II/III (21) The administrator/manager shall maintain on the premises an individual personnel record on each facility employee, which shall include the following: (A) The employee’s name and address; (B) Social Security number; (C) Date of birth; (D) Date of employment; (E) Documentation of experience and education including, for positions requiring licensure or certification, documentation evidencing competency for the position held, which includes copies of current licenses, transcripts when applicable, or for those individuals requiring certification, such as level I medication aides (LIMA), certified nurse aides, certified medication technicians (CMT), and insulin administration aides; printing the Web Registry search results page available at www.health.mo.gov/cnaregistry shall meet the requirements of the employer’s check regarding valid certification; (F) References, if available; (G) The results of background checks required by section 192.2495, RSMo, and a copy of any good cause waiver granted by the department, if applicable; (H) Position in the facility; (I) Documentation of the employee’s tuberculin screening status; (J) Documentation of what the employee was instructed on during orientation training; and (K) Reason for termination if the employee was terminated due to abuse or neglect of a resident, residents’ rights issues, or resident injury. III (22) Personnel records shall be maintained for at least two (2) years following termination of employment. III (23) There shall be written documentation maintained in the facility showing actual hours worked by each employee. III (24) No one individual shall be on duty with responsibility for oversight of residents longer than eighteen (18) hours per day except in a residential care facility licensed for twelve (12) or fewer residents. I/II (25) 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 (26) One (1) employee at least eighteen (18) years of age shall be on duty at all times. I/II (27) Staffing for Residential Care Facility. (A) The facility shall have an adequate number and type of personnel on duty at all times for the proper care of residents and upkeep of the facility. At a minimum, one (1) employee shall be on duty for every forty (40) residents to provide protective oversight to residents and for fire safety. I/II Staff Residents 1 1–40 2 41–80 3 81–120 4 121–160 (B) The required staff person shall be in the facility awake, dressed and prepared to assist residents in case of emergency, except that in a facility licensed for twelve (12) or fewer residents, this person may be asleep during the night hours. In a facility licensed for twenty (20) or fewer residents, the required staff person may be asleep if there is a sprinkler system or if there is a complete automatic fire detection system. I/II (C) In a facility of more than one hundred (100) residents, the administrator/manager shall not be counted when determining the personnel required. II (D) If the facility is opened in conjunction with and is immediately adjacent to and contiguous to another licensed long-term care facility and if— 1. The resident bedrooms of the residential care facility are on the same floor or on the ground floor immediately below that of the other licensed facility; 2. There is an approved call system in each resident’s bedroom and bathroom or a patient-controlled system connected to a nursing station of the other licensed facility; 3. There is a complete fire alarm system in the residential care facility connected to the complete fire alarm system in the other licensed facility; 4. The staffing of the other licensed facility is greater than their minimum requirements; and 5. Periodic visits to the residential care facility are made by a staff person to determine the welfare of the resident in the residential care facility; then, for a facility serving twenty (20) or fewer residents, there need not be an attendant on duty during the day and evening shifts and the attendant may be asleep during the night shift; or if the facility is on the same floor as the other licensed facility, there need not be an attendant at night. If there are more than twenty (20) residents, there shall be at least one (1) staff person awake and dressed at all times for every forty (40) residents or fraction of forty (40). I/II (E) Those facilities which have only an asleep attendant during the night-time period and those facilities which have only the minimum staff required by subsection (27)(D) during SENIOR SERVICES the night-time period shall not accept residents who are blind, use assistive devices, such as walkers or wheelchairs, or who need care greater than can be provided with the staffing pattern in those facilities. Those residents who were living in a residential care facility prior to July 11, 1980, may remain in that facility with an asleep attendant even though they may be blind, deaf or use assistive devices provided they can demonstrate the ability to reach safety unassisted or with assistive devices. II (28) All residents shall be physically and mentally capable of negotiating a normal path to safety unassisted or with the use of assistive devices within five (5) minutes of being alerted of the need to evacuate the facility as defined in subsection (1)(C) of this rule. I/II (29) 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 (30) 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 discharged from the facility. I/II (31) In the event a resident is transferred from the facility, staff shall forward a report of the resident’s current medical status, physician’s orders/prescriptions, and if applicable, a copy of the resident’s advanced directives/living will to the facility to which the resident is being transferred. If the resident is transferring to a private residence, facility staff shall provide the reports to the resident or his or her designee or legally authorized representative. II/III (32) Residents admitted to a facility on referral by the Department of Mental Health shall have an individual treat ment plan or individual habilitation plan on file prepared by the Department of Mental Health, updated annually. II (33) 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 unless an area of refuge as defined in 19 CSR 30-86.022 is provided. 