Rules of Department of Health and Senior Services · Department of Health and Senior Services...

CODE OF STATE REGULATIONS 1ROBIN CARNAHAN (3/31/06)Secretary of State

Rules of

Department of Health andSenior Services

Division 30�Division of Regulation and LicensureChapter 81�Certification

Title Page

19 CSR 30-81.010 General Certification Requirements .........................................................3

19 CSR 30-81.015 Resident Assessment Instrument .............................................................6

19 CSR 30-81.020 Prelong-Term Care Screening (Rescinded February 28, 2006) .........................6

19 CSR 30-81.030 Evaluation and Assessment Measures for Title XIX Recipients andApplicants in Long-Term Care Facilities ..................................................7

Title 19�DEPARTMENT OFHEALTH AND SENIOR SERVICESDivision 30�Division of Regulation and

LicensureChapter 81�Certification

19 CSR 30-81.010 General CertificationRequirements

PURPOSE: This rule sets forth applicationprocedures and general certification require-ments for nursing facilities certified under theTitle XIX (Medicaid) program and skillednursing facilities under Title XVIII(Medicare), and procedures to be followed bynursing facilities when requesting a nursestaffing waiver.

PUBLISHER�S NOTE: The secretary of statehas determined that the publication of theentire text of the material which is incorpo-rated by reference as a portion of this rulewould be unduly cumbersome or expensive.This material as incorporated by reference inthis rule shall be maintained by the agency atits headquarters and shall be made availableto the public for inspection and copying at nomore than the actual cost of reproduction.This note applies only to the reference mate-rial. The entire text of the rule is printedhere.

(1) Definitions. (A) Certification shall mean the determi-

nation by the Missouri Department of Healthand Senior Services, or the Centers forMedicare and Medicaid Services, that alicensed skilled nursing or intermediate carefacility (SNF/ICF) licensed under Chapter198, RSMo, or an ICF for person with men-tal retardation (ICF/MR), is in substantialcompliance with all federal requirements andis approved to participate in the Medicaid orMedicare programs.

(B) CMS shall mean the Centers forMedicare and Medicaid Services of the U.S.Department of Health and Human Services.

(C) Cost reporting year shall mean thefacility�s twelve (12)-month fiscal reportingperiod covering the same twelve (12)-monthperiod that the facility uses for its federalincome tax reporting.

(D) Distinct part shall mean a portion of aninstitution or institutional complex that is cer-tified to provide SNF or NF services. A dis-tinct part must be physically distinguishablefrom the larger institution and must consist ofall beds within the designated area. The dis-tinct part may be a separate building, floor,wing, ward, hallway or several rooms at oneend of a hall or one side of a corridor.

(E) Department shall mean the MissouriDepartment of Health and Senior Services.

(F) ICF/MR shall mean intermediate carefacility for persons with mental retardation.

(G) Medicaid shall mean Title XIX of thefederal Social Security Act.

(H) Medicare shall mean Title XVIII of thefederal Social Security Act.

(I) Nursing facility (NF) shall mean anSNF or ICF licensed under Chapter 198,RSMo which has signed an agreement withthe Department of Social Services to partici-pate in the Medicaid program and which iscertified by the department. As used withinthe contents of this rule, licensed SNFs,SNF/ICF and ICFs participating in theMedicaid program are subject to state andfederal laws and regulations for participationas an NF.

(J) Section for Long Term Care (SLTC)shall mean that section of the departmentresponsible for licensing and regulating long-term care facilities licensed under Chapter198, RSMo.

(K) Skilled nursing facility (SNF) shallmean an SNF licensed under Chapter 198,RSMo which has a signed agreement with theCMS to participate in the Medicare programand which has been recommended for certifi-cation by the department.

(L) Title XVIII shall mean the Medicareprogram as provided for in the federal SocialSecurity Act.

(M) Title XIX shall mean the Medicaidprogram as provided for in the federal SocialSecurity Act.

(2) An operator of an SNF or ICF licensed bythe department electing to be certified as aprovider of skilled nursing services under theTitle XVIII (Medicare) or NF services underthe Title XIX (Medicaid) program of theSocial Security Act; or an operator of a facil-ity electing to be certified as an ICF/MRfacility under Title XIX shall submit applica-tion materials to the department as requiredby federal law and shall comply with stan-dards set forth in the Code of FederalRegulations (CFR) of the United StatesDepartment of Health and Human Services in42 CFR chapter IV, part 483, subpart B fornursing homes and 42 CFR chapter IV, part483, subpart I for ICF/MR facilities, asappropriate.

(A) For Medicaid, the application shallinclude:

1. Long Term Care Facility Applicationfor Medicare and Medicaid, Form CMS-671(12/02), incorporated by reference in thisrule and available through the Centers forMedicare and Medicaid website:http://www.cms.hhs.gov/forms/, or by mail

at: Centers for Medicare and MedicaidServices, 7500 Security Boulevard,Baltimore, MD 21244-1850;

2. Form DA-113, Bed Classification forLicensure and Certification by Category (8-05), incorporated by reference in this ruleand available through the department�s web-site: www.dhss.mo.gov, or by mail at:Department of Health and Senior ServicesWarehouse, Attention General ServicesWarehouse, PO Box 570, Jefferson City, MO65102-0570, telephone: (573) 526-3861.

(B) For Medicare, the application shallinclude:

1. Long Term Care Facility Applicationfor Medicare and Medicaid;

2. Expression of Intermediary Prefer-ence Form (8-05), incorporated by referencein this rule and avail-able through the depart-ment�s website: www.dhss.mo.gov, or bymail at: Department of Health and SeniorServices Warehouse, Attention GeneralServices Warehouse, PO Box 570, JeffersonCity, MO 65102-0570, telephone: (573) 526-3861;

3. Form DA-113, Bed Classification forLicensure and Certification by Category;

4. Three (3) copies of Health InsuranceBenefit Agreement, Form CMS-1561(07/01), incorporated by reference in this ruleand available through the Centers forMedicare and Medicaid website:http://www.cms.hhs.gov/forms/, or by mailat: Centers for Medicare and MedicaidServices, 7500 Security Boulevard, Balti-more, MD 21244-1850;

5. Three (3) copies of Assurance ofCompliance, Form HHS-690 (5/97), incor-porated by reference in this ruleand available through the Centers forMedicare and Medicaid website:http://www.cms.hhs.gov/forms, or by mail atthe U.S. Department of Health and HumanServices, 200 Independence Avenue, SW,Washington, DC 20201, telephone: (202)619-0257; Toll Free: 1 (877) 696-6775.

6. The forms incorporated by referencein subsections (2)(A) and (B) do not includeany later amendments or additions.

(C) SNFs or NFs which are newly certifiedor which are undergoing a change of owner-ship shall submit an initial certification fee inthe amount up to one thousand dollars($1,000) as stipulated by the department inwriting to the operator following receipt ofthe properly completed application materialreferenced in section (2). The amount for theinitial certification fee shall be the proratedportion of one thousand dollars ($1,000) withprorating based on the month of receipt of theapplication in relation to the beginning of the


Chapter 81�Certification 19 CSR 30-81

next federal fiscal year. This initial certifica-tion fee shall be nonrefundable and a facilityshall not be certified until the fee has beenpaid.

(D) All SNFs or NFs certified to partici-pate in the Medicaid or Medicare program(s)shall submit to the department an annual cer-tification fee of one thousand dollars ($1,000)prior to October 1 of each year. If the fee isnot received by that date each year, a late feeof fifty dollars ($50) per month shall bepayable to the department. If payment of anyfees due is not received by the department bythe time the facility license expires or byDecember 31 of that year, whichever is earli-er, the department shall notify the Division ofMedical Services and the CMS recommend-ing termination of the Medicaid or Medicareagreement as denial of license will occur asprovided in 19 CSR 30-82.010 and section198.022, RSMo.

(3) Application material shall be signed anddated and submitted to the department�sSLTC licensure unit at least fourteen (14)working days prior to the date the facility isready to be surveyed for compliance with fed-eral regulations (Initial Certification Survey).The operator or authorized representativeshall notify the appropriate departmentregional office by letter or by phone as to thedate the facility will be ready to be surveyed.There shall be at least two (2) residents in thefacility before a survey can be conducted.The facility shall already be licensed or withlicensure in process shall be in compliancewith all state rules.

(4) Any facility certified for participation asan NF in the Title XIX Medicaid programelecting to participate in the Title XVIIIMedicare program shall submit an applica-tion signed and dated by the operator or hisor her authorized representative to the depart-ment�s SLTC central office licensure unit.The department will recommend Medicarecertification to the CMS effective the date theapplication material is received by the depart-ment or a subsequent date if requested by theprovider, provided the facility was in compli-ance with all federal and state regulations forSNFs at the last survey conducted by thedepartment and provided the facility�s appli-cation is complete and has been approved bythe Medicare fiscal intermediary.

(5) Any facility certified for participation inthe Medicare program wishing to participatein the Medicaid program shall submit asigned and dated application to the depart-ment central office. The department will cer-tify the facility for Medicaid participation

effective the date the application is receivedby the department or a subsequent daterequested by the provider, provided the facil-ity was in compliance with all federal regula-tions at the last survey conducted by thedepartment and the application is complete.

(6) For newly certified facilities, the facilitywill be certified for either Medicare orMedicaid participation effective the date thefacility receives a license at the proper levelor the date the facility achieves substantialcompliance with the federal participationrequirements, whichever is the later date. Theapplication shall be completed. For certifica-tion in the Title XVIII (Medicare) program,the Medicare fiscal intermediary mustapprove the application and the CMS mustconcur with the department�s recommenda-tion.

(7) The department shall conduct federal sur-veys in SNFs, NFs and ICF/MR facilities,utilizing regulations and procedures con-tained in�

(A) The State Operations Manual (SOM)(HCFA Publication 7);

(B) The Survey and Certification Regionalletters received by the department from theCMS;

(C) For SNFs and NFs, federal regulation42 CFR chapter IV, part 483, subpart B; and

(D) For ICF/MR facilities, federal regula-tion 42 CFR chapter IV, part 483, subpart I.

(8) A facility, in its application, shall desig-nate the number of beds to be certified andtheir location in the facility. A facility can bewholly or partially certified. If partially cer-tified, the beds shall be in a distinct part ofthe facility and all beds shall be contiguous.

(9) If a facility certified to participate in theTitle XIX (Medicaid) or Title XVIII(Medicare) program elects to change the sizeof its distinct part, it must submit a writtenrequest to the Licensure/Certification Unit orthe ICF/MR Unit of the department, as appli-cable. The request shall specify the roomnumbers involved, the number of beds ineach room and the facility cost reporting yearend date. The request must include a floordiagram of the facility and a signed DA-113form, Bed Classification for Licensure andCertification by Category. A facility isallowed two (2) changes in the size of its dis-tinct part during the facility cost reportingyear. This may be two (2) increases or one (1)increase and one (1) decrease. It may not betwo (2) decreases. The first change can bedone only at the beginning of the facility costreporting year and the second change can be

done effective at the beginning of a facilitycost reporting quarter within that facility costreporting year. All requests must be submit-ted to the Licensure/Certification Unit or theICF/MR Unit of the department at leastforty-five (45) days in advance. Any facilitywishing to eliminate its distinct part to go tofull certification may do so effective at thebeginning of the next facility cost reportingquarter with forty-five (45) days notice. Thedistinct part may be reestablished only at thebeginning of the next facility cost reportingyear. A facility may change the location of thedistinct part with thirty (30) days notice to theLicensure/Certification Unit or the ICF/MRUnit of the department.

(10) If a facility certified to participate in theTitle XIX (Medicaid) or Title XVIII(Medicare) program undergoes a change ofoperator, the new operator shall submit anapplication as specified in section (2) of thisrule. The application shall be submitted with-in five (5) working days of the change ofoperator. For applications made for the TitleXIX (Medicaid) program, the departmentshall provide the application to the Divisionof Medical Services of the Department ofSocial Services so that a provider agreementcan be negotiated and signed. For applica-tions made for the Title XVIII (Medicare)program, the department shall provide theapplication to the CMS. Certification statuswill be retained unless or until formallydenied.

(11) If it is determined by the department thata facility certified to participate in Medicaidor Medicare does not comply with federalregulations at the time of a federal survey,complaint investigation or state licensureinspection, the department shall take enforce-ment action using the regulations and proce-dures contained in the following sources:

(A) 42 CFR chapter IV, part 431, subpartsD, E and F;

(B) 42 CFR chapter IV, part 442;(C) 42 U.S.C. Section 1395i�3;(D) 42 U.S.C. Section 1396(r);(E) Sections 198.026 and 198.067, RSMo;

and(F) 13 CSR 70-10.015 and 13 CSR 70-

10.030.

