Administrative, Personnel, and Resident Care Requirements for Assisted Living Facilities

PURPOSE: This rule establishes standards for all assisted living facilities licensed pursuant to sections 198.005 and 198.073, RSMo (CCS HCS SCS SB 616, 93rd General Assembly, Second Regular Session (2006)), and required to meet assisted living facility standards pursuant to section 198.073.3, RSMo (CCS HCS SCS SB 616, 93rd General Assembly, Second Regular Session (2006)), and section 198.076, RSMo 2000. PUBLISHER’S NOTE: The secretary of state has determined that publication of the entire text of the material that is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here. AGENCY NOTE: All rules relating to long-term care facilities licensed by the department are followed by a Roman Numeral notation which refers to the class (either Class I, II, or III) of standard as designated in section 198.085.1., RSMo. (1) Facilities licensed as assisted living facilities shall be inspected pursuant to the standards outlined herein beginning April 1, 2007. An assisted living facility may request, in writing to the department, to comply with these standards prior to April 1, 2007. Upon receipt of the request, the department shall conduct an inspection to determine compliance with the standards outlined herein prior to issuing a license indicating such compliance. (2) Consumer Education Requirements. The facility shall disclose to a prospective resident, or legal representative of the resident, information regarding the services the facility is able to provide or coordinate, the cost of such services to the resident, and the grounds for discharge or transfer as permitted or required by the Omnibus Nursing Home Act, Chapter 198, RSMo, and the department’s regulations, including the provisions set forth in section (29) of this rule. II (3) Nothing in this rule shall be construed to allow any facility that has not met the requirements of 198.073(4) and (6), RSMo (CCS HCS SCS SB 616, 93rd General Assembly, Second Regular Session (2006)), and 19 CSR 30-86.045 to care for any individual with a physical, cognitive or other impairment that prevents the individual from safely evacuating the facility with minimal assistance. I/II (4) Definitions. For the purpose of this rule, the following definitions shall apply: (A) Appropriately trained and qualified individual means an individual who is licensed or registered with the state of Missouri in a health care related field or an individual with a degree in a health care related field or an individual with a degree in a health care, social services, or human services field or an individual licensed under Chapter 344, RSMo, and who has received facility orientation training under 19 CSR 3086.047, and dementia training under section 192.2000, RSMo, and twenty-four (24) hours of additional training, approved by the department, consisting of definition and assessment of activities of daily living, assessment of cognitive ability, service planning, and interview skills; (B) Area of refuge—A space located in or immediately adjacent to a path of travel leading to an exit that is protected from the effects of fire, either by means of separation from other spaces in the same building or its location, permitting a delay in evacuation. An area of refuge may be temporarily used as a staging area that provides relative safety to its occupants while potential emergencies are assessed, decisions are made, and evacuation is begun; (C) Assisted living facility (ALF)—Is as defined in 19 CSR 3083.010; (D) Chemical restraint—Is as defined in 19 CSR 30-83.010; (E) Community based assessment—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, 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; (F) Evacuating the facility—For the purpose of this rule, evacuating the facility shall mean moving to an area of refuge or from one smoke section to another or exiting the facility; (G) 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: 1. A living room and common use areas for social interactions and activities; 2. Kitchen and family style eating area for use by the residents; 3. Laundry area for use by residents; 4. A toilet room that contains a toilet, lavatory and bathing unit in each resident’s room; 5. Resident room preferences for residents who wish to share a room, and for residents who wish to have private bedrooms; 6. Outdoor area for outdoor activities and recreation; and 7. 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; (H) 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; (I) Keeping residents in place—Means 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 a lower risk of injury; (J) Minimal assistance— 1. Is the criterion which determines whether or not staff must develop and include an individualized evacuation plan as part of the resident’s service plan; 2. Minimal assistance may be the verbal intervention that staff must provide for a resident to initiate evacuating the facility; 3. Minimal assistance may be the physical intervention that staff must provide, such as turning a resident in the correct direction, for a resident to initiate evacuating the facility; 4. A resident needing minimal assistance is one who is able to prepare to leave and then evacuate the facility within five (5) minutes of being alerted of the need to evacuate and requires no more than one (1) physical intervention and no more than three (3) verbal interventions of staff to complete evacuation from the facility; 5. The following actions required of staff are considered to be more than minimal assistance: A. Assistance to traverse down stairways; B. Assistance to open a door; and C. Assistance to propel a wheelchair; (K) Physical restraint—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: 1. Using side rails that keep a resident from voluntarily getting out of bed; 2. Tucking in or using Velcro to hold a sheet, fabric, or clothing tightly so that a resident’s movement is restricted; 3. 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; 4. Placing the resident in a chair that prevents a resident from rising; and 5. 