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 or an area of refuge as defined in 19 CSR 30-86.022. II (34) Requirements for facilities which admit or retain residents with mental illness or mental retardation diagnosis and residents with assaultive or disruptive behaviors: (A) Each resident who exhibits mental and psychosocial adjustment difficulty(ies) shall receive treatment and services to address the resident’s needs and behaviors as stated in the individual service plan; I/II (B) If specialized rehabilitative services for mental illness or mental retardation are required to enable a resident to reach and to comply with the individualized service plan, the facility must ensure the required services are provided; and II (C) The facility shall maintain in the resident’s record the most recent progress notes and personal plan developed and provided by the Department of Mental Health or designated administrative agent for each resident whose care is funded by the Department of Mental Health or designated administrative agent. III (35) The use of interventions to manage disruptive or assaultive resident behaviors shall be employed with sufficient safeguards to ensure the safety, welfare and rights of the resident and shall be in accordance with the therapeutic goals for the resident. I/II (36) Residents under sixteen (16) years of age shall not be admitted. III (37) 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 (38) The facility shall follow appropriate infection control procedures. The administrator or his or her designee shall make a report to the local health authority or the department of the presence or suspected presence of any diseases or findings listed in 19 CSR 20-20.020, sections (1)–(3) according to the specified time frames as follows: (A) Category I diseases or findings shall be reported to the local health authority or to the department within twentyfour (24) hours of first knowledge or suspicion by telephone, facsimile, or other rapid communication; I/II (B) Category II diseases or findings shall be reported to the local health authority or the department within three (3) days of first knowledge or suspicion; I/II (C) Category III. The occurrence of an outbreak or epidemic of any illness, disease or condition which may be of public health concern, including any illness in a food handler that is potentially transmissible through food. This also includes public health threats such as clusters of unusual diseases or manifestations of illness and clusters of unexplained deaths. Such incidents shall be reported to the local authority or to the department by telephone, facsimile, or other rapid communication within twenty-four (24) hours of first knowledge or suspicion. I/II (39) 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 (40) Residents shall receive proper care to meet their needs. Physician orders shall be followed. I/II (41) In case of behaviors that present a reasonable likelihood of serious harm to himself or herself or others, serious illness, significant change in condition, injury or death, staff shall take appropriate action and shall promptly attempt to contact the individual listed in the resident’s record as the legally authorized representative, designee, or placement authority. The facility shall contact the attending physician or designee and notify the local coroner or medical examiner immediately upon the death of any resident of the facility prior to transferring the deceased resident to a funeral home. II/III (42) The facility shall encourage and assist each resident based on his or her individual preferences and needs, to be clean and free of body and mouth odor. II (43) 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 (44) If the resident brings unsealed medications to the facility, the medications shall not be used unless a pharmacist, physician or nurse examines, identifies, and determines the contents to be suitable for use. The individual performing the identification shall document his or her review. II/III (45) 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. A 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. Written approval for self-control of prescription medication shall be rewritten as needed but at least annually and after any period of hospitalization. II/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. Medication shall be accessible only to persons authorized to administer medications. II/III (A) 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 or her absence, although this does not preclude access by a responsible employee of the facility. II/III (B) Schedule II controlled substances shall be stored in locked compartments separate from non-controlled medications, except that single doses of Schedule II controlled substances may be controlled by a resident in compliance with the requirements for self-control of medication of this rule. II/III (C) Medication that is not in current use and is not destroyed shall be stored separately from medication that is in current use. II/III (47) All prescription medications shall be supplied as individual prescriptions except where an emergency medication supply is allowed. 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. 