(12) If a facility certified to participate in theMedicaid Title XIX program has been decer-tified as a result of noncompliance with thefederal requirements, the facility can be read-mitted to the Medicaid program by submit-ting an application for initial participation inthe Medicaid program. After having receivedthe application, the department shall conduct

4 CODE OF STATE REGULATIONS (3/31/06) ROBIN CARNAHANSecretary of State

19 CSR 30-81�DEPARTMENT OF HEALTH ANDSENIOR SERVICES Division 30�Division of Regulation and Licensure

a survey at the earliest possible date to deter-mine if the facility is in substantial compli-ance with all federal participation require-ments. The effective date of participationwill be the date the facility is found to sub-stantially comply with all federal require-ments.

(13) If a change in the administrator or thedirector of nursing of a facility occurs, thefacility shall provide written notice to thedepartment�s SLTC central office licensureunit within ten (10) calendar days of thechange. The notice shall show the effectivedate of the change, the identity of the newdirector of nursing or administrator and acopy of his or her license or the license num-ber. Change of administrator informationshall be submitted as a notarized statement bythe operator in accordance with section198.018, RSMo.

(14) An NF may request a waiver of nursestaffing requirements to the extent the facili-ty is unable to meet the requirements includ-ing the areas of twenty-four (24)-hourlicensed nurse coverage, the use of a regis-tered nurse for eight (8) consecutive hoursseven (7) days per week and the use of a reg-istered nurse as director of nursing.

(A) Requests for waivers shall be made inwriting to the director of the Section for LongTerm Care.

(B) Requests for waivers will be consid-ered only from facilities licensed underChapter 198, RSMo as ICFs which do nothave a nursing pool agency that is within fifty(50) miles, within state boundaries, andwhich can supply the needed nursing person-nel.

(C) The department shall consider eachrequest for a waiver and shall approve or dis-approve the request in writing postmarkedwithin thirty (30) working days of receipt or,if additional information is needed, shallrequest from the facility the additional infor-mation or documentation within ten (10)working days of receipt of the request.

(D) Approval of a nurse waiver requestshall be based on an evaluation of whether thefacility has been unable, despite diligentefforts�including offering wages at the com-munity prevailing rate for nursing facilities�to recruit the necessary personnel. Diligenteffort shall mean prominently advertising forthe necessary nursing personnel in a varietyof local and out-of-the-area publications,including newspapers and journals within afifty (50)-mile radius, and which are withinstate boundaries; contacts with nursingschools in the area; and participation in job

fairs. The operator shall submit evidence ofthe diligent effort including:

1. Copies of newspapers and journaladvertisements, correspondence with nursingschools and vocational programs, and anyother relevant material;

2. If there is a nursing pool agency with-in fifty (50) miles which is within stateboundaries and the agency cannot consistent-ly supply the necessary personnel on a perdiem basis to the facility, the operator shallsubmit a letter from the agency so stating;

3. Copies of current staffing patternsincluding the number and type of nursingstaff on each shift and the qualifications oflicensed nurses;

4. A current Resident Census andCondition of Residents, Form CMS-672(10/98), incorporated by reference in thisrule and available through the Centers forMedicare and Medicaid website:http://www.cms.hhs.gov/forms/, or by mailat: Centers for Medicare and MedicaidServices, 7500 Security Boulevard,Baltimore, MD 21244-1850. This rule doesnot incorporate any subsequent amendmentsor additions;

5. Evidence that the facility has a regis-tered nurse consultant required under 19 CSR30-85.042 and evidence that the facility hasmade arrangements to assure registered nurseinvolvement in the coordination of the assess-ment process as required under 42 CFR483.20(3);

6. Location of the nurses� stations andany other pertinent physical feature informa-tion the facility chooses to provide;

7. Any other information deemedimportant by the facility including personnelprocedures, promotions, staff orientation andevaluation, scheduling practices, benefit pro-grams, utilization of supplemental agencypersonnel, physician-nurse collaboration,support services to nursing personnel and thelike; and

8. For renewal requests, the informationsupplied shall show diligent efforts to recruitappropriate personnel throughout the priorwaiver period. Updates of prior submittedinformation in other areas are acceptable.

(E) In order to meet the conditions speci-fied in federal regulation 42 CFR 483.30, thefollowing shall be considered in grantingapproval:

1. There is assurance that a registerednurse or physician is available to respondimmediately to telephone calls from the facil-ity for periods of time in which licensed nurs-ing services are not available;

2. There is assurance that if a facilityrequesting a waiver has or admits afterreceiving a waiver any acutely ill or unstable

residents requiring skilled nursing care, theskilled care shall be provided in accordancewith state licensure rule 19 CSR 30-85.042;and

3. The facility has not received a Class Inotice of noncompliance in resident carewithin one hundred twenty (120) days of thewaiver request or the department has not con-ducted an extended survey in the facilitywithin one (1) year of the waiver request.Any facility which receives a Class I notice ofnoncompliance in resident care or an extend-ed survey while under waiver status will nothave the waiver renewed unless the problemhas been corrected and steps have been takento prevent recurrence. If a facility receivedmore than one (1) Class I notice of noncom-pliance in resident care during a waiver peri-od, the department will consider revocationof the waiver.

(F) The facility shall cooperate with thedepartment in providing the proper documen-tation. For renewal requests, the request andproper documentation shall be submitted tothe department at least forty-five (45) daysprior to the ending date of the current waiverperiod. If any changes occur during a waiverperiod that affect the status of the waiver, aletter shall be submitted to the deputy direc-tor of institutional services within ten (10)days of the changes. The request for a waiveror renewal of a waiver shall be denied if thefacility fails to abide by these previouslymentioned time frames.

(G) If a waiver request is denied, thedepartment shall notify the facility in writingand within twenty (20) days, the facility shallsubmit to the department a written plan forhow the facility will recruit the required per-sonnel. If appropriate personnel are not hiredwithin two (2) months, the department shallinitiate enforcement proceedings.

AUTHORITY: section 660.050 RSMo 2005.*This rule originally filed as 13 CSR 15-9.010.Emergency rule filed Sept. 18, 1990, effectiveOct. 1, 1990, expired Jan. 25, 1991. Originalrule filed Nov. 2, 1990, effective June 10,1991. Amended: Filed June 3, 1993, effectiveDec. 9, 1993. Amended: Filed Feb. 1, 1995,effective Sept. 30, 1995. Amended: Filed May11, 1998, effective Nov. 30, 1998. Amended:Filed Nov. 27, 2000, effective July 30, 2001.Emergency amendment filed July 13, 2001,effective July 30, 2001, expired Feb. 28,2002. Moved to 19 CSR 30-81.010, effectiveAug. 28, 2001. Amended: Filed July 13,2001, effective Feb. 28, 2002. Amended:Filed Nov. 1, 2005, effective April 30, 2006.

*Original authority: 660.050, RSMo 1984, amended 1988,1992, 1993, 1994, 1995, 2001.



19 CSR 30-81.015 Resident AssessmentInstrument

PURPOSE: This rule designates the residentassessment instrument to be used by nursingfacilities certified under the Title XIX(Medicaid) program and Title XVIII(Medicare) program for all residents in certi-fied beds.

PUBLISHER�S NOTE: The secretary of statehas determined that the publication of theentire text of the material which is incorpo-rated by reference as a portion of this rulewould be unduly cumbersome or expensive.Therefore, the material which is so incorpo-rated is on file with the agency who filed thisrule, and with the Office of the Secretary ofState. Any interested person may view thismaterial at either agency�s headquarters orthe same will be made available at the Officeof the Secretary of State at a cost not toexceed actual cost of copy reproduction. Theentire text of the rule is printed here. Thisnote refers only to the incorporated by refer-ence material.

(1) Effective January 1, 1991 a residentassessment instrument (RAI) shall be utilizedby all nursing facilities (NFs) certified underTitle XIX (Medicaid) and Title XVIII(Medicare) to perform uniform residentassessments for all residents in certified beds,regardless of payment source, as required byTitle 42 U.S.C. Section 1396(r)(3)(A) of theSocial Security Act.

(2) The RAI utilized shall be the one desig-nated by the Health Care FinancingAdministration (HCFA) of the United StatesDepartment of Health and Human Services(HHS). It is comprised of three (3) parts�

(A) The utilization guidelines, which areinstructions concerning when and how to usethe RAI;

(B) The minimum data set (MDS) of coreelements and definitions, which is a mini-mum set of screening and assessment ele-ments, including common definitions andcoding categories, needed to comprehensive-ly assess an individual nursing home resi-dent. The items in the MDS standardize com-munication about resident problems and con-ditions within facilities, between facilities,and between facilities and outside agencies;and

(C) The resident assessment protocols(RAPs), which are structured frameworks fororganizing MDS elements and additionalclinically relevant information about an indi-vidual that contributes to care planning.

(3) Resident assessments shall be document-ed on the MDS and the RAPs shall be uti-lized.

(4) Frequency of Assessments. (A) A newly admitted resident to a certi-

fied bed shall have an assessment within four-teen (14) days of admission to the facility.

(B) Each resident in a certified bed shallhave an updated assessment within fourteen(14) days after a significant change in the res-ident�s physical or mental condition.

(C) Each resident shall be examined quar-terly and the MDS core elements specified inthe utilization guidelines shall be reviewedand any changes documented.

(D) Each resident in a certified bed shallhave a full annual assessment no later thantwelve (12) months following the last fullassessment. Residents in certified beds onOctober 1, 1990 shall have a full assessmentcompleted by October 1, 1991.

(5) The division shall provide each certifiedfacility with a copy of the RAI, includingguidelines for completion. Facilities may thenduplicate the RAI or purchase the instrumenteither in paper or computerized form from aprivate supplier for use when performingassessments.

(6) A paper copy of all MDSs and RAP sum-mary sheets completed for each resident shallbe in the resident�s record. A facility maydocument on the MDS form additional infor-mation regarding a resident which is notincluded in the standard MDS, or may use aversion of the MDS which has special codesor notations, but if information is added, theadditional information shall be either in anappendix or the facility shall provide a copyof the MDS in its standard form without theadditional information for use in review. AllMDSs and RAP summary sheets completedwithin the last two (2) years must be easilyretrievable from the resident�s record ifrequested by a representative of the Divisionof Aging or the federal survey and certifica-tion agency.

(7) All resident assessments shall be per-formed and the MDSs and RAPs shall becompleted in accordance with the utilizationguidelines, the definitions and all other direc-tions as given on the forms.

(8) Whenever a resident assessment is com-pleted on any resident in a Medicaid- orMedicare-certified bed, a legible copy of thefully completed MDS portion of the RAIshall be sent to the division within thirty (30)calendar days of completion. Forms shall be

sent to: Missouri Division of Aging,Attention: MDS Unit, P.O. Box 1337,Jefferson City, MO 65102. The forms shallbe submitted by each facility as a group onceper month for all residents assessed in the lastthirty (30) days and submitted in paper formunless the facility has requested in writingand has received written permission from thedivision to submit the MDS information on aproperly formatted computer disk by mail orelectronically.

(9) Effective June 1, 1993, all facilities shallsend to the Missouri Division of Aging, toeither the Attention of the MDS Unit, P.O.Box 1337, Jefferson City, MO 65102 or theappropriate regional Division of Agingoffice, at the same time the monthly MDSform or MDS data are being mailed, a list ofnames of all residents who have died or whohave been discharged from the facility (andnot readmitted) during the preceding month.In addition, included with the mailing at theend of June, the facility shall submit a list ofthose residents who have died or who weredischarged from the facility since August 1,1992. This listings shall include the completename of the resident, as well as some specif-ic identifying information for each, such asthe Social Security number, the birthdate orthe department client number (DCN).

AUTHORITY: section 536.021, RSMo Supp.1993.* This rule originally filed as 13 CSR15-9.015. Emergency rule filed Dec. 18,1990, effective Dec. 31, 1990, expired April29, 1991. Emergency rule filed May 7, 1991,effective May 17, 1991, expired Sept. 13,1991. Original rule filed Dec. 18, 1990,effective June 10, 1991. Emergency amend-ment filed June 16, 1992, effective Aug. 1,1992, expired Nov. 28, 1992. Amended: FiledJune 16, 1992, effective Feb. 26, 1993.Emergency amendment filed May 14, 1993,effective June 1, 1993, expired Sept. 28,1993. Emergency amendment filed July 14,1993, effective July 25, 1993, expired Nov.21, 1993. Amended: Filed May 14, 1993,effective Dec. 9, 1993. Moved to 19 CSR 30-81.015, effective Aug. 28, 2001.

*Original authority: 536.021, RSMo 1975, amended 1976,1989, 1992, 1993.

19 CSR 30-81.020 Prelong-Term CareScreening(Rescinded February 28, 2006)

AUTHORITY: sections 207.020 and 208.159,RSMo 1986 and 208.153, RSMo Supp.1991.* This rule was previously filed as 13CSR 40-81.086 and 13 CSR 15-9.020.