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; (L) Significant change—Means any change in the resident’s physical, emotional or psychosocial condition or behavior that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one (1) area of the resident’s health status, and requires interdisciplinary review or revision of the individualized service plan, or both; (M) Skilled nursing facility—Means 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 twenty-four (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; (N) Skilled nursing placement—Means placement in a skilled nursing facility as defined in subsection (4)(M) of this rule; and (O) 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. (5) The operator shall designate an individual for administrator who is currently licensed as an administrator by the Missouri Board of Nursing Home Administrators, in accordance with Chapter 344, RSMo. II (6) The operator shall be responsible to assure compliance with all applicable laws and regulations. The administrator shall be fully authorized and empowered to make decisions regarding the operation of the facility and shall be held responsible for the actions of all employees. The administrator’s responsibilities shall include oversight of residents to assure that they receive care as defined in the individualized service plan. II/III (7) The administrator cannot be listed or function in more than one (1) licensed facility at the same time unless he or she serves no more than five (5) facilities within a thirty- (30-) mile radius and licensed to serve in total no more than one hundred (100) residents, and the administrator has an individual designated as the daily manager of each facility. However, the administrator may serve as the administrator SENIOR SERVICES of more than one (1) licensed facility if all facilities are on the same premises. II (8) The administrator shall designate, in writing, a staff member in charge in the administrator’s absence. If the administrator is absent for more than thirty (30) consecutive days, during which time he or she is not readily accessible for consultation by telephone with the delegated individual, the individual designated to be in charge shall be an administrator currently licensed by the Missouri Board of Nursing Home Administrators, in accordance with Chapter 344, RSMo. Such thirty (30) consecutive day absences may only occur once within any consecutive twelve- (12-) month period. II/III (9) The facility shall not care for more residents than the number for which the facility is licensed. However, if the facility operates a non-licensed adult day care program for four (4) or fewer participants within the licensed facility, the day care participants shall not be included in the total facility census. Adult day care participants shall be counted in staffing determination during the hours the day care participants are in the facility. II/III (10) 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 (11) 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 (12) All persons who have any contact with the residents in the facility shall not knowingly act or omit any duty in a manner that would materially and adversely affect the health, safety, welfare, or property of residents. No person who is listed on the Employee Disqualification List (EDL) maintained by the department as required by section 198.070, RSMo, shall work or volunteer in the facility in any capacity whether or not employed by the operator. For the purpose of this rule, a volunteer is an unpaid individual formally recognized by the facility as providing a direct care service to residents. The facility is required to check the EDL for individuals who volunteer to perform a service for which the facility might otherwise have to hire an employee. The facility is not required to check the EDL for individuals or groups such as scout groups, bingo leaders, or sing-along leaders. The facility is not required to check the EDL for an individual such as a priest, minister, or rabbi visiting a resident who is a member of the individual’s congregation. However, if a 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 (13) Prior to allowing any person who has been hired in a fulltime, part-time, or temporary position to have contact with any resident, the facility shall or, in the case of temporary employees hired through or contracted from an employment agency, the employment agency shall, prior to sending a temporary employee to a facility— (A) Request a criminal background check for the person, as provided in section 192.2495, RSMo. Each facility shall maintain documents verifying that the background checks were requested, the date of each such request, and the nature of the response received for each such request. II 1. The facility shall ensure that any person hired or retained to have contact with any resident who discloses that he or she has been 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 section 198.070.3., RSMo, or section 568.020, RSMo, shall not be retained in such a position. I/II 2. Upon receipt of the criminal background check, the facility shall ensure that if the criminal background check indicates that the person hired or retained by the facility has been 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 section 198.070.3., RSMo, or section 568.020, RSMo, the person shall not have contact with any resident unless and until the facility obtains verification from the department that a good cause waiver has been granted for each qualifying offense and maintains a copy of the verification in the individual’s personnel file; I/II (B) Make an inquiry to the department, as provided in section 192.2490, RSMo, as to whether the person is listed on the EDL. Each facility shall maintain documents verifying that the EDL checks were requested, the date of each such request, and the nature of the response received for each such request. The inquiry may be made through the department’s website 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 FCSR in order to meet the requirements of subsections (13)(A) and (13) (B) of this rule. The FCSR is available through the department’s website; and (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 