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. Medication labels shall not be altered by facility staff and medications shall not be repackaged by facility staff except as allowed by section (48) of this rule. Over-the-counter medications for individual residents shall be labeled with at least the resident’s name. II/III (48) Controlled substances and other prescription and nonprescription medications for administration when a resident temporarily leaves a facility shall be provided as follows: (A) Separate containers of medications for the leave period may be prepared by the pharmacy. The facility shall have a policy and procedure for families to provide adequate advance notice so that medications can be obtained from the pharmacy; II/III (B) Prescription medication cards or other multiple-dose prescription containers currently in use in the facility may be provided by any authorized facility medication staff member if the containers are labeled by the pharmacy with complete pharmacy prescription labeling for use. Original manufacturer containers of non-prescription medications, along with instructions for administration, may be provided by any authorized facility medication staff member; II/III (C) When medications are supplied by the pharmacy in customized patient medication packages that allow separation of individual dose containers, the required number of containers may be provided by any authorized facility medication staff member. The individual dose containers shall be placed in an outer container that is labeled with the name and address of the facility and the date; II/III (D) When multiple doses of a medication are required and it is not reasonably possible to obtain prescription medication labeled by the pharmacy, and it is not appropriate to send a container of medication currently in use in the facility, up to a twenty-four- (24-) hour supply of each prescription or nonprescription medication may be provided by a licensed nurse in United States Pharmacopeia (USP) approved containers labeled with the facility name and address, resident’s name, medication name and strength, quantity, instructions for use, date, initials of individual providing, and other appropriate information; II/III (E) When no more than a single dose of a medication is required, any authorized facility medication staff member may prepare the dose as for in-facility administration in a USP approved container labeled with the facility name and address, resident’s name, medication name and strength, quantity, instructions for use, date, initials of person providing, and other appropriate information; (F) The facility may have a policy that limits the quantity of medication sent with a resident without prior approval of the prescriber; II/III (G) Returned containers shall be identified as having been sent with the resident, and shall not later be returned to the pharmacy for reuse; and II/III (H) The facility shall maintain accurate records of medications provided to and returned by the resident. II/III (49) Upon discharge or transfer of a resident, the facility shall release prescription medications, including controlled substances, held by the facility for the resident when the physician writes an order for each medication to be released. Medications shall be labeled by the pharmacy with current instructions for use. Prescription medication cards or other containers may be released if the containers are labeled by the pharmacy with complete pharmacy prescription labeling. II/III (50) Injections shall be administered only by a physician or licensed nurse, except that insulin injections may be administered by a CMT or LIMA who has successfully completed the state-approved course for insulin administration, taught by a department-approved instructor. A resident who requires insulin, may administer his or her own insulin if approved SENIOR SERVICES in writing by the resident’s physician and trained to do so by a licensed nurse or physician. The facility is responsible to monitor the resident’s condition and continued ability for selfadministration. I/II (51) The administrator/manager shall develop and implement a safe and effective system of medication control and use, which assures that all residents’ medications are administered by personnel at least eighteen (18) years of age, in accordance with physicians’ instructions using acceptable nursing techniques. The facility shall employ a licensed nurse eight (8) hours per week for every thirty (30) residents to monitor each resident’s condition and medication. Administration of medication shall mean delivering to a resident his or 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. All individuals who administer 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 (52) 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 the medication, dosage, frequency and route of administration, and the orders shall be renewed at least every three (3) months. Computer generated signatures may be used if safeguards are in place to prevent their misuse. Computer identification codes shall be accessible to and used only by the individuals whose signatures they represent. Orders that include optional doses or include pro re nata (PRN) administration frequencies shall specify a maximum frequency and the reason for administration. II/III (C) Telephone and other verbal orders shall be received 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 or other verbal order is given to a medication technician or level I medication aide, an initial dosage shall not be administered until the order has been reviewed by telephone, facsimile, or in person by a licensed nurse or pharmacist. II (D) The review shall be documented by the licensed nurse’s or pharmacist’s signature within seven (7) days. III (E) The physician shall sign all telephone and other verbal orders within seven (7) days. III (F) Medication staff shall record administration of medication on a medication sheet or directly in the resident’s record. If administration of medication is recorded on a medication sheet, the medication sheet shall be made part of the resident’s medical record. The same individual who prepares and administers the medication shall record the administration. II/III (53) Influenza and pneumococcal polysaccharide immuniza tions may be administered per physician-approved facility policy after assessment for contraindications. (A) The facility shall develop a policy