Emergency rule filed March 14, 1984, effec-tive April 12, 1984, expired Aug. 8, 1984.Original rule filed March 14, 1984, effectiveAug. 9, 1984. Amended: Filed Aug. 3, 1992,effective May 6, 1993. Moved to 19 CSR 30-81.020, effective Aug. 28, 2001. Rescinded:Filed Aug. 12. 2005, effective Feb. 28, 2006.

19 CSR 30-81.030 Evaluation and Assess-ment Measures for Title XIX Recipientsand Applicants in Long-Term CareFacilities

PURPOSE: This rule sets the requirementsfor the periodic evaluation and assessmentsof residents in long-term care facilities inrelationship to evaluation and assessmentprocesses, level-of-care needed by individu-als, and appropriate placement of individualsin order to receive this care.

PUBLISHER�S NOTE: The secretary of statehas determined that the publication of theentire text of the material which is incorpo-rated by reference as a portion of this rulewould be unduly cumbersome or expensive.This material as incorporated by reference inthis rule shall be maintained by the agency atits headquarters and shall be made availableto the public for inspection and copying at nomore than the actual cost of reproduction.This note applies only to the reference mate-rial. The entire text of the rule is printedhere.

(1) For purposes of this rule only, the follow-ing definitions shall apply:

(A) Applicant�any resident or prospectiveresident of a certified long-term care facilitywho is seeking to receive inpatient Title XIXassistance;

(B) Certified long-term care facility�anylong-term care facility which has beenapproved to participate in the inpatient pro-gram and receives Title XIX funding for eli-gible recipients;

(C) Initial assessment forms�the formsutilized to collect information necessary for adetermination of level-of-care need pursuantto 19 CSR 30-81.030 and designated FormsDA-124 A/B (dated 6-05) and DA-124 C(dated 4-05) and Notice To Applicant Form,DA-124C ATT. (attachment) (dated 12-01),incorporated by reference in this rule andavailable through the Department of Healthand Senior Services website:www.dhss.mo.gov or by mail at: Departmentof Health and Senior Services Warehouse,Attention General Services Warehouse, POBox 570, Jefferson City, Missouri 65102-0570; telephone: (573) 526-3861; fax: (573)

751-1574, shall be considered the approvedInitial Assessment Forms. This rule does notincorporate any subsequent amendments oradditions.

(D) Inpatient Title XIX assistance�TitleXIX payments for intermediate or skillednursing care in a certified long-term carefacility;

(E) Level-of-care assessment�the determi-nation of level-of-care need based on anassessed point count value for each categorycited in subsection (4)(B) of this rule;

(F) Level-of-care need�the decisionwhether an individual qualifies for long-termcare facility care;

(G) Long-term care facility�a skillednursing facility (SNF), an intermediate carefacility (ICF), or a hospital which providesskilled nursing care or intermediate nursingcare in a distinct part or swing bed underChapter 197, RSMo;

(H) Pro re nata (PRN)�medication ortreatment ordered by a physician to be admin-istered as needed, but not regularly sched-uled;

(I) Recipient�any resident in a certifiedlong-term care facility who is receiving inpa-tient Title XIX assistance;

(J) Redetermination of level-of-care�theperiodic assessment of the recipients� contin-ued eligibility and need for continuation atthe previously assigned level-of-care.Periodic assessment includes but it not limit-ed to the following:

1. Assessment of new admissions to along-term care facility;

2. Assessment of a change in mental andor physical status for a resident who is beingreadmitted to a long-term care facility aftertransfer to an acute care facility, and the pre-vious DA-124 A/B or C forms do not reflectthe resident�s current care needs; and

3. Assessment of DA-124 forms asrequested by Department of Social Services,Family Support Division;

(K) Resident�a person seventeen (17)years or older who by reason of aging, ill-ness, disease, or physical or mental infirmityreceives or requires care and services fur-nished by a long-term care facility and whoresides in, is cared for, treated or accommo-dated in such long-term care facility for aperiod exceeding twenty-four (24) consecu-tive hours; and

(L) The department�Department ofHealth and Senior Services.

(2) Initial Determination of Level-of-CareNeeds Requirements.

(A) For the purpose of making a determi-nation of level-of-care need and in accor-dance with 42 CFR sections 456.370 and

483.104, the department or its designatedagents, or both, will conduct a review andassessment of the evaluations made by theattending physician for an applicant in orseeking admission to a long-term care facili-ty. The review and assessment shall be con-ducted using the criteria in section (5) of thisrule.

(B) The department shall complete theassessment within ten (10) working days ofreceipt of all documentation required by sec-tion (5) of this rule unless further evaluationby the State Mental Health Authority isrequired by 42 CFR 483.100 to 483.138.

(3) Redetermination of Level-of-Care Re-quirements.

(A) Redetermination of level-of-care ofindividual recipients who are eligible forplacement in long-term care facilities shall beconducted by the department through areview and assessment of the DA-124 A/Band C forms and any documentation providedby the resident�s attending physician.

(B) Required documentation on the DA-124 C form shall include the resident�s physi-cian�s signature and his or her PhysicianIdentification Number.

(4) Level-of-Care Criteria for Long-TermCare Facility Care�Qualified Title XIXRecipients and Applicants.

(A) Individuals will be assessed with theultimate goal to achieve placement for theseindividuals in the least restrictive environ-ment possible, yet enable them to receive allservices required by their physical/mentalcondition.

(B) The specific areas which will be con-sidered when determining an individual�sability or inability to function in the leastrestrictive environment are�mobility,dietary, restorative services, monitoring,medication, behavioral, treatments, personalcare and rehabilitative services.

(C) To qualify for intermediate or skillednursing care, an applicant or recipient shallexhibit physical impairment, which may becomplicated by mental impairment or mentalimpairment which may be complicated byphysical impairment, severe enough torequire intermediate or skilled nursing care.

(5) Assessed Needs Point DesignationsRequirements.

(A) Applicants or recipients will beassessed for level-of-care by the assignmentof a point count value for each category citedin subsection (4)(B) of this rule.

(B) Points will be assessed for the amountof assistance required, the complexity of thecare and the professional level of assistance

necessary, based on the level-of-care criteria.If the applicant�s or recipient�s records showthat the applicant�s or recipient�s attendingphysician has ordered certain care, medica-tion or treatments for an applicant or recipi-ent, the department will assess points for aPRN order if the applicant or recipient hasactually received or required that care, medi-cation or treatment within the thirty (30)days prior to review and evaluation by thedepartment.

(C) For individuals seeking admission to along-term care facility on or after July 1,2005, the applicant or recipient will be deter-mined to be qualified for long-term care facil-ity care if he or she is determined to needcare with an assessed point level of twenty-one (21) points or above, using the assess-ment procedure as required in this rule.

(D) For individuals seeking admission to along-term care facility on or after July 1,2005, an applicant with eighteen (18) pointsor lower will be assessed as ineligible forTitle XIX-funded long-term care in a long-term care facility, unless the applicant quali-fies as otherwise provided in subsections,(5)(E) and/or (F) of the rule.

(E) Applicants or recipients may occasion-ally require care or services, or both, whichcould qualify as long-term care facility ser-vices. In these instances, a single nursing ser-vice requirement may be used as the qualify-ing factor, making the individual eligible forlong-term care facility care regardless of thetotal point count. The determining factor willbe the availability of professional personnel toperform or supervise the qualifying care ser-vices. Qualifying care services may include,but are not limited to:

1. Administration of levine tube or gas-trostomy tube feedings;

2. Nasopharyngeal and tracheotomyaspiration;

3. Insertion of medicated or sterile irri-gation and replacement catheters;

4. Administration of parenteral fluids;5. Inhalation therapy treatments;6. Administration of injectable medica-

tions other than insulin, if required other thanon the day shift; and

7. Requirement of intensive rehabilita-tion services by a professional therapist atleast five (5) days per week.

(F) An applicant or recipient will be con-sidered eligible for inpatient Title XIX assis-tance regardless of the total point count if theapplicant or recipient is unable to meet phys-ical/mental requirements for residential carefacility (RCF) residency as specified by sec-tion 198.073, RSMo. In order to meet thisrequirement, an applicant or recipient mustbe able to reach and go through a required

exit door on the floor where the resident islocated by�

1. Responding to verbal direction or thesound of an alarm;

2. Moving at a reasonable speed; and3. If using a wheelchair or other assis-

tive device, such as a walker or cane, beingable to transfer into the wheelchair or reachthe assistive device without staff assistance.

(G) Points will be assigned to each catego-ry, as required by subsection (4)(B) of thisrule, in multiples of three (3) according to thefollowing requirements:

1. Mobility is defined as the individual�sability to move from place-to-place. Theapplicant or recipient will receive�

A. Zero (0) points if assessed as inde-pendently mobile, in that the applicant orrecipient requires no assistance for transfersor mobility. The applicant or recipient mayuse assistive devices (cane, walker,wheelchair) but is consistently capable ofnegotiating without assistance of anotherindividual;

B. Three (3) points if assessed asrequiring minimum assistance, in that theapplicant or recipient is independently mobileonce the applicant or recipient receives assis-tance with transfers, braces or prosthesisapplication or other assistive devices, or acombination of these (example, independentuse of wheelchair after assistance with trans-fer). This category includes individuals whoare not consistently independent and needassistance periodically;

C. Six (6) points if assessed as requir-ing moderate assistance, in that the applicantor recipient is mobile only with direct staffassistance. The applicant or recipient must beassisted even when using canes, walker orother assistive devices; and

D. Nine (9) points if assessed asrequiring maximum assistance, in that theapplicant or recipient is totally dependentupon staff for mobility. The applicant orrecipient is unable to ambulate or participatein the ambulation process, requires position-ing, supportive device, application, preven-tion of contractures or pressure sores andactive or passive range of motion exercises;

2. Dietary is defined as the applicant�sor recipient�s nutritional requirements andneed for assistance or supervision withmeals. The applicant or recipient willreceive�

A. Zero (0) points if assessed as inde-pendent in dietary needs, in that the applicantor recipient requires no assistance to eat. Theapplicant or recipient has physician�s ordersfor a regular diet, mechanically altered dietor requires only minor modifications (exam-

ple, limited desserts, no salt or sugar ontray);

B. Three (3) points if assessed asrequiring minimum assistance, in that theapplicant or recipient requires meal supervi-sion or minimal help, such as cutting food orverbal encouragement. Calculated diets forstabilized conditions shall be included;

C. Six (6) points if assessed as requir-ing moderate assistance, in that the applicantor recipient requires help, including constantsupervision during meals, or actual feeding.Calculated diets for unstable conditions areincluded; and

D. Nine (9) points if assessed asrequiring maximum assistance, in that theapplicant or recipient requires extensiveassistance for special dietary needs or witheating, which could include enteral feedingsor parenteral fluids;

3. Restorative services are defined asspecialized services provided by trained andsupervised individuals to help applicants orrecipients obtain and/or maintain their opti-mal highest practicable functioning potential.Each applicant or recipient must have anindividual overall plan of care developed bythe provider with written goals andresponse/progress documented. Restorativeservices may include, but are not limited to:applicant or recipient teaching program (self-transfer, self-administration of medications,self-care), range of motion, bowel and blad-der program, remotivational therapy, valida-tion therapy, patient/family program and indi-vidualized activity program. The applicant orrecipient will receive�

A. Zero (0) points if restorative ser-vices are not required;

B. Three (3) points if assessed asrequiring minimum services in order to main-tain level of functioning;

C. Six (6) points if assessed as requir-ing moderate services in order to restore theindividual to a higher level of functioning;and

D. Nine (9) points if assessed asrequiring maximum services in order torestore to a higher level of functioning. Theseare intensive services, usually requiring pro-fessional supervision or direct services;

4. Monitoring is defined as observationand assessment of the applicant�s or recipi-ent�s physical and/or mental condition. Thismonitoring could include assessment of�routine laboratory work, including but notlimited to, evaluating digoxin and coumadinlevels, measurement and evaluation of bloodglucose levels, measurement and evaluationof intake and output of fluids the individualhas received and/or excreted, weights and



other routine monitoring procedures. Theapplicant or recipient will receive�

A. Zero (0) points if assessed asrequiring only routine monitoring, such asmonthly weights, temperatures, blood pres-sures and other routine vital signs and routinesupervision;

B. Three (3) points if assessed asrequiring minimal monitoring, in that theapplicant or recipient requires periodicassessment due to mental impairment, moni-toring of mild confusion, or both, or period-ic assessment of routine procedures when therecipient�s condition is stable;

C. Six (6) points if assessed as requir-ing moderate monitoring, in that the appli-cant or recipient requires recurring assess-ment of routine procedures due to the appli-cant�s or recipient�s unstable physical ormental condition; and

D. Nine (9) points if assessed asrequiring maximum monitoring, which isintensive monitoring usually by professionalpersonnel due to applicant�s or recipient�sunstable physical or mental condition;

5. Medication is defined as the drug regi-men of all physician-ordered legend medica-tions, and any physician-ordered nonlegendmedication for which the physician hasordered monitoring due to the complexity ofthe medication or the condition of the appli-cant or recipient. The applicant or recipientwill receive�

