Program Policies and Participant Care Requirements and Rights

PURPOSE: This rule establishes the minimum requirements for operating an adult day care program and providing care to participants; establishing and preserving certain rights of participants; and requiring adult day care providers to have written program policies. (1) The adult day care provider shall neither knowingly admit, nor continue to care for, participants whose needs cannot be met by the program directly or in cooperation with outside resources. (2) Each adult day care provider shall have a written emergency medical plan that assures the following: (A) Transportation to a hospital or other type of facility providing emergency or urgent care; (B) A written agreement, signed by each participant or legal guardian, shall be on file in the facility granting permission to transport the participant in need of emergency care to the designated hospital or other type of facility; (C) Notes in the participant’s record shall be made immediately of any accident, injury or illness and the emergency procedures taken; (D) Emergency telephone numbers for each participant shall be available to staff at all times; and (E) At a minimum, those first-aid supplies, as recommended by the American Red Cross or other comparable source, shall be readily available on-site. (3) The adult day care provider shall require a medical assessment by the participant’s physician or that physician’s designated agent of the participant’s medical condition to include activity needs and restrictions, dietary modifications, indicated therapies and medication as applicable prior to the first day of participation, signed by the physician or that physician’s designated agent within five (5) working days of the first day of participation. (4) The adult day care provider shall develop a written individual plan of care for each participant within five (5) contact days following the entry of the participant into the adult day care program. The plan shall be designed to maintain the participant at, or to restore to, optimal capability for self-care. The plan shall be based on a functional assessment and information obtained from the participant, participant’s family, physician and the person or agency referring the participant. The plan shall address the participant’s physical, social and psychological needs, goals and means of accomplishing goals to the degree that the program is designed and the staff are qualified to meet these goals. The plan shall identify the positions of persons responsible for specific individualized activities provided for the participant that are not documented by the regularly scheduled plan of activities for the program. The plan of care shall identify the participant’s regularly scheduled days for attendance, including arrival and departure times. The plan of care shall be revised as frequently as warranted by the participant’s condition, but shall be reviewed at least every six (6) months and updated as necessary. (5) The program director or program director’s designee shall maintain communication with participants and their families or other responsible persons to solve day-to-day problems which confront the participants. Referrals to other community resources should be made and services coordinated as needed. (6) The adult day care provider or program director or an other employee of the adult day care program shall report any suspected incidents of physical or mental abuse, neglect, exploitation, or a combination of these, of its participants to the Elderly Abuse and Neglect Hotline (1-800-392-0210). (7) The adult day care provider is required to offer at least the following services: (A) Activities of Daily Living. This includes providing assistance and training in walking, toileting, feeding, personal care and other activities of daily living in accordance with each participant’s individual plan of care; (B) Planned Group Activities. This includes providing planned activities during at least fifty percent (50%) of the time that the program is open for daily operation, with a maximum four (4) hours of planned activities required. Activities shall be suited to the needs and interests of participants and designed to stimulate interest, rekindle motivation and encourage physical exercise. Activities shall be conducted individually and in small and large groups. Planned activities include meals, rest periods, exercise, recreation and social activities. Physical exercise shall be designed in relation to each individual’s needs, impairments and abilities and shall be alternated with rest periods or quiet activities; (C) Food Service. This includes assuring the availability of meals and supplemental snacks in accordance with each participant’s individual plan of care. Meals served by the adult day care provider shall provide at least one-third (1/3) of the recommended dietary allowance of the National Research Council. Supplemental snacks shall consist of nourishing food and beverages. Food may be prepared, stored, served, or any combination of these, on-site in compliance with the requirements of the local health department or applicable rule established by the department under the provisions of 19 CSR 20-1.010. Food prepared away from the site shall be prepared in a food preparation facility which meets the requirements of the local health department or applicable rules established by the department under 19 CSR 20-1.010. The adult day care provider shall arrange for special diets and other diet modifications as ordered by a physician or the physician’s designated agent. Such diets shall be served as ordered by the participant’s physician or the physician’s designated agent with food preparation and service being reviewed by a qualified dietitian, physician or nurse at least every six (6) months. Modified diets shall be in effect for the specified number of days indicated in the physician’s order. If no time is specified, the period may not exceed one (1) calendar year, at which time another order from the physician shall be obtained; and (D) Observation. The health, functional and psychosocial status of each participant shall be observed and documented in the participant’s record at least monthly by the adult day care program director or other designated professional staff and the plan of care modified if necessary. (8) The adult day care provider may offer the following services: (A) Transportation. If transportation services are offered, directly or through a contract, they shall meet the requirements of 19 CSR 15-7.040; (B) Counseling Services. If counseling services are offered, they shall be provided by qualified professional personnel; (C) Rehabilitation Services. If rehabilitation services are offered, they shall be prescribed by a physician and performed by qualified therapists. Orders for the various therapies and treatments shall be in effect for the specified number of days indicated by the physician’s written order. If no time period is specified, then the time period shall not exceed sixty (60) days and a new order by the physician must be obtained. Therapy services provided shall be summarized in the participant’s record and progress noted at least monthly by the therapist; (D) Medical Services. If medical services are offered, a licensed nurse shall be available at all times that the program is in operation. Medical services shall be provided in accordance with the particular needs of each participant. The licensed nurse shall be the only individual authorized to receive, control and manage the medication and drug program. The licensed nurse shall be responsible for the following: 1. A safe, effective system of identifying, handling and storing each participant’s medications. 