shall either require a criminal background check or ensure that the individual is sufficiently monitored by facility staff while in the facility to reasonably ensure the safety of all residents. I/II (14) 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 of this rule 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 (15) 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 (16) 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 (17) 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 (18) The administrator shall be responsible to prevent 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 2020.010 through 19 CSR 20-20.100. II/III (19) The facility shall screen residents and staff for tuberculosis as required for long-term care facilities by 19 CSR 20-20.100. II (20) The administrator 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 certified medication technicians, level I medication aides 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 (21) Personnel records shall be maintained for at least two (2) years following termination of employment. III (22) There shall be written documentation maintained in the facility showing actual hours worked by each employee. III (23) No one individual shall be on duty with responsibility for oversight of residents longer than eighteen (18) hours per day. I/II (24) 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. One employee at least eighteen (18) years of age shall be on duty at all times. II (25) Each facility resident shall be under the medical supervision of a physician licensed to practice in Missouri 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. III (26) The facility shall ensure that each resident being admitted or readmitted to the facility receives an admission physical examination by a licensed physician. The facility shall request documentation of the physical examination prior to admission but must have documentation of the physical examination on file no later than ten (10) days after admission. The physical examination shall contain documentation regarding the individual’s current medical status and any special orders or procedures to be followed. If the resident is admitted directly from an acute care or another long-term care facility and is accompanied on admission by a report that reflects his or her current medical status, an admission physical shall not be required. III (27) Residents under sixteen (16) years of age shall not be admitted. III (28) The facility may admit or retain an individual for residency in an assisted living facility only if the individual does not require hospitalization or skilled nursing placement as defined in this rule, and only if the facility— (A) Provides for or coordinates oversight and services to meet the needs, the social and recreational preferences in accordance with the individualized service plan of the resident as documented in a written contract signed by the resident, or legal representative of the resident; II (B) Has twenty-four (24) hour staff appropriate in numbers and with appropriate skills to provide such services; II (C) Has a written plan for the protection of all residents in the event of a disaster such as tornado, fire, bomb threat or severe weather, including— 1. Keeping residents in place; 2. Evacuating residents to areas of refuge; 3. Evacuating residents from the building if necessary; or 4. Other methods of protection based on the disaster and the individual building design; I/II (D) Completes a premove-in screening conducted as required by section 198.073.4(4), RSMo (CCS HCS SCS SB 616, 93rd General Assembly, Second Regular Session (2006)); II (E) The premove-in screening shall be completed prior to admission with the participation of the prospective resident and be designed to determine if the individual is eligible for SENIOR SERVICES admission to the assisted living facility and shall be based on the admission restrictions listed at section (29) of this rule; II (F) Completes a community based assessment conducted by an appropriately trained and qualified individual as defined in section (4) of this rule: 1. Time frame requirements for assessment shall be— A. Within five (5) calendar days of admission; II B. At least semiannually; and II C. Whenever a significant change has occurred in the resident’s condition, which may require a change in services; II 2. The facility shall use form MO 580-2835, Assessment for Admission To Assisted Living Facilities (9-06), incorporated by reference, provided by the Department of Health and Senior Services, PO Box 570, Jefferson City, MO 65102-0570 and which is available to long-term care facilities at www.dhss.mo.gov or by telephone at (573) 526-8548. This rule does not incorporate any subsequent amendments or additions; or II 3. The facility may use another assessment form if approved in advance by the department; II (G) Develops an individualized service plan (ISP), which means the planning document prepared by an assisted living facility which outlines a resident’s needs and preferences, services to be provided, and goals expected by the resident or the resident’s legal representative in partnership with the facility; II (H) Reviews the ISP with the resident, or legal representative of the resident, at least annually or when there is a significant change in the resident’s condition which may require a change in services; II (I) Includes the signatures of an authorized representative of the facility and the resident or the resident’s legal representative in the individualized service plan to acknowledge that the service plan has been reviewed and understood by the resident or legal representative; II (J) Develops and implements a plan to protect the rights, privacy, and safety of all residents and to protect against the financial exploitation of all residents; and II (K) Complies with the dementia specific training requirements of subsection 8 of section 660.050, RSMo. II (29) The facility shall not admit or continue to care for a resident who— (A) Has exhibited behaviors that present a reasonable likelihood of serious harm to himself or herself or others; I/II (B) Requires physical