A. Zero (0) points if assessed asrequiring no medication, or has not requiredPRN medication within the thirty (30) daysprior to review and evaluation by the depart-ment;

B. Three (3) points if assessed asrequiring any regularly scheduled medicationand the applicant or recipient exhibits a sta-ble condition;

C. Six (6) points if assessed as requir-ing moderate supervision of regularly sched-uled medications, requiring daily monitoringby licensed personnel; and

D. Nine (9) points if assessed asrequiring maximum supervision of regularlyscheduled medications, a complex medicationregimen, unstable physical or mental statusor use of medications requiring professionalobservation and assessment, or a combinationof these;

6. Behavioral is defined as an individu-al�s social or mental activities. The applicantor recipient will receive�

A. Zero (0) points if assessed asrequiring little or no behavioral assistance.Applicant or recipient is oriented and memo-ry intact;

B. Three (3) points if assessed asrequiring minimal behavioral assistance in

the form of supervision or guidance on aperiodic basis. Applicant or recipient maydisplay some memory lapses or occasionalforgetfulness due to mental or developmentaldisabilities, or both. Applicant or recipientgenerally relates well with others (positive orneutral) but needs occasional emotional sup-port;

C. Six (6) points if assessed as requir-ing moderate behavioral assistance in theform of supervision due to disorientation,mental or developmental disabilities or unco-operative behavior; and

D. Nine (9) points if assessed asrequiring maximum behavioral assistance inthe form of extensive supervision due to psy-chological, developmental disabilities or trau-matic brain injuries with resultant confusion,incompetency, hyperactivity, hostility, severedepression, or other behavioral characteris-tics. This category includes residents whofrequently exhibit bizarre behavior, are ver-bally or physically abusive, or both, or areincapable of self-direction. Applicants orrecipients who exhibit uncontrolled behaviorthat is dangerous to themselves or othersmust be transferred immediately to an appro-priate facility;

7. Treatments are defined as a system-atized course of nursing procedures orderedby the attending physician. The applicant orrecipient will receive�

A. Zero (0) points if no treatments areordered by the physician;

B. Three (3) points if assessed asrequiring minimal type-ordered treatments,including nonroutine and preventative treat-ments, such as whirlpool baths and other ser-vices;

C. Six (6) points if assessed as requir-ing moderate type-ordered treatments requir-ing daily attention by licensed personnel.These treatments could include: daily dress-ings, PRN oxygen, oral suctioning, cathetermaintenance care, treatment of stasis or pres-sure sore ulcers, wet/moist packs, maximistand other such services; and

D. Nine (9) points if assessed asrequiring maximum type-ordered treatmentsof an extensive nature requiring provision,direct supervision, or both, by professionalpersonnel. These treatments could include:intratrachial suctioning; insertion or mainte-nance of suprapubic catheter; continuousoxygen; new or unregulated ostomy care;dressings of deep draining lesions more thanonce daily; care of extensive skin disorders,such as advanced pressure sore or necroticlesions; infrared heat and other services;

8. Personal care is defined as activitiesof daily living, including hygiene; personalgrooming, such as dressing, bathing, oral and

personal hygiene, hair and nail care, shaving;and bowel and bladder functions. Points willbe determined based on the amount of assis-tance required and degree of assistanceinvolved in the activity. The applicant orrecipient will receive�

A. Zero (0) points if assessed asrequiring no assistance with personal care inthat the applicant or recipient is an indepen-dent, self-care individual. No assistance isrequired with personal grooming; the appli-cant or recipient has complete bowel andbladder control;

B. Three (3) points if assessed asrequiring minimal assistance with personalcare, in that the applicant or recipientrequires assistance with personal grooming,and/or exhibits infrequent incontinency (oncea week or less);

C. Six (6) points if assessed as requir-ing moderate assistance with personal care,in that the applicant or recipient requiresassistance with personal grooming, requiringclose supervision or exhibits frequent incon-tinency (incontinent of bladder daily but hassome control or incontinent of bowel two (2)or three (3) times per week), or a combina-tion of these; and

D. Nine (9) points if assessed asrequiring maximum assistance with personalcare, in that the applicant or recipientrequires total personal care to be performedby another individual, and/or exhibits contin-uous incontinency all or most of the time; and

9. Rehabilitation is defined as therestoration of a former or normal state ofhealth through medically-ordered therapeuticservices either directly provided by or underthe supervision of a qualified professional.Rehabilitation services include, but are notlimited to: physical therapy, occupationaltherapy, speech therapy and audiology. Ifordered by the physician, each resident musthave an individually planned and implement-ed program with written goals andresponse/progress documented. Points willbe determined by intensity of required ser-vices and the applicant�s or recipient�s poten-tial for rehabilitation as determined by therehabilitation evaluation. The applicant orrecipient will receive�

A. Zero (0) points if assessed asrequiring no ordered rehabilitation services;

B. Three (3) points, if assessed asrequiring minimal-ordered rehabilitation ser-vices of one (1) time per week;

C. Six (6) points if assessed as requir-ing moderate-ordered rehabilitative servicesof two (2) or three (3) times per week; and

D. Nine (9) points if assessed asrequiring maximum-ordered rehabilitativeservices of four (4) times per week or more.



AUTHORITY: sections 192.006 and 198.079,RSMo 2000 and 660.050, RSMo Supp.2004.* This rule was previously filed as 13CSR 40-81.084 and 13 CSR 15-9.030.Original rule filed Aug. 9, 1982, effectiveNov. 11, 1982. Emergency rescission filedNov. 24, 1982, effective Dec. 4, 1982,expired March 10, 1983. Rescinded: FiledNov. 24, 1982, effective March 11, 1983.Readopted: Filed Dec. 15, 1982, effectiveMarch 11, 1983. Emergency amendment filedDec. 21, 1983, effective Jan. 1, 1984, expiredApril 11, 1984. Emergency amendment filedMarch 14, 1984, effective April 12, 1984,expired June 10, 1984. Amended: FiledMarch 14, 1984, effective June 11, 1984.Moved to 19 CSR 30-81.030, effective Aug.28, 2001. Emergency amendment filed June20, 2005, effective July 1, 2005, expired Dec.27, 2005. Amended: Filed June 20, 2005,effective Dec. 30, 2005.

*Original authority: 192.006, RSMo 1993, amended1995; 198.079, RSMo 1979; and 660.050, RSMo 1984,amended 1988, 1992, 1993, 1994, 1995, 2001.




Rules of


Division 30—Division of Regulation and LicensureChapter 82—General Licensure Requirements

Title Page

19 CSR 30-82.010 General Licensure Requirements ...........................................................3

19 CSR 30-82.015 Long-Term Care Receiverships .............................................................7

19 CSR 30-82.020 Classification of Rules........................................................................8

19 CSR 30-82.030 Assessment of Availability of Beds.........................................................9

19 CSR 30-82.050 Transfer and Discharge Procedures.......................................................10

19 CSR 30-82.060 Hiring Restrictions—Good Cause Waiver ...............................................12

19 CSR 30-82.070 Alzheimer’s Demonstration Projects .....................................................14

19 CSR 30-82.080 Nursing Facility Quality of Care Improvement Program .............................16

Title 19—DEPARTMENT OFHEALTH AND SENIOR SERVICESDivision 30—Division of Regulation and

LicensureChapter 82—General Licensure

Requirements

19 CSR 30-82.010 General LicensureRequirements

PURPOSE: This rule sets forth general licen-sure and application procedures and outlinesthe request for an exception procedure relat-ed to long-term care facility licensure.

PUBLISHER’S NOTE: The secretary of statehas determined that the publication of theentire text of the material which is incorpo-rated by reference as a portion of this rulewould be unduly cumbersome or expensive.This material as incorporated by reference inthis rule shall be maintained by the agency atits headquarters and shall be made availableto the public for inspection and copying at nomore than the actual cost of reproduction.This note applies only to the reference mate-rial. The entire text of the rule is printedhere.

(1) Persons wishing to operate a skilled nurs-ing facility, intermediate care facility, assistedliving facility or residential care facility shallcomplete form MO 580-2631 (8-07), Appli-cation for License to Operate a Long-TermCare Facility, incorporated by reference inthis rule and available through the Depart-ment of Health and Senior Services’ (depart-ment’s) website at www.dhss.mo.gov, or bymail at: Department of Health and SeniorServices, Section for Long-Term Care Regu-lation, Licensure Unit, PO Box 570, Jeffer-son City, MO 65102-0570, telephone: (573)526-8524. This rule does not incorporate anysubsequent amendments or additions. Theapplication shall be signed by a person withthe express authority to sign on behalf of theoperator, who shall attest by signature that theinformation submitted is true and correct tothe best of the applicant’s knowledge andbelief and that all required documents areeither included with the application or arecurrently on file with the department. Thecompleted application form may be submittedby mail or electronically. If submitted elec-tronically, send the completed application [email protected]. The applica-tion fee for application processing should besubmitted by separate mail. If submitted bymail, send the application form and fee toDepartment of Health and Senior Services,Section for Long-Term Care Regulation, FeeReceipts, PO Box 570, 920 Wildwood, Jef-

ferson City, MO 65102. One (1) applicationmay be used to license multiple facilities iflocated on the same premises.

(A) The applicant shall submit the follow-ing documents and information as listed inthe application:

1. Financial information demonstratingthat the applicant has the financial capacity tooperate the facility;

2. A document disclosing the location,capacity, and type of licensure and certifica-tion of any support buildings, wings, or floorshousing residents on the same or adjoiningpremises or plots of ground;

3. A document disclosing the name,address, and type of license of all other long-term care facilities owned or operated byeither the applicant or by the owner of thefacility for which the application is being sub-mitted;

4. A copy of any executed managementcontracts between the applicant and the man-ager of the facility;

5. A copy of any executed contract con-veying the legal right to the facility premises,including, but not limited to, leases, subleas-es, rental agreements, contracts for deed, andany amendments to those contracts;

6. A copy of any contract by which thefacility’s land, building, improvements, fur-nishings, fixtures, or accounts receivable arepledged in whole or in part as security, if thevalue of the asset pledged is greater than fivehundred dollars ($500);

7. A nursing home surety bond or non-cancelable escrow agreement, if the applicantholds or will hold facility residents’ personalfunds in trust;

8. A document disclosing the name,address, title, and percentage of ownership ofeach affiliate of any general partnership, lim-ited partnership, general business corpora-tion, nonprofit corporation, limited liabilitycompany, or governmental entity which ownsor operates the facility or is an affiliate of anentity which owns or operates the facility. Ifan affiliate is a corporation, partnership, orLLC, a list of the affiliate’s affiliates mustalso be submitted. As used in this rule, theword “affiliate” means:

A. With respect to a partnership, eachpartner thereof;

B. With respect to a limited partner-ship, the general partner and each limitedpartner with an interest of five percent (5%)or more in the limited partnership;

C. With respect to a corporation, eachperson who owns, holds, or has the power tovote five percent (5%) or more of any class ofsecurities issued by the corporation, and eachofficer and director;

D. With respect to an LLC, the LLC

managers and members with an interest offive percent (5%) or more;

9. If applicable, a document stating thename and nature of any additional businessesin operation on the facility premises and thedocument issued by the division giving itsprior written approval for each business;

10. A list of all principals in the opera-tion of the facility and their addresses andtitles and, so that the department may verifythe information disclosed pursuant to para-graphs (1)(A)11. and (1)(A)12. of this rule,the Social Security numbers or employeridentification numbers of the operator and allprincipals in the operation of the facility. Asused in this rule, “principal” means officer,director, owner, partner, key employee, orother person with primary management orsupervisory responsibilities;

11. Disclosure concerning whether theoperator or any principals in the operation ofthe facility are excluded from participation inthe Title XVIII (Medicare) or Title XIX(Medicaid) program of any state or territory;

12. Disclosure concerning whether theoperator or any principals in the operation ofthe facility have ever been convicted of afelony in any state or federal court concern-ing conduct involving either management of along-term care facility or the provision orreceipt of health care services;

13. Emergency telephone, fax, andemail contact information for the facilityadministrator, director of nursing, and theoperator’s corporate office; and

14. Disclosure concerning whether thefacility has a Department of Mental Health(DMH) license.

(B) Every facility that provides specializedAlzheimer’s or dementia care services, asdefined in sections 198.500 to 198.515,RSMo, by means of an Alzheimer’s specialcare unit or program shall submit to thedepartment with the licensure application orrenewal, the following:

1. Form MO 580-2637, Alzheimer’sSpecial Care Services Disclosure (2-07),incorporated by reference in this rule andavailable through the department’s website:www.dhss.mo.gov, or by mail at: Departmentof Health and Senior Services, Section forLong-Term Care Regulation, Licensure Unit,PO Box 570, Jefferson City, MO 65102-0570, telephone: (573) 526-8524. This ruledoes not incorporate any subsequent amend-ments or additions. The form shall be com-pleted showing how the care provided by thespecial care unit or program differs from careprovided in the rest of the facility in the fol-lowing areas:


Chapter 82—General Licensure Requirements 19 CSR 30-82

A. The Alzheimer’s special careunit’s or program’s written statement of itsoverall philosophy and mission which reflectsthe needs of residents afflicted with demen-tia;

B. The process and criteria for place-ment in, or transfer or discharge from, theunit or program;

C. The process used for assessmentand establishment of the plan of care and itsimplementation, including the method bywhich the plan of care evolves and is respon-sive to changes in condition;

D. Staff training and continuing edu-cation practices;

E. The physical environment anddesign features appropriate to support thefunctioning of cognitively impaired adult res-idents;

F. The frequency and types of residentactivities;

G. The involvement of families andthe availability of family support programs;

H. The costs of care and any addi-tional fees; and

I. Safety and security measures; and2. Form Guide to Selecting an

Alzheimer’s Special Care Unit (6/06) #455,incorporated by reference in this rule andavailable through the department’s website: athttp://www.dhss.mo.gov/Ombudsman, or bymail at: Department of Health and SeniorServices, Section for Long-Term Care Regu-lation, Licensure Unit, PO Box 570, Jeffer-son City, MO 65102-0570, telephone: (573)526-8524 or a document of choice whichcontains, but is not limited to, all informationon selecting an Alzheimer’s special care unitor program that is contained in the Guide toSelecting an Alzheimer’s Special Care Unit(6/06) #455. This rule does not incorporateany subsequent amendments or additions.