2. A system for administering and storing medications that is reviewed not less than every ninety (90) days by a licensed nurse. 3. Administration of medications and treatments, including the following requirements: A. Participants who are responsible for taking their own medication at home shall be permitted and encouraged to continue to be responsible for taking their own medication during the hours spent in the program. If a participant is unable to self-administer medication, then the adult day care provider shall assume responsibility in accordance with the applicable provisions of this rule. If a participant refuses medication, this refusal shall be documented in the participant’s record and the participant and their primary caregiver informed of the possible consequences of not receiving the medication; B. Medications or treatments may not be administered without an order signed by a licensed physician. Physician’s phone orders may be taken only by a licensed nurse. Phone orders shall be written into the participant’s record by the licensed nurse receiving them and shall be signed by that person. The physician shall sign and date the order within five (5) working days after giving the phone order; C. Orders concerning treatments and medications shall be in effect for a specified number of days as indicated by the physician. If not specified, the period may not exceed sixty (60) days; D. The licensed nurse shall communicate as indicated with the participant’s physician to report observed changes in health status, including reaction to medications and treatments. If an adverse reaction to medications, treatments or diet is observed, the licensed nurse shall promptly notify the participant’s physician. If contact cannot be made with the personal physician, emergency medical procedures shall be followed; and E. All medications, including overthe-counter medications, shall be packaged and labeled in accordance with applicable professional pharmacy standards, state and federal drug laws and regulations. Labeling shall include accessory and cautionary instructions as well as the expiration date, when applicable and the name of the medication as specified in the physician’s order. Over-the-counter medications for individual participants shall be labeled with at least the participant’s name; and 4. Medication storage that meets the following requirements: A. The adult day care provider shall have a safe, secure, locked place for storing medications or drugs and make them available to the participant according to the instructions of his or her personal physician; B. Controlled substances shall be locked separately from non-controlled substance medications; C. Medications requiring refrigeration shall be kept refrigerated in a locked room or in a separate locked refrigerator or in a locked box within the refrigerator or in a refrigerator in a locked room; and D. Nonprescription medicines may be retained in the facility for administration as ordered by the participant’s physician. 5. Medication records that meet the following requirements: A. A written record of medications, including over-the-counter medications, administered shall be maintained; B. Records shall be kept of the receipt and disposition of all controlled substances, separate from other records for two (2) years; C. Inventories of controlled substances shall be reconciled at the time of the medication system review and as needed to ensure accountability; D. Receipt records of controlled substances shall include the date, source of supply, resident name, prescription number, medication name and strength, quantity and signatures of the supplier and the receiver; E. Administration records of controlled substances shall include the date, time, resident name, medication name, dose administered and signature of the person administering; F. Documentation of waste of controlled substances at the time of administration shall include the reason for the waste and the signature of an authorized employee witness; and G. All variances of controlled substance records shall be documented and reported to the director for review and investigation. All losses of controlled substances shall be reported to the appropriate authorities. (9) Each participant of the adult day care program shall be assured of the following rights: (A) To be treated as an adult, with respect and dignity regardless of race, color, sex or creed; (B) To participate in a program of services and activities which promote positive attitudes regarding one’s usefulness and capabilities; (C) To participate in a program of services designed to encourage learning, growth and awareness of constructive ways to develop one’s interests and talents; (D) To maintain one’s independence to the extent that conditions and circumstances permit, and to be involved in a program of services designed to promote personal independence; (E) To be encouraged to attain self-determination within the adult day care setting, including the opportunity to participate in developing one’s plan for services; (F) To decide whether or not to participate in any given activity and to be involved in the extent possible in program planning and operation; (G) To be cared for in an atmosphere of sincere interest and concern in which needed support and services are provided; (H) To have access to a telephone to make or receive calls, unless necessary restrictions are indicated in the individual’s care plan; (I) To have privacy and confidentiality; (J) To be free of mental or physical abuse; (K) To be free to choose whether or not to perform services for the program; (L) To be free of restraint, unless under physician’s order as indicated in the individual’s care plan; and (M) To be free of interference, coercion, discrimination or reprisal. (10) Participants and their families shall be advised of participants’ rights and program policies upon admission to the adult day care program. (11) Participants’ rights shall be posted in a conspicuous location in the adult day care facility. (12) The adult day care provider shall have a written program description, copies of which are available to the division, participants, families and other interested agencies and individuals. The written program description shall contain at least the following: (A) Administrative organization, including role of the advisory committee if applicable; (B) Maximum number of participants that can be served; (C) Types of participants that shall and shall not be admitted; (D) Days of the week and hours of operation; (E) Services available to participants and families; (F) Procedures and requirements for admission; (G) Emergency arrangements for participants; (H) Criteria and procedure for discontinuing service to a participant; (I) Participant and family procedures for resolving grievances; (J) Confidentiality of participant information and records; and (K) A copy of the Alzheimer’s SCS form (MO FORM 886-3548) (if applicable) available at http://www.oa.state.mo.us/gs/form/ fm_indiv.htm AUTHORITY: sections 660.050, RSMo Supp. 2003 and 660.418, RSMo 2000. This rule was originally filed as 13 CSR 15-8.050. Original rule filed Oct. 15, 1984, effective Jan. 11, 1985. Moved to 19 CSR 30-90.050, effective Aug. 28, 2001. Amended: Filed Sept. 14, 2004, effective March 30, 2005. ** *Original authority: 660.050, RSMo 1984, amended 1988, 1992, 1993, 1994, 1995, 2001 and 660.418, RSMo 1984, amended 1993, 1994. **Pursuant to Executive Order 21-07, 19 CSR 30-90.050, subparagraph (8)(D)3.C. was suspended from April 22, 2020 through May 1, 2021 and section (3) was suspended from April 22, 2020 through August 31, 2021. Pursuant to Executive Order 21-09, 19 CSR 3090.050, section (4) was suspended from April 22, 2020 through December 31, 2021.