that provides recommendations and assessment parameters for the administration of such immunizations. The policy shall be approved by the facility medical director for facilities having a medical director, or by each resident’s attending physician for facilities that do not have a medical director, and shall include the requirements to— 1. Provide education regarding the potential benefits and side effects of the immunization to each resident or the resident’s designee or legally authorized representative; II/III 2. Offer the immunization to the resident or obtain permission from the resident’s designee or legally authorized representative when it is medically indicated, unless the resident has already been immunized as recommended by the policy; II/III 3. Provide the opportunity to refuse the immunization; and II/III 4. Perform an assessment for contraindications. II/III (B) The assessment for contraindications and documentation of the education and opportunity to refuse the immunization shall be dated and signed by the nurse performing the assessment and placed in the medical record. II/III (C) The facility shall with the approval of each resident’s physician, access screening and immunization through outside sources, such as county or city health departments, and the facility shall document in the medical record that the requirements in subsection (53)(B) were performed by outside sources. II/III (54) Stock supplies of nonprescription medication may be kept when specific medications are approved in writing by a consulting physician, a registered nurse or a pharmacist. No stock supply of prescription medication may be kept in the facility. II/III (55) Records shall be maintained upon receipt and disposition of all controlled substances and shall be maintained separately from other records, for two (2) years. (A) Inventories of controlled substances shall be reconciled as follows: II/III 1. Controlled Substance Schedule II medications shall be reconciled each shift; and II 2. Controlled Substance Schedule III–V medications shall be reconciled at least weekly and as needed to ensure accountability. II/III (B) Inventories of controlled substances shall be reconciled by the following: 1. Two (2) medication personnel, one of whom is a licensed nurse; or 2. Two (2) medication personnel, one of whom is the administrator/manager when no nurse is available on staff; or 3. Two (2) medication personnel either medication technicians or level I medication aides when neither a licensed nurse nor the administrator/manager is available. II/III (C) Receipt records shall include the date, source of supply, resident name and prescription number when applicable, medication name and strength, quantity and signature of the supplier and receiver. Administration records shall include the date, time, resident name, medication name, dose administered, and the initials of the individual administering. The signature and initials of each medication staff documenting on the medication administration record must be signed in the signature area of the medication record. II/III (D) When self-control of medication is approved a record shall be made of all controlled substances transferred to and administered from the resident’s room. Inventory reconciliation shall include controlled substances transferred to the resident’s room. I/II (56) Documentation of the wasting of controlled substances at the time of administration shall include the reason for the waste and the signature of another medication staff member or the administrator who witnesses the waste. If no medication staff member or the administrator is available at the time of administration, the controlled substance shall be properly labeled, clearly identified as unusable, stored in a locked area, and destroyed as soon as a medication staff member or the administrator is available to witness the waste. When no medication staff member or the administrator is available and the controlled substance is contaminated by patient body fluids, the controlled substance shall be destroyed immediately and the circumstances documented. II/III (57) At least every three (3) months in a residential care facility, a pharmacist or registered nurse shall review the controlled substance recordkeeping including reconciling the inventories of controlled substances. This shall be done at the time of the drug regimen review of each resident. All discrepancies in controlled substance records shall be reported to the administrator or manager for review and investigation. The theft or loss of controlled substances shall be reported as follows: II/III (A) The facility shall notify the department’s Section for Long Term Care (SLTC) and other appropriate authorities of any theft or significant loss of any controlled substance medication written as an individual prescription for a specific resident upon the discovery of the theft or loss. The facility shall consider at least the following factors in determining if a loss is significant: 1. The actual quantity lost in relation to the total quantity; 2. The specific controlled substance lost; 3. Whether the loss can be associated with access by specific individuals; 4. Whether there is a pattern of losses, and if the losses appear to be random or not; 5. Whether the controlled substance is a likely candidate for diversion; and 6. Local trends and other indicators of diversion potential; II/III (B) If an insignificant amount of such controlled substance is lost during lawful activities, which includes but are not limited to receiving, recordkeeping, access auditing, administration, destruction and returning to the pharmacy, a description of the occurrence shall be documented in writing and maintained with the facility’s controlled substance records. The documentation shall include the reason for determining that the loss was insignificant. II/III (58) A pharmacist or registered nurse shall review the medication regimen of each resident. This shall be done at least every three (3) months in a residential care facility. The review shall be performed in the facility and shall include but shall not be limited to indication for use, dose, possible medication interactions and medication/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/manager. 