(C) If, after filing an application, the oper-ator identifies an error or if any informationchanges the issuance of the license, includingbut not limited to, a change in the adminis-trator, board of directors, officers, level ofcare, number of beds, or change in the nameof the operating entity, the operator shall—

1. Submit the correction or additionalinformation to the department’s Licensureand Certification Unit in a letter. The lettershall be signed by a person with expressauthority to sign on behalf of the operatorattesting by signature that the informationbeing submitted is true and correct to the bestof the operator’s knowledge and belief; or

2. Submit the correction or additionalinformation to the department’s Licensure andCertification Unit. The additional informationmay be submitted electronically or by mail.Information shall be submitted using form

MO 580-2623 (8-07), Corrections For Long-Term Care Facility License Application,incorporated by reference in this rule andavailable through the Department of Healthand Senior Services’ (department’s) websiteat www.dhss.mo.gov, or by mail at: Depart-ment of Health and Senior Services, Sectionfor Long-Term Care Regulation, LicensureUnit, PO Box 570, Jefferson City, MO 65102-0570, telephone: (573) 526-8524. This ruledoes not incorporate any subsequent amend-ments or additions. The completed correctionform shall be signed by a person with expressauthority to sign on behalf of the operatorattesting by signature that the informationsubmitted is true and correct to the best of theoperator’s knowledge and belief and shall besubmitted by electronic mail to [email protected], or by mail to: Departmentof Health and Senior Services, Section forLong-Term Care Regulation, Fee Receipts,PO Box 570, 920 Wildwood, Jefferson City,MO 65102.

(D) If, as a result of an application review,the department requests a correction or addi-tional information, the operator, within ten(10) working days of receipt of the writtenrequest shall—

1. Submit the correction or additionalinformation to the department in a letterattesting by signature that the informationbeing submitted is true and correct to the bestof the operator’s knowledge and belief; or

2. Submit the correction or additionalinformation using form MO 580-2623 (8-07),Corrections For Long-Term Care FacilityLicense Application referenced in paragraph(1)(C)2. of this rule.

(E) A new facility shall submit an applica-tion for an original license not less than thir-ty (30) days before the anticipated openingdate. The department must approve the appli-cation before a licensure inspection is sched-uled. Sixty (60) days after its receipt, thedepartment shall consider any application foran original license withdrawn if it is submit-ted without all the required information anddocuments. If intending to continue withlicensure, the operator shall submit a newapplication and fee along with all necessarydocuments.

(F) An operator shall submit a relicensureapplication thirty (30) to ninety (90) daysprior to the existing license’s expiration date.

(G) If, during the license’s effective peri-od, an operator which is a partnership, limit-ed partnership or corporation undergoes anyof the changes described in section198.015.4, RSMo, or a new corporation,partnership, limited partnership, limited lia-bility company or other entity assumes facil-ity operation, within ten (10) working days of

the effective date of that change, the operatorshall submit an application for a new license.

(H) The department shall issue eachlicense only for the premises and operatornamed in the application. This license shallcover the entire premises unless stipulatedotherwise and shall not be transferable. If thelicensed operator of a facility is replaced byanother operator, the new operator shallapply for a new license before the effectivedate of the change. A change of operator shallinclude a change in form of business as wellas a change of person. Upon receipt of theapplication and receipt of confirmation thatthe change of operator has taken place, thedepartment shall grant the new operator atemporary operating permit of sufficientduration to allow the department time to eval-uate the application, conduct any necessaryinspection(s) to determine substantial compli-ance with the law and the rules, and to eitherissue or deny a license to the new operator.The new operator shall be subject to all theterms and conditions under which the previ-ous operator’s license or temporary operatingpermit was issued. This includes any existingstatement of deficiencies, plans of correctionand compliance with any additional require-ments imposed by the department as a resultof any existing substantial noncompliance.The new operator, however, shall apply to thedepartment for renewal in his/her/its namefor any exception to the rules that had beengranted the previous operator under the pro-visions of section (3) of this rule.

(I) The operator shall accompany eachapplication for a license to operate a long-term care facility (skilled nursing facility,intermediate care facility, assisted livingfacility or residential care facility with alicense fee of one hundred dollars ($100) forthose facilities which have a resident capaci-ty of at least three (3) but less than twenty-five (25), three hundred dollars ($300) forthose facilities which have a resident capaci-ty of twenty-five through one hundred(25–100), and six hundred dollars ($600) forthose facilities with a capacity of over onehundred (100+). The operator shall submit aseparate fee for each facility’s license appli-cation. This fee is nonrefundable unless thefacility withdraws the application within ten(10) days of receipt by the department. Thedepartment will issue a license for a period ofno more than two (2) years for the premisesand operator named in the application. If thelicense is for less than two (2) years, thedepartment will prorate the fees accordingly.

(J) An operator may apply for licenses fortwo (2) or more different levels of care locat-ed on the same premises either by submittingone (1) application or by submitting a separate

4 CODE OF STATE REGULATIONS (9/30/08) ROBIN CARNAHAN

Secretary of State

19 CSR 30-82—DEPARTMENT OF HEALTH ANDSENIOR SERVICES Division 30—Division of Regulation and Licensure

application for each level of care. If an oper-ator elects to submit one (1) application fortwo (2) or more levels of care located on thesame premises—

1. The application shall specify sepa-rately the number of beds of each level ofcare being applied for;

2. The application shall be accompaniedby a license fee for each level of care appliedfor, as required by subsection (1)(I) of thisrule; and

3. An application for two (2) or morelevels of care on the same premises shall indi-cate one (1) facility name only.

(K) The department shall issue a separatelicense for each level of care located on thesame premises, whether applied for by one(1) application or more than one (1). If theoperator uses one (1) application for two (2)or more levels of care on the same premises,the department shall issue licenses with one(1) expiration date. If two (2) or more levelsof care have existing licenses with differentexpiration dates and the operator elects toapply for licenses for the levels of care bysubmitting one (1) relicensure application,the expiration dates of the licenses issuedshall be two (2) years subsequent to the expi-ration date of the license of the level of careexpiring earliest following receipt of theapplication by the department. Fees forunused portions of licenses resulting from thesubmission of one (1) application for two (2)or more levels of care are nonrefundable.

(L) After receiving a license application,the department shall review the application,investigate the applicant and the statementssworn to in the application for license andconduct any necessary inspections. A licenseshall be issued if—

1. The department has determined thatthe application is complete, and that all nec-essary documents have been filed with theapplication including an approved nursinghome bond or noncancelable escrow agree-ment if personal funds of residents are held intrust;

2. The department has determined thatthe statements in the application are true andcorrect;

3. The department has determined thatthe facility and the operator are in substantialcompliance with the provisions of sections198.003–198.096, RSMo and the corre-sponding rules;

4. The department has determined thatthe applicant has the financial capacity tooperate the facility;

5. The department has verified that theadministrator of a residential care facility thatwas licensed as a residential care facility II onAugust 27, 2006 and chooses to continue to

meet all laws, rules and regulations that werein place on August 27, 2006 for a residentialcare facility II, assisted living facility, anintermediate care facility or a skilled nursingfacility is currently licensed by the MissouriBoard of Nursing Home Administratorsunder the provisions of Chapter 344, RSMo;

6. The department has received the feerequired by subsection (1)(I) of this rule;

7. The applicant meets the definition ofoperator as defined in 19 CSR 30-83.010;

8. The applicant has received a Certifi-cate of Need, if required, or has received adetermination from the Certificate of NeedProgram that no certificate is required, hascompleted construction, and is in substantialcompliance with the licensure rules and laws;

9. The department has determined thatneither the operator, owner or any principalsin the operation of the facility have ever beenconvicted of an offense concerning the oper-ation of a long-term care facility or otherhealth care facility or, while acting in a man-agement capacity, ever knowingly acted orknowingly failed to perform any duty whichmaterially and adversely affected the health,safety, welfare or property of a resident;

10. The department has determined thatneither the operator, owner or any principalsin the operation of the facility are excludedfrom participation in the Title XVIII (Medi-care) or Title XIX (Medicaid) program of anystate or territory;

11. The department has determined thatneither the operator, owner or any principalsin the operation of the facility have ever beenconvicted of a felony in any state or federalcourt concerning conduct involving eithermanagement of a long-term care facility orthe provision or receipt of health care ser-vices; and

12. The department has determined thatall fees due the state have been paid.

(M) If, during the period in which alicense is in effect, a change occurs whichcauses the statements in the application to nolonger be correct, including change of admin-istrator, or if any document is executed whichreplaces, succeeds or amends any of the doc-uments filed with the application, within ten(10) working days of the effective date of thechange, the operator shall—

1. Submit a letter to the department’sLicensure and Certification Unit that containsa correction of the application with notifica-tion of the effective date of the change and acopy of any new documents. The operatormust ensure the letter is signed by a personwith the express authority to sign on behalf ofthe operator, who shall attest by signature thatthe information being submitted is true and

correct to the best of the operator’s knowl-edge and belief; or

2. Submit to the department a correctionof the application and a copy of any new doc-umentation and information by submittingform Corrections for Long-Term Care Facili-ty License Application referenced in para-graph (1)(C) 2. of this rule.

(N) If from an analysis of financial infor-mation submitted with the application, or iffrom information obtained during the term ofa license, the operator appears insolvent orshows a tendency toward insolvency, thedepartment shall have the right to requestadditional financial information from theoperator. Within ten (10) working days afterreceiving a written request from the depart-ment, the operator shall—

1. Submit to the department the addi-tional information requested in a letteraccompanied by a statement attesting by sig-nature that the information being submitted istrue and correct to the best of the operator’sknowledge and belief; or

2. Submit the financial information tothe department on form Corrections forLong-Term Care Facility License Applicationreferenced in paragraph (1)(C)2. of this rule.

(O) A license applicant’s financial infor-mation, data and records submitted to thedepartment as required by this rule, includ-ing, but not limited to, copies of any InternalRevenue Service forms, shall be open forinspection and be released only—

1. To designated employees of thedepartment;

2. To the applicant furnishing this infor-mation or to his/her representative as desig-nated in writing;

3. To the director of the department orto his/her representative as designated inwriting;

4. To the state auditor or his/her repre-sentative as designated in writing;

5. To appropriate committees of theGeneral Assembly or their representatives asdesignated in writing;

6. In any judicial or administrative pro-ceeding brought under the Omnibus NursingHome Act; or

7. When so ordered by a court of com-petent jurisdiction.

(P) To obtain a license for an additionallevel of care on the premises, the licensedoperator shall submit a written request by elec-tronic mail to [email protected],or mail to the department for the issuance of alicense for the desired level of care. Therequest shall indicate the level of care, thenumber of beds desired, the name and addressof the facility, the name and address of theoperator, and shall include the signature of the



operator. The request shall be signed by aperson with the express authority to sign onbehalf of the operator, who shall attest by sig-nature that the information submitted is trueand correct to the best of the operator’sknowledge and belief. The licensure fee shallaccompany this request. Requests are subjectto department approval. The operator shallsubmit this request no less than sixty (60)days prior to the initiation date of the newlevel of care. The department shall coordinatethis license’s expiration date with that of theoriginal license and the department shall pro-rate the license fee accordingly.