restraint as defined in this rule; II (C) Requires chemical restraint as defined in this rule; II (D) Requires skilled nursing services as defined in section 198.073.4, RSMo, for which the facility is not licensed or able to provide; II (E) Requires more than one (1) person to simultaneously physically assist the resident with any activity of daily living, with the exception of bathing and transferring; or II/III (F) Is bed-bound or similarly immobilized due to a debilitating or chronic condition. II (30) The requirements of subsections (29)(D), (E), and (F) shall not apply to a resident receiving hospice care, provided the resident, his or her legally authorized representative or designee, or both, and the facility, physician and licensed hospice provider all agree that such program of care is appropriate for the resident. II (31) Programs and Services Requirements for Residents. (A) The facility shall designate a staff member to be responsible for leisure activity coordination and for promoting the social model, multiple staff role directing all staff to provide routine care in a manner that emphasizes the opportunity for the resident and the staff member to enjoy a visit rather than simply perform a procedure. II/III (B) The facility shall make available and implement self-care, productive and leisure activity programs which maximize and encourage the resident’s optimal functional ability for residents. The facility shall provide person-centered activities appropriate to the resident’s individual needs, preferences, background and culture. Individual or group activity programs may consist of the following: 1. Gross motor activities, such as exercise, dancing, gardening, cooking and other routine tasks; 2. Self-care activities, such as dressing, grooming and personal hygiene; 3. Social and leisure activities, such as games, music and reminiscing; 4. Sensory enhancement activities, such as auditory, olfactory, visual and tactile stimulation; 5. Outdoor activities, such as walking and field trips; 6. Creative arts; or 7. Other social, leisure or therapeutic activities that encourage mental and physical stimulation or enhance the resident’s well-being. II/III (C) Staff shall inform residents in advance of any organized group activity including the time and place of the activity. II/III (32) Requirements for Facilities Providing Care to Residents Having Mental Illness or Mental Retardation Diagnosis. (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 individualized 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 shall ensure the required services are provided. 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 (33) No facility shall accept any individual with a physical, cognitive, or other impairment that prevents the individual from safely evacuating the facility with minimal assistance unless the facility meets all requirements of section 198.073, RSMo (CCS HCS SCS SB 616, 93rd General Assembly, Second Regular Session (2006)), and those standards set forth in 19 CSR 30-86.045. I/II (34) 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; (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; (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 (35) 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 (36) Residents shall receive proper care as defined in the individualized service plan. I/II (37) 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 person 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. I/II (38) 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 (39) 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 person performing the identification shall document his or her review. II/III (40) Self-control of prescription medication by a resident may be allowed only if approved in writing by the resident’s physician and included in the resident’s individualized service plan. 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 (41) 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. (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. (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 (42) 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 (43) of this rule. Over-the-counter medications for individual residents shall be labeled with at least the resident’s name. II/III (43) 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; (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; (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; (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; (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; (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 SENIOR SERVICES (H) The facility shall maintain accurate records of medications provided to and returned by the resident. II/III (44) 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 (45) Injections shall be administered only by a physician or licensed nurse, except that insulin injections may also be administered by a certified medication technician or level I medication aide who has successfully completed the state-approved course for insulin administration, taught by a department-approved instructor. Anyone trained prior to December 31, 1990, who completed the state-approved insulin administration course taught by an approved instructor shall be considered qualified to administer insulin in an assisted living facility. A resident who requires insulin may administer his or her own insulin if approved in writing by the resident’s physician and trained to do so by a licensed nurse or physician. The facility shall monitor the resident’s condition and ability to continue self-administration. I/II (46) The administrator 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 cup 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 (47) Medication Orders. (A) No medication, treatment or diet shall be administered without an order from an individual lawfully authorized to prescribe such and the order shall be followed. II/III (B) Physician’s written and signed orders shall include: name of 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 by only 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, certified medication technician, level I medication aide or pharmacist, and shall be immediately reduced to writing and signed by that individual. A certified medication technician or level I medication aide may receive a telephone or other verbal order only for a medication or treatment that the technician or level I medication aide is authorized to administer. 