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/manager shall contact or recontact the physician to determine if he or she received the information and if there are any new instructions. II/III (59) All medication errors and adverse reactions shall be promptly documented and reported to the administrator/ manager and the resident’s physician. If the pharmacy made a dispensing error, it shall also be reported to the issuing pharmacy. II/III (60) Medications that are not in current use shall be disposed of as follows: (A) Single doses of contaminated, refused, or otherwise unus able non-controlled substance medications may be destroyed by any authorized medication staff member at the time of administration. Single doses of unusable controlled substance medications shall be destroyed according to section (56) of this rule; (B) Discontinued medications may be retained up to one hundred twenty (120) days prior to other disposition if there is reason to believe, based on clinical assessment of the resident, that the medication might be reordered; (C) Medications may be released to the resident or family upon discharge according to section (49) of this rule; (D) After a resident has expired, medications, except for controlled substances, may be released to the resident’s legal representative upon written request of the legal representative that includes the name of the medication and the reason for the request; (E) Medications may be returned to the pharmacy that dispensed the medications pursuant to 4 CSR 220-3.040 or returned pursuant to the Prescription Drug Repository Program, 19 CSR 20-50.020; (F) All other medications, including all controlled substances and all expired or otherwise unusable medications, shall be destroyed within thirty (30) days as follows: II/III 1. Medications shall be destroyed within the facility by a pharmacist and a licensed nurse or by two (2) licensed nurses or when two (2) licensed nurses are not available on staff by two (2) individuals who have authority to administer medications, one (1) of whom shall be a licensed nurse or a pharmacist; and II/III 2. A record of medication destroyed shall be maintained and shall include the resident’s name, date, medication name and strength, quantity, prescription number, and signatures of the individuals destroying the medications; and II/III (G) A record of medication released or returned to the phar macy shall be maintained and shall include the resident’s name, date, medication name and strength, quantity, prescrip tion number, and signatures of the individuals releasing and receiving the medications. III (61) Residents shall be encouraged to be active and to participate in activities. In a residential care 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 (62) The facility shall maintain a record in the facility for each resident which shall include the following: SENIOR SERVICES (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 numbers (if applicable); name, address, and telephone number of the resident’s physician and alternate; diagnosis; name, address, and telephone number of the resident’s legally authorized representative or designee to be notified in case of emergency; and preferred dentist, pharmacist, and funeral director; III (B) 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 or her own medication, noting if prescription medications are being used in appropriate quantities; a daily record of administration of medication; a logging of the medication 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 resident incidents including behaviors that present a reasonable likelihood of serious harm to himself or herself or others and accidents that potentially could result in injury or did result in injuries involving the resident; and III (C) Any Physician’s Orders. Except as allowed by section (52) of this rule, the facility shall submit to the physician written versions of any oral or telephone orders within four (4) days of the giving of the oral or telephone order. III (63) A record of the daily resident census shall be retained in the facility. III (64) Resident records shall be maintained by the operator for at least five (5) years after a resident leaves the facility or after the resident reaches the age of twenty-one (21), whichever is longer and must include reason for discharge or transfer from the facility and cause of death, if applicable. III AUTHORITY: sections 198.005 and 198.076, RSMo 2016, and section 198.006, RSMo Supp. 2025.* This rule originally filed as 13 CSR 15-15.042. Original rule filed July 13, 1983, effective Oct. 13, 1983. 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 March 14, 1985, effective June 13, 1985. Amended: Filed May 13, 1987, effective Aug. 13, 1987. Amended: Filed April 17, 1990, effective June 30, 1990. Amended: Filed Feb. 13, 1998, effective Sept. 30, 1998. Moved to 19 CSR 3086.042, 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 Aug. 23, 2006, effective April 30, 2007. ** Amended: Filed Jan. 23, 2026, effective July 30, 2026. *Original authority: 198.005, RSMo 2006; 198.006, RSMo 1979, amended 1984, 1987, 2003, 2006, 2022; and 198.076, RSMo 1979, amended 1984, 2007. **Pursuant to Executive Order 21-07, 19 CSR 30-86.042, section (37) was suspended from April 17, 2020 through May 1, 2021 and sections (17) and (18) was suspended from April 17, 2020 through August 31, 2021. Pursuant to Executive Order 21-09, 19 CSR 30-86.042, section (58) was suspended from April 17, 2020 through September 3, 2021; subsection (21)(I) and sections (50) and (51) was suspended from April 15, 2020 through December 31, 2021; and section (7) was suspended from April 17, 2020 through December 31, 2021.