(Q) To request issuance of an amendedlicense or temporary operating permit cur-rently in effect, the operator shall—

1. Submit a written request to thedepartment containing the request for amend-ment, the date the operator would like theamendment to be effective, and the numberof the license or temporary operating permitto be amended; and

2. Submit a fee for the issuance of theamended license or temporary operating per-mit as required by subsection (1)(R) of thisrule.

(R) If an operator initiates a request toamend a license or temporary operating per-mit currently in effect, the departmentrequires the following fees:

1. If the request is for an increase in bedcapacity, the operator shall submit a fee withthe request which is the greater of—

A. The amount that would have beenrequired by subsection (1)(I) of this rule if theincrease in bed capacity has been included inthe application, less any amount actually paidunder that subsection; or

B. Fifty dollars ($50); and 2. If the request is for a decrease in res-

ident capacity or any other change, the oper-ator shall submit a fee of twenty-five dollars($25) with the request.

(S) The department shall approve allrequests for bed changes prior to issuance ofan amended license or temporary operatingpermit. The effective date of the amendedlicense or temporary operating permit shallbe no earlier than the date the departmentapproved the request for bed change.

(T) If the department issues a temporaryoperating permit, and then subsequentlyissues a regular license, the licensing periodshall include the period of operation underthe temporary operating permit. The licens-ing period shall also include any period dur-ing which the department was enjoined orstayed from revoking or denying a license orrendering the temporary operating permitnull and void.

(U) Unless an operator indicates other-wise, all the rooms and space on the premis-es and all persons eighteen (18) years of ageand over living on the premises shall be con-sidered as part of the facility and its licensedcapacity or staff and shall be subject to com-pliance with all rules governing the operationof a licensed facility. If an operator, whenapplying or reapplying for a license, wants toexclude some portion of the premises frombeing licensed or wants to exclude a relativeas a resident, a statement to that effect shallbe filed as a separate document indicating theuse which will be made of that area of thepremises and who or what occupies the area,and what the relationship is of the relative(s)being excluded. The statement shall be signedby a person with the express authority to signon behalf of the operator, who shall attest bysignature that the information submitted istrue and correct to the best of the operator’sknowledge and belief.

(V) The operator shall not provide care inany area on the premises to any related per-son who requires protective oversight unlessthere has been a written request to the depart-ment to consider any portion of the facilityfor private use and that indicates facility staffshall not be used at any time to care for therelative(s). Prior to the area being used inthat manner, the operator shall submit therequest for the department’s approval. Thedepartment, after investigation, shall approveor disapprove the request in writing withinthirty (30) days and shall issue or reissue thelicense indicating clearly which portion of thepremises is excluded from licensure or whichspecific relative(s) is/are not considered aresident(s).

(2) If a facility was licensed under Chapter197 or 198, RSMo and was in operationbefore September 28, 1979, or if an applica-tion was on file or construction plans wereapproved prior to September 28, 1979, thefacility shall comply with construction, firesafety and physical plant rules applicable toan existing or existing licensed facility pro-vided there has been continuous operation ofthe facility under a license or temporaryoperating permit issued by the division. If,however, there was an interruption in theoperation of the facility due to license denial,license revocation or voluntary closure, thefacility may be relicensed utilizing the samefire safety, construction and physical plantrules that were applicable prior to the licensedenial, license revocation or voluntary clo-sure; provided that the facility reapplies for alicense within one (1) year of the date of thedenial, revocation or voluntary closure.Regardless of licensure, application, or con-

struction plan approval date, intermediatecare facilities and skilled nursing facilitiesshall comply with the fire safety standardspublished in 19 CSR 30-85.022.

(A) If a facility changes from a skillednursing or intermediate care facility to anyother level, or if the facility changes from aan assisted living facility to a residential carefacility, the facility shall comply with con-struction, fire safety and physical plant rulesapplicable to an existing or existing licensedfacility as defined in 19 CSR 30-83.010.

(B) If the facility changes from a residen-tial care facility to any other level or if anassisted living facility changes to an interme-diate care or skilled nursing facility, the facil-ity shall comply with construction, fire safe-ty and physical plant rules applicable to a newor newly licensed facility as defined in 19CSR 30-83.010.

(C) The facility shall comply with the rulesapplicable to a new or newly licensed facilityif an application for relicensure has not beenfiled with the department within one (1) yearof the license denial, license revocation orvoluntary closure. All such facilities seekinglicensure as an assisted living facility shallalso comply with the requirements of 19 CSR30-86.047 and, if applicable, 19 CSR 30-86.045.

(3) If a licensed facility discontinues opera-tion as evidenced by the fact that no residentsare in care or at any time the department isunable to freely gain entry into the facility toconduct an inspection, the facility shall beconsidered closed. The department shall noti-fy the operator in writing requesting the vol-untary surrender of the license. If the depart-ment does not receive the license withinthirty (30) days, it shall be void. If the oper-ator should choose to again license the facil-ity, the operator shall submit a completeapplication. The provisions of section (1)shall apply.

(4) The department may grant exceptions forspecified periods of time to any rule imposedby the department if the department hasdetermined that the exception to the rulewould not potentially jeopardize the health,safety or welfare of any residents of a long-term care facility.

(A) The owner or operator of the facilityshall make requests for exceptions in writingto the director of the department. Theserequests shall contain—

1. A copy of the latest Statement ofDeficiencies which shows a violation of therule being cited, if the exception request isbeing made as a result of a deficiency issuedduring an inspection of the facility;


Secretary of State


2. The section number and text of therule being cited;

3. If applicable, specific reasons whycompliance with the rule would impose anundue hardship on the operator, including anestimate of any additional cost that might beinvolved;

4. An explanation of any extenuatingfactors that may be relevant; and

5. A complete description of the indi-vidual characteristics of the facility or resi-dents, or of any other factors that would safe-guard the health, safety and welfare of theresidents if the exception were granted.

(B) With the advice of the division’s licen-sure inspection field staff, the departmentwill consider any requests that contain all theinformation required in subsection (4)(A).The department shall notify the operator, inwriting, of the decision on any request for anexception, stating the reason(s) for accep-tance or denial, and, if granted, the length oftime the exception is to be in effect and anyadditional corrective factors upon whichacceptance may be conditioned.

(C) The department shall only grant excep-tions to licensure requirements set out inrules imposed by the department and cannotgrant exceptions to requirements establishedby state statute or federal regulations. Opera-tors wishing to obtain waivers of regulationsunder Title XVIII or Title XIX of the SocialSecurity Act shall follow procedures estab-lished by the Centers for Medicare and Med-icaid (CMS).

(5) When the department issues a notice ofnoncompliance to a facility pursuant to theOmnibus Nursing Home Act (section198.026, RSMo), the department, only afteraffording the facility operator a reasonableopportunity to remedy the situation, shall—

(A) Make every reasonable effort to pro-vide residents of the facility or their legallyauthorized representatives or designees, ifany—

1. A written notice of the noncompli-ance;

2. A list of other licensed facilitiesappropriate to the resident’s needs; and

3. A list of agencies that will assist theresident if he/she moves from the facility;and

(B) After providing the informationrequired by subsection (5)(A) and allowing atime period for the residents of the facility torelocate if they wish, notify the Social Secu-rity Administration in writing that a notice ofnoncompliance has been issued to the facili-ty, and the effective date of the notice. If thefacility achieves substantial compliance withstandards and rules later, the department shall

notify the Social Security Administration ofthe effective date of the facility’s substantialcompliance.

(6) A licensed facility shall comply with theprovisions of Title VI of the Civil Rights Act1964, as amended; Section 504 of the Reha-bilitation Act of 1973; Title IX of the Educa-tion Amendment of 1972; the Age Discrimi-nation Act of 1975; the Omnibus Budget andReconciliation Act of 1982; the Americanswith Disabilities Act of 1990; and the KeyesAmendment to the Social Security Act. Noperson shall be denied admission to, bedenied benefits of, or be subjected to dis-crimination under any program, activity orservice provided by the facility based onhis/her race, color, national origin, sex, reli-gion, age or disability, including HumanImmunodeficiency Virus (HIV) or AcquiredImmunodeficiency Syndrome (AIDS). Everylicensed facility shall complete and sign formMO 580-2622 (9-05), Assurance of Compli-ance, incorporated by reference in this ruleand available through the department’s web-site at www.dhss.mo.gov or by telephone at(573) 526-8505 and file the form with theapplication for licensure or relicensure. Thisrule does not incorporate any subsequentamendments or additions.

(7) The department shall make available byInternet at www.dhss.mo.gov to interestedindividuals or without charge a single copyof—

(A) A complete set of the standards pro-mulgated for each type of facility;

(B) An explanation of the procedures usedin the state to ensure the enforcement of stan-dards;

(C) A list of any facilities granted excep-tion from a standard, including the justifica-tion for the exception; and

(D) A list of any facilities issued notices ofnoncompliance, including the details of thenoncompliance.

(8) Every skilled nursing facility, intermedi-ate care facility, residential care facility andassisted living facility issued a license or tem-porary operating permit by the departmentshall submit the required certificate of needquarterly surveys to the department on orbefore the fifteenth day of the first month fol-lowing the previous Social Security quarter.(For example, for the Social Security quarterending December 31, the due date is by Jan-uary 15; for the Social Security quarter end-ing March 31, the due date is by April 15; forthe Social Security quarter ending June 30,the due date is by July 15; and for the SocialSecurity quarter ending September 30, the

due date is by October 15). The informationshall be submitted on the ICF/SNF Certifi-cate of Need Quarterly Survey form or theRCF/ALF Certificate of Need Quarterly Sur-vey form obtained from the Missouri Certifi-cate of Need Program, PO Box 570, Jeffer-son City, MO 65102.

AUTHORITY: Executive Order 77-9 of theGovernor filed Jan. 31, 1979, effective Sept.28, 1979, and sections 198.018, 198.073,198.076, and 198.079, RSMo Supp. 2007.*This rule was originally filed as 13 CSR 15-10.010. Emergency rule filed Aug. 13, 1979,effective Oct. 1, 1979, expired Jan. 25, 1980.Original rule filed Aug. 13, 1979, effectiveDec. 13, 1979. Emergency amendment filedOct. 15, 1980, effective Oct. 25, 1980,expired Feb. 26, 1981. Amended: Filed Dec.10, 1980, effective May 11, 1981. Amended:Filed Dec. 7, 1981, effective May 11, 1982.Amended: Filed March 15, 1983, effectiveJuly 11, 1983. Amended: Filed July 13, 1983,effective Oct. 11, 1983. Amended: Filed Sept.12, 1984, effective Dec. 11, 1984. Amended:Filed June 17, 1986, effective Oct. 24, 1986.Amended: Filed Aug. 1, 1988, effective Nov.10, 1988. Emergency amendment filed Aug.14, 1992, effective Aug. 28, 1992, expiredDec. 25, 1992. Rescinded and readopted:Filed April 14, 1993, effective Oct. 10, 1993.Amended: Filed Feb. 13, 1998, effective Sept.30, 1998. Moved to 19 CSR 30-82.010, effec-tive Aug. 28, 2001. Amended: Filed Aug. 23,2006, effective April 30, 2007. Amended:Filed March 13, 2008, effective Oct. 30,2008.

*Original authority: 198.018, RSMo 1979, amended 1984,1987, 1988, 1994, 2007; 198.073, RSMo 1979, amended1984, 1992, 1999, 2006, 2007; 198.076, RSMo 1979,amended 1984, 2007; and 198.079, RSMo 1979, amended2007.

19 CSR 30-82.015 Long-Term CareReceiverships

PURPOSE: This rule establishes guidelinesfor the determination of qualified receivers,maintenance of the list of receivers, and theselection and removal of receivers.

(1) A person requesting to act as a receivershall submit a completed application to thedepartment. The application shall include thefollowing information:

(A) Full name of the receiver, date of birthand Social Security number;

(B) Information that establishes the receiv-er has the necessary experience to operate along-term care facility or the ability to



contract with another party for the operationof a facility; and

(C) Information that establishes the receiv-er has the financial capacity to operate along-term care facility as a receiver in com-pliance with state laws and regulations.

(2) Based on the information submitted in theapplication, if the applicant has the necessaryexperience to operate a long-term care facili-ty or the ability to contract with another partyfor the operation of a facility and the financialcapacity to operate a facility, and the appli-cant does not have any disqualifying charac-teristics, the applicant will be approved to bea receiver. Disqualifying characteristics aredefined as:

(A) The applicant has been convicted of afelony offense in any state or federal courtarising out of conduct involving the operationor management of a long-term care facility orother health care facility or the provision orreceipt of health care;

(B) The applicant has ever knowingly actedor knowingly failed to perform any dutywhich materially and adversely affected thehealth, safety, welfare or property of a resi-dent of a long-term care facility, while actingin a management capacity; or

(C) The applicant is under exclusion fromparticipation in the Title XVIII (Medicare) orTitle XIX (Medicaid) program of any state orterritory.