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. The review shall be documented by the reviewer co-signing the telephone or other verbal order. II (D) The review shall be documented by the licensed nurse’s or pharmacist’s signature within seven (7) days. III (E) 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 (F) Influenza and pneumococcal polysaccharide immuni zations may be administered per physician-approved facility policy after assessment for contraindications— 1. 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— A. Provide education to each resident or the resident’s designee or legally authorized representative regarding the potential benefits and side effects of the immunization; II/III B. Offer the immunization to the resident or obtain permission from the resident’s designee or legally authorized representative when the immunization is medically indicated unless the resident has already been immunized as recommended by the policy; II/III C. Provide the opportunity to refuse the immunization; and II/III D. Perform an assessment for contraindications; II/III 2. 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; or 3. 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. II/III (G) The administration of medication shall be recorded on a medication sheet or directly in the resident’s record and, if recorded on a medication sheet, shall be made part of the resident’s record. The administration shall be recorded by the same individual who prepares the medication and administers it. II/III (48) The facility may keep an emergency medication supply if approved by a pharmacist or physician. Storage and use of medications in the emergency medication supply shall assure accountability. When the emergency medication supply contains controlled substances, the facility shall be registered with the Bureau of Narcotics and Dangerous Drugs (BNDD) and shall be in compliance with 19 CSR 30-1.052 and other applicable state and federal controlled substance laws and regulations. II/III (49) Automated dispensing systems may be controlled by the facility or may be controlled on-site or remotely by a pharmacy. (A) Automated dispensing systems may be used for an emergency medication supply. (B) Automated dispensing systems that are controlled by a pharmacy may be used for continuing doses of controlled substance and non-controlled substance medications. When continuing doses are administered from an automated dispensing system that is controlled by a pharmacy, a pharmacist shall review and approve each new medication order prior to releasing the medication from the system. The pharmacy and the facility may have a policy and procedure to allow the release of initial doses of approved medications when a pharmacist is not available in lieu of a separate emergency medication supply. When initial doses are used when a pharmacist is not available, a pharmacist shall review and approve the order within twenty-four (24) hours of administration of the first dose. (C) Automated dispensing systems shall be used in compliance with state and federal laws and regulations. When an automated dispensing system controlled by the facility contains controlled substances for an emergency medication supply, the facility shall be registered with the BNDD. When an automated dispensing system is controlled by a pharmacy, the facility shall use it in compliance with 20 CSR 2220-2.900. II/III (50) 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. II/III (51) 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: 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 (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, who are certified medication technicians or level I medication aides, when a licensed nurse is not available. II (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 (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. II (52) Documentation of waste of controlled substances at the time of administration shall include the reason for the waste and the signature of another facility medication staff member who witnesses the waste. If a second medication staff member is not 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 is available to witness the waste. When a second medication staff member is not available and the controlled substance is contaminated by patient body fluids, the controlled substance shall be destroyed immediately and the circumstances documented. II/III (53) At least every other month, 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 for review and investigation. The theft or loss of controlled substances shall be reported as follows: (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; (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; and (C) When the facility is registered with the BNDD, the facility shall report to or document for the BNDD any loss of any stock supply controlled substance in compliance with 19 CSR 301.034. II/III (54) A physician, pharmacist or registered nurse shall review the medication regimen of each resident. This shall be done at least every other month. 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 shall contact or recontact the physician to determine if he or she received the information and if there are any new instructions. II/III (55) All medication errors and adverse reactions shall be promptly documented and reported to the administrator and the resident’s physician. If the pharmacy made a dispensing error, it shall also be reported to the issuing pharmacy. II/III SENIOR SERVICES (56) Medications that are not in current use shall be disposed of as follows: (A) Single doses of contaminated, refused, or otherwise unusable 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 may be destroyed according to section (52) 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 (44) 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 dis pensed the medications pursuant to 20 CSR 2220-3.040 or re turned pursuant to the Prescription Drug Repository Program, 19 CSR 20-50.020. All other medications, including all con trolled substances and all expired or otherwise unusable med ications, shall be destroyed within thirty (30) days as follows: 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 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 (F) 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. II/III (57) Residents experiencing short periods of incapacity due to illness or 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 (58) The facility shall maintain a record in the facility for each resident, which shall include the following: (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 (C) Any physician’s orders. 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 (59) A record of the resident census shall be retained in the facility. III (60) 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, as applicable. III (61) Staffing Requirements. (A) The facility shall have an adequate number and type of personnel for the proper care of residents, the residents’ social well being, protective oversight of residents and upkeep of the facility. At a minimum, the staffing pattern for fire safety and care of residents shall be one (1) staff person for every fifteen (15) residents or major fraction of fifteen (15) during the day shift, one (1) person for every twenty (20) residents or major fraction of twenty (20) during the evening shift and one (1) person for every twenty-five (25) residents or major fraction of twenty-five (25) during the night shift. I/II Time Personnel Residents 7 a.m. to 3 p.m. (Day)* 1 3–15 3 p.m. to 9 p.m. (Evening)* 1 3–20 9 p.m. to 7 a.m. (Night)* 1 3–25 *If the shift hours vary from those indicated, the hours of the shifts shall show on the work schedules of the facility and shall not be less than six (6) hours. III (B) The administrator shall count toward staffing when physically present in the facility. II (C) The required staff shall be in the facility awake, dressed and prepared to assist residents in case of emergency. I/II (D) Meeting these minimal staffing requirements may not meet the needs of residents as outlined in the residents’ assessments and individualized service plans. I/II (E) There shall be a licensed nurse employed by the facility to work at least eight (8) hours per week at the facility for every thirty (30) residents or additional major fraction of thirty (30). The nurse’s duties shall include, but shall not be limited to, review of residents’ charts, medications, and special diets or other orders, review of each resident’s adjustment to the facility, and observation of each individual resident’s general physical and mental condition. The nurse shall inform the administrator of any problems noted, and these shall be brought to the attention of the resident’s physician. II/III (62) Prior to or on the first day that a new employee works in the facility he or she shall receive orientation of at least two (2) hours 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; (I) Instruction regarding working with residents with mental illness; and (J) Instruction regarding person-centered care and the con cept of a social model of care, and techniques that are effective in enhancing resident choice and control over his or her own environment. II/III (63) In addition to the orientation training required in section (62) 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, techniques for creating a safe, secure and socially oriented environment, provision of structure, stability and a sense of routine for residents based on their needs, and understanding and dealing with family issues; and 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 (64) All in-service or orientation training relating to the special needs, care and safety of residents with Alzheimer’s disease and other dementia shall be conducted, presented or provided by an individual who is qualified by education, experience or knowledge in the care of individuals with Alzheimer’s disease or other dementia. II/III (65) Requirements for training related to safely transferring residents. (A) The facility shall ensure that all staff responsible for transferring residents are appropriately trained to transfer residents safely. Individuals authorized to provide this training include a licensed nurse, a physical therapist, a physical therapy assistant, an occupational therapist or a certified occupational therapy assistant. The individual who provides the transfer training shall observe the caregiver’s skills when checking competency in completing safe transfers, shall document the date(s) of training and competency and shall sign and maintain training documentation. Initial training shall include a minimum of two (2) classroom instruction hours in addition to the on-the-job training related to safely transferring residents who need assistance with transfers. II/III (B) The facility shall ensure that a minimum of one (1) hour of transfer training is provided by a licensed nurse annually regarding safe transfer skills. II/III AUTHORITY: sections 198.073 and 198.076, RSMo 2016.* Original rule filed Aug. 23, 2006, effective April 30, 2007. Amended: Filed March 13, 2008, effective Oct. 30, 2008. Amended: Filed March 1, 2012, effective Sept. 30, 2012. ** Amended: Filed Nov. 3, 2025, effective May 30, 2026. *Original authority: 198.073, RSMo 1979, amended 1984, 1992, 1999, 2006, 2007, and 198.076, RSMo 1979, amended 1984, 2007. **Pursuant to Executive Order 21-07, 19 CSR 30-86.047, section (26) was suspended from April 17, 2020 through May 1, 2021 and sections (18) and (19) was suspended from April 17, 2020 through August 31, 2021. Pursuant to Executive Order 21-09, 19 CSR 30-86.047, section (54) was suspended from April 17, 2020 through September 3, 2021; subsection (20)(I), sections (3), (10), (45), (46), and section 198.073.4, RSMo was suspended from April 15, 2020 through December 31, 2021; and sections (9) and (45) was suspended from April 17, 2020 through December 31, 2021.