(3) Once a completed application is receivedand approved, the person will be placed onthe list of qualified receivers. Receivers willbe placed on the list in the order their com-pleted application was received. If two (2) ormore completed applications are received onthe same day, and any two (2) or more areapproved, they will be placed on the list ofqualified receivers in alphabetical orderaccording to the receivers’ last names.

(4) If any of the information in an applicationchanges, or if a qualified receiver has anychange of status, including a change in dis-qualifying characteristics, that could affecthis/her ability to serve as a receiver, he/shemust notify the department in writing withinten (10) working days. Given the additionalinformation, the department will make adetermination as to whether the receiverremains qualified to act as a receiver. If thereceiver is no longer qualified, his/her namewill be removed from the list of qualifiedreceivers. The department will notify thereceiver in writing of the removal.

(5) If the department otherwise becomesaware of a change in any information in theapplication or a change in status of a qualified

receiver that affects the receiver’s ability toserve as a receiver, the department mayremove the receiver from the list of qualifiedreceivers. The department will notify thereceiver in writing of the removal.

(6) If a receiver no longer wishes to beincluded on the list of qualified receivers, thereceiver shall notify the department in writ-ing of his/her desire to be removed from thelist and the effective date of the removal.

AUTHORITY: sections 198.009, RSMo 2000and 198.105, RSMo Supp. 2003.* Emergencyrule filed Sept. 12, 2003, effective Sept. 22,2003, expired March 19, 2004. Original rulefiled Sept. 12, 2003, effective Feb. 29, 2004.

*Original authority: 198.009, RSMo 1979, amended1993, 1995 and 198.105, RSMo 1979, amended 1984,2003.

19 CSR 30-82.020 Classification of Rules

PURPOSE: This rule adds to the classifica-tion of the standards for long-term care facil-ities as cited in chapters 13 CSR 15-12, 13CSR 15-14, 13 CSR 15-15 and 13 CSR 15-16and as required in section 198.085.1, RSMo.

(1) All rules relating to long-term care facili-ties licensed by the Division of Aging, otherthan those rules which are informational incharacter, shall be followed by a notation atthe end of each rule, section, subsection orpertinent part. This notation shall consist of aRoman numeral(s). These Roman numeralsrefer to the class (either class I, class II orclass III) of standard as designated in section198.085.1, RSMo and will be used when thatrule, section, subsection or portion of a rulecarrying the notation is violated by the facili-ty.

(2) In those instances where a particular rule,section, subsection or portion of a rule is fol-lowed by a notation consisting of more thanone (1) Roman numeral, the lower classifica-tion shall be applied unless the division canshow that the higher classification is meritedbecause of the extent of the violation, the vio-lations effect on residents or the impact whencombined with other deficiencies. The divi-sion, on the Statement of Deficiency, shallindicate for the operator which classificationhas been applied and if the higher one isused, for what reason.

(3) A violation of a class I standard is onewhich would present either an imminent dan-ger to the health, safety or welfare of any res-ident or a substantial probability that death or

serious physical harm would result. If a vio-lation of a class I standard is not immediate-ly corrected, or corrective action instituted,the division shall proceed as required undersection 198.029, RSMo. The division shallalso take all other necessary steps to protectthe health, safety or welfare of a residentwhich may include: initiation of license revo-cation action under section 198.036, RSMo;initiation of an action under section 198.067,RSMo; injunctive relief or assessment of acivil penalty, initiation of an action under sec-tion 198.070.6, RSMo; protection of resi-dents from further abuse or neglect; initiationof an action under section 198.105 or198.108, RSMo for appointment of a receiv-er; and appointment of a monitor under sec-tion 198.103, RSMo.

(4) A violation of a class II standard is onewhich has a direct or immediate relationshipto the health, safety or welfare of any resi-dent, but which does not create any imminentdanger. When a violation is noted, the opera-tor shall either correct the violation immedi-ately or prior to the time of the reinspectionor shall be correcting it in accordance withthe time schedules set out in the operator’sapproved plan of correction, as provided forunder section 198.026.2, RSMo. If not, orthe plan of correction is not approved and theviolation not corrected, the violation willconstitute substantial noncompliance underthe Omnibus Nursing Home Act. Afterreview by the division director or his/herdesignee, the division may initiate any actionauthorized by law, including those providedfor in sections 198.026, 198.036, 198.067,198.070.6, 198.103, 198.105 and 198.108,RSMo. Where specific standards are set outin sections 198.003–198.186, RSMo and arenot otherwise classified, those standards willbe treated as class II standards.

(5) A violation of a class III standard is onewhich has an indirect or a potential impact onthe health, safety or welfare of any resident.When a violation is noted, the operator shalleither correct the violation immediately orprior to the time of the reinspection, or shallbe correcting it in accordance with the timeschedules set out in the operator’s approvedplan of correction as provided for under sec-tion 198.026, RSMo. If not, if the plan ofcorrection is not approved and the violationnot corrected, a point value of one (1) pointeach will be noted for violations of each dis-tinct class III standard not corrected; howev-er, the points will not be assessed if there arefive (5) or fewer class III standards violated.

(A) If the points total twenty (20) or morepoints, the facility will be deemed to be in


Secretary of State


substantial noncompliance under theOmnibus Nursing Home Act and the divisionmay initiate any action as authorized by law,including issuance of a notice of noncompli-ance, as provided under section 198.026,RSMo.

(B) If the points total less than twenty (20)points, the points will remain on the facility’srecord until the time the violations are cor-rected and are noted as corrected during areinspection. If during the reinspection aclass III standard violated in the prior inspec-tion continues to be violated, the previouslyassessed points will be doubled unless theoperator immediately corrects the violation.If after the reinspection the points for all pre-viously noted and left uncorrected violationsof distinct class III standards total twenty (20)or more, the facility will be deemed to be insubstantial noncompliance under the Omni-bus Nursing Home Act and the division maytake action as provided under section198.026, RSMo.

(C) The division shall not revoke an oper-ator’s license to operate a long-term carefacility for violations of class III standardsunless—

1. The uncorrected violations taken alltogether present either an imminent danger tothe health, safety or welfare of any residentor a substantial probability of death or seri-ous physical harm; or

2. The operator or his/her agent know-ingly acted or knowingly omitted any dutywhich would materially and adversely affectthe health, safety, welfare or property of aresident.

(D) Points will not be assessed for class IIIviolations if the operator can show that theviolation had been corrected since it was ini-tially noted, that the operator made a goodfaith effort, as judged by the division, to stayin compliance and that the violation againoccurred for reasons beyond the operator’scontrol.

(6) The division shall not initiate any actionagainst an operator as authorized by law,including issuance of a notice of noncompli-ance for uncorrected violations of class II orIII standards, unless the facility’s record, thecited violations and the circumstances arereviewed by the director of the division orhis/her designee.

AUTHORITY: sections 198.009 and198.085.1, RSMo 1986.* This rule was orig-inally filed as 13 CSR 15-10.020. Originalrule filed Dec. 10, 1981, effective May 13,1982. Amended: Filed July 13, 1983, effec-tive Oct. 13, 1983. Moved to 19 CSR 30-82.020, effective Aug. 28, 2001.

*Original authority: 198.009, RSMo 1979 and 198.085,RSMo 1979, amended 1984.

19 CSR 30-82.030 Assessment of Avail-ability of Beds

PURPOSE: This rule sets forth the proce-dures followed by the Division of Aging indetermining for the Missouri Health FacilitiesReview Committee whether or not a needexists in a particular locale for additionalMedicaid certified beds.

(1) The Department of Social Services/Divi-sion of Aging will determine whether therepresently exists a need for additional beds ina particular county or locality after theDepartment of Social Services/Division ofAging is notified by the State Health Planningand Development Agency that a Certificate ofNeed letter of intent has been filed for a pro-ject in that particular county or locality. TheDepartment of Social Services/Division ofAging will obtain from the State Health Plan-ning and Development Agency informationconcerning the project’s projected completiondate, the number of beds to be licensed foreach level of care and the number of beds forwhich Medicaid certification will be sought.

(2) The Department of Social Services/Di-vision of Aging will consider the need forintermediate care facility and skilled nursingfacility licensed beds and will evaluate sepa-rately the need for licensed beds certified toparticipate in Missouri’s Title XIX (Medi-caid) program.

(3) Once per quarter, the Department ofSocial Services/Division of Aging will deter-mine the total number of licensed only bedsand the total number of beds certified to par-ticipate in the Medicaid program in everycounty or locality in the state and the per-centage of those beds which are occupied.

(4) If the Department of Social Services/Di-vision of Aging is notified by the State HealthPlanning and Development Agency that aCertificate of Need letter of intent has beenfiled for a project, the Department of SocialServices/Division of Aging will determine ifa present need actually exists for additionallicensed beds in the county or locality and theminimum number of additional beds needed,taking into account, one (1) or more of thefollowing factors:

(A) Legal or administrative actions towhich the Department of Social Services/Di-vision of Aging may or may not be a party,which may affect availability of licensed

intermediate care facility or skilled nursingfacility beds in the county or locality;

(B) The number of beds under actual con-struction for which a certificate of need hasbeen issued in that county or locality; and

(C) Whether ninety percent (90%) or moreof the existing licensed long-term care beds inthe county or locality are occupied.

(5) If the Department of Social Services/Di-vision of Aging is notified by the State HealthPlanning and Developing Agency that a Cer-tificate of Need letter of intent has been filedfor a project for any county or locality wherefifteen percent (15%) or less of the totalMedicaid-certified beds in that county orlocality are available, or if that county orlocality has no certified beds, the Departmentof Social Services/Division of Aging willdetermine if a present need actually exists foradditional Medicaid-certified beds in thatcounty or locality and the minimum numberof additional Medicaid-certified beds needed,taking into account, one (1) or more of thefollowing factors:

(A) The number of certifiable and poten-tially certifiable beds in existence in thecounty or locality;

(B) The number of potentially certifiablebeds under construction in that county orlocality for which a Certificate of Need hasbeen issued which are scheduled for comple-tion on or before the date scheduled for com-pletion for beds proposed in the applicationin question; and

(C) Legal or administrative action to whichthe Department of Social Services/Divisionof Aging may or may not be a party, whichmay affect availability of licensed and Medi-caid-certified intermediate care facility andskilled nursing facility beds in the county orlocality.

(6) Available Medicaid-certified beds are—(A) Those which are certified to partici-

pate in the Medicaid program, currentlystaffed and capable of being occupied by aresident and not occupied by either a Medi-caid or private pay resident; or

(B) Those, if occupied by a private pay res-ident in a distinct part facility, where thefacility has verified in writing to the Depart-ment of Social Services/Division of Agingthat the private pay resident will be trans-ferred to a noncertified bed in the same facil-ity if a Medicaid recipient or Medicaid-eligi-ble individual requests placement.

(7) The Department of Social Services/Divi-sion of Aging finds a present need exists foradditional beds of the classification proposedin a particular Certificate of Need letter of



intent, the Department of SocialServices/Division of Aging will certify theproposed facility to the Missouri HealthFacilities Review Committee for whateveraction it deems appropriate on that proposedfacility including action pursuant to section197.330, RSMo. If a Certificate of Need let-ter of intent has been filed for more than one(1) project in a county or locality in whichthe Department of Social Services/Divisionof Aging has found existence of a need foradditional beds of the classification(s) pro-posed in the letters of intent, the Departmentof Social Services/Division of Aging will cer-tify all such proposed facilities to the Mis-souri Health Facilities Review Committee todetermine which, if any, of the proposedfacilities will be issued a Certificate of Needto meet the present need for additional bedsdetermined by the Department of Social Ser-vices/Division of Aging. Where the Depart-ment of Social Services/Division of Agingfinds a present need for additional beds in aparticular county or locality, the report to theMissouri Health Facilities Review Committeewill specify whether licensed long-term carebeds are needed or whether the need is forlong-term care beds which are also certifiedto participate in the Medicaid program andwhat minimum number of beds is needed foreach classification.

AUTHORITY: sections 197.318, RSMo Supp.1992 and 198.009, RSMo 1986.* This rulewas originally filed as 13 CSR 15-10.030.Emergency rule filed June 17, 1986, effectiveJune 27, 1986, expired Oct. 24, 1986. Orig-inal rule filed June 17, 1986, effective Oct.24, 1986. Moved to 19 CSR 30-82.030, effec-tive Aug. 28, 2001.

*Original authority: 197.318, RSMo 1986, amended 1992and 198.009, RSMo 1979.

19 CSR 30-82.050 Transfer and DischargeProcedures

PURPOSE: This rule provides instructionsfor persons who are discharged from alicensed long-term care facility under invol-untary circumstances. When this proposedrule becomes effective it will replace 13 CSR15-9.010(17) which will be rescinded by sub-sequent rulemaking. This rule also includesthe provisions of section 198.088, RSMoapplicable to transfer or discharge and thenotice and due process required of alllicensed facilities.

(1) For the purposes of this rule, the follow-ing terms shall be defined as follows:

(A) Transfer means moving a resident fromone institutional setting to another institution-al setting for care and under circumstanceswhere the releasing facility has decided that itwill not readmit the resident or a legallyauthorized representative of the resident hasnot consented or agreed with the transfer.Unless indicated otherwise from the contextof this rule, a transfer shall be deemed thesame as a discharge;

(B) Discharge means releasing from afacility or refusing to readmit a resident froma community setting under circumstanceswhere the resident or a legally authorizedrepresentative of the resident has not consent-ed or agreed with the move or decision torefuse readmittance. Refusal to readmit aformer resident shall not constitute a dis-charge if the former resident has been absentfrom the facility for more than ninety (90)days;

(C) Consent to or agreement with transferor discharge means one of the following:

1. The resident or a legally authorizedrepresentative of the resident has consentedto, agreed with, or requested the discharge;or

2. The resident’s treating physician hasordered the transfer and the releasing facili-ty intends to readmit the resident if requestedto do so;

(D) Consent of the resident means that theresident, with sufficient mental capacity tofully understand the effects and consequencesof the transfer or discharge, consents to oragrees with the transfer or discharge; and

(E) Legally authorized representative of aresident means a duly appointed guardian oran attorney-in-fact who has current and validpower to make health care decisions for theresident.

(2) The facility shall permit each resident toremain in the facility unless—

(A) The transfer or discharge is appropri-ate because the resident’s welfare and the res-ident’s needs cannot be met by the facility;

(B) The transfer or discharge is appropri-ate because the resident’s health hasimproved sufficiently so the resident nolonger needs the services provided by thefacility;

(C) The safety of individuals in the facilityis endangered;

(D) The health of individuals in the facili-ty would otherwise be endangered;

(E) The resident has failed, after reason-able and appropriate notice, to pay for (orhave paid under Medicare or Medicaid) a stayat the facility. For a resident who becomeseligible for Medicaid after admission to a

facility, the facility may charge that residentonly allowable charges under Medicaid; or

(F) The facility ceases to operate.

(3) When the facility transfers or discharges aresident under any of the circumstances spec-ified in subsections (2)(A)–(E), the resident’sclinical record shall be documented. Thefacility shall ensure that documentation forthe transfer or discharge is obtained from—

(A) The resident’s personal physician whentransfer or discharge is necessary under sub-sections (2)(A)–(B); and

(B) A physician when transfer or dischargeis necessary under subsection (2)(D); and

(C) The facility administrator or the facili-ty director of nursing in all circumstances.

(4) Before a facility transfers or discharges aresident, the facility shall:

(A) Send written notice to the resident in alanguage and manner reasonably calculatedto be understood by the resident. The noticemust also be sent to any legally authorizedrepresentative of the resident and to at leastone family member. In the event that there isno family member known to the facility, thefacility shall send a copy of the notice to theappropriate regional coordinator of the Mis-souri State Ombudsman’s office;

(B) Include in the written notice the fol-lowing information:

1. The reason for the transfer or dis-charge;

2. The effective date of transfer or dis-charge;

3. The resident’s right to appeal thetransfer or discharge notice to the director ofthe Division of Aging or his/her designatedhearing official within thirty (30) days of thereceipt of the notice;

4. The address to which the request fora hearing should be sent: AdministrativeHearings Unit, Division of Legal Services,P.O. Box 1527, Jefferson City, MO 65102-1527;

5. That filing an appeal will allow a res-ident to remain in the facility until the hear-ing is held unless a hearing official finds oth-erwise;

6. The location to which the resident isbeing transferred or discharged;

7. The name, address and telephonenumber of the designated regional long-termcare ombudsman office;

8. For Medicare and Medicaid certifiedfacility residents with developmental disabili-ties, the mailing address and telephone num-ber of the Missouri Protection and AdvocacyAgency, 925 South Country Club Drive, Jef-ferson City, MO 65109, (573) 893-3333, orthe current address and telephone number of


Secretary of State


the protection advocacy agency if it haschanged. The protection and advocacy agen-cy is responsible for the protection and advo-cacy of developmentally disabled individualsestablished under Part C of the Developmen-tal Disabilities Assistance and Bill of RightsAct. For Medicare and Medicaid certifiedfacility residents with mental illness, theaddress and telephone number of MissouriProtection and Advocacy Agency, the agencyresponsible for persons with mental illnessunder the Protection and Advocacy for Men-tally Ill Individuals Act; and

(C) Record and document in detail in eachaffected resident’s record the reason for thetransfer or discharge. The recording of thereason for the transfer or discharge shall beentered into the resident’s record prior to thedate the resident receives notice of the trans-fer or discharge, or prior to the time whenthe transferring or discharging facilitydecides to transfer or discharge the resident.

(5) The notice of transfer or dischargedescribed in this rule shall be made by thefacility no less than thirty (30) days before theresident is to be transferred or discharged. Inthe case of an emergency discharge, thenotice shall be made as soon as practicablebefore the discharge when it is specificallyalleged in the notice that—

(A) The safety of individuals in the facili-ty would be endangered under subsection(2)(C) of this rule and the notice containsspecific facts upon which the facility hasbased its determination that the safety of saidindividuals would be so endangered;

(B) The health of individuals in the facilitywould be endangered under subsection (2)(D)of this rule and the notice contains specificfacts upon which the facility has based itsdetermination that the safety of said individ-uals would be so endangered;

(C) The resident’s health has improved suf-ficiently to allow a more immediate transferor discharge under subsection (2)(B) of thisrule;

(D) An immediate transfer or discharge isrequired by the resident’s urgent medicalneeds under subsection (2)(A) of this rule; or

(E) The resident has not resided in thefacility for thirty (30) days.

(6) Any resident of a facility who receivesnotice of discharge from the facility in whichhe/she resides may file an appeal of the noticewith the Administrative Hearings Section,Division of Legal Services, P.O. Box 1527,Jefferson City, MO 65102-1527 within thirty(30) days of the date the resident received thedischarge notice from the facility. The resi-dent’s legal guardian, the resident’s attorney-

in-fact appointed under sections404.700–404.725, RSMo (Durable Power ofAttorney Law of Missouri) or pursuant tosections 404.800–404.865, RSMo (DurablePower of Attorney for Health Care Act) orany other individual may file an appeal on theresident’s behalf. A Nursing Facility Transferor Discharge Hearing Request form (MOForm 886-3245) to request a hearing may beobtained from the Division of Aging or theregional ombudsman. However, the use of aform is not required in order to file a requestfor a hearing. The request for a hearing shallbe verified in writing by the resident, his/herlegal guardian, attorney-in-fact, or any otherparty requesting a hearing on the resident’sbehalf by attesting to the truth of the resi-dent’s request for a hearing.

(7) The director of the Department of SocialServices shall designate a hearing official tohear and decide the resident’s appeal.

(A) The designated hearing official shallnotify the resident, the state long-term careombudsman and the facility that the requestfor a hearing has been received and that ahearing has been scheduled.

(B) The hearing may be held by telephoneconference call or in person at any locationthe designated hearing official deems reason-ably appropriate to accommodate the resi-dent’s needs.

(8) The discharge of the resident shall bestayed at the time the request for a hearingwas filed unless the facility can show goodcause why the resident should not remain inthe facility until a written hearing decisionhas been issued by the designated hearingofficial. Good cause shall include, but is notlimited to, those exceptions when the facilitymay notify the resident of a discharge fromthe facility with less than thirty (30) daysnotice as set forth in section (5) of this rule.

(A) The facility may show good cause fordischarging the resident prior to a hearingdecision being issued by the designated hear-ing official by filing a written Motion to SetAside the Stay with the Administrative Hear-ings Unit at the address in paragraph (4)(B)4.The facility must provide a copy of theMotion to Set Aside the Stay to the resident,or to the resident’s legally authorized repre-sentative and to at least one (1) family mem-ber, if one is known. In the event that a res-ident has no legally authorized representativeand no known family members, then a copyof the Motion to Set Aside the Stay must beprovided to the Missouri State Long-TermCare Ombudsman’s Office.

(B) Within five (5) days after a writtenMotion to Set Aside the Stay has been filed

with the Administrative Hearings Unit, thedesignated hearing official shall schedule ahearing to determine whether the facility hasgood cause to discharge the resident prior toa written hearing decision being issued.Notice of the good cause hearing need not bein writing. All parties and representativeswho received a copy of the Motion to SetAside the Stay under subsection (8)(A) of thisrule shall also be notified of the good causehearing.

1. The designated hearing official shallhave the discretion to consolidate the facili-ty’s good cause hearing with the dischargehearing requested by the resident. In the caseof an emergency discharge, an expeditedhearing shall be held upon the request of theresident, legally authorized representative,family member, and in a case where noticewas required to be sent to the regionalombudsman, to the state long-term careombudsman, so long as the parties waive theten (10)-day notice requirement specified insection (9).

2. Subsequent to the good cause hear-ing, the designated hearing official shall issuean order granting or denying the facility’sMotion to Set Aside the Stay. If the facility’sgood cause hearing and the resident’s dis-charge hearing were consolidated, the ordershall also set forth whether the facility maydischarge the resident.

(9) Written notice of a hearing shall containthe date and time for the hearing and shall bemailed to the facility, the resident or the res-ident’s legally authorized representative, andto any and all parties in interest, includingany family members who received notice ofthe discharge, that are known to the designat-ed hearing official. The written notice shallbe mailed to the parties at least ten (10) daysprior to the hearing.

(10) If the facility’s good cause hearing andthe resident’s discharge hearing were not con-solidated and the designated hearing officialissues an order denying the facility’s Motionto Set Aside the Stay, the designated hearingofficial shall schedule the discharge hearingsubsequent to the date the order which deniedthe facility’s motion was issued. After thehearing, the designated hearing official shallissue a written decision setting forth whetherthe facility may discharge the resident. Thewritten decision shall be mailed to the facili-ty, the resident or the resident’s legally autho-rized representative and counsels for all par-ties, if any. If the state long-term careombudsman’s office received notice of thedischarge, a copy of the hearing decisionshall be sent to the ombudsman’s office. If a



member of the resident’s family receivednotice of the discharge, a copy of the hearingdecision shall be mailed to the family mem-ber upon request.

(11) The burden of showing that the facilityhas complied with all requirements for appro-priate discharge of the resident shall be uponthe facility. The resident may provide anyadditional evidence competent to show thatthe facility has not met its burden.

(12) The resident may obtain legal counsel,represent him/herself or use a relative, afriend or other spokesperson. All natural par-ties, including residents, sole proprietors of afacility and a partner of a facility operated inthe partnership form of business, may repre-sent themselves in a pro se capacity on behalfof the facility. Corporate operators of a facil-ity may only be represented by an attorneylicensed to practice law in Missouri.

(13) Hearings shall be subject to the hearingprocedures found in 42 CFR Chapter IV, Part483, subpart E and the Missouri Administra-tive Procedures Act, specifically sections536.070 through 536.080, RSMo, whichinclude, but are not limited to, oral and writ-ten evidence, witnesses, objections, officialnotices, affidavits, transcripts, depositionsand other discovery methods, sanctions, oralarguments and written briefs. Written medi-cal statements by a physician, psychiatrist orpsychologist shall be admitted as relevant andprobative evidence and shall be given dueweight in consideration by the director orhis/her designated hearing official. An audio-tape recording of the hearing shall be madeunless it is agreed by both parties to substitutea certified transcript.

(14) If the decision is that there is no causefor discharge, the resident shall be permittedto remain in the facility. If the decision is inthe facility’s favor, the resident shall be grant-ed an additional ten (10) days after the deci-sion is received for purpose of relocation, andthe facility shall assist the resident in makingsuitable arrangements for relocation. If theresident prevails and has already been dis-charged, the facility shall notify the resident,the qualified representative, or any otherresponsible party who will assure that theresident is made aware of the decision andthat the resident may return to the facility. Inthe event that there are no beds available, thefacility shall admit the resident to occupy thefirst available bed without regard to any wait-ing list maintained by the facility.

AUTHORITY: sections 198.088, RSMo 1994and 660.050, RSMo Supp. 1997.* This rulewas originally filed as 13 CSR 15-10.050.Original rule filed Feb. 13, 1998, effectiveSept. 30, 1998. Moved to 19 CSR 30-82.050,effective Aug. 28, 2001.

Original authority: 198.088, RSMo 1997, amended 1988,1989, 1994 and 660.050, RSMo 1984, amended 1988,1992, 1993, 1994, 1995.

19 CSR 30-82.060 Hiring Restrictions—Good Cause Waiver

PURPOSE: This rule is being promulgated toestablish the procedure by which persons withcriminal convictions may seek a waiverallowing them to be employed by health careand mental health providers despite the hiringrestrictions found in section 660.317, RSMo.The waivers are to be for “good cause” asdefined by that statute. This rule sets forthboth the procedure for seeking waivers andthe facts and circumstances to be consideredby the Department of Social Services in deter-mining “good cause.”

(1) Definitions.(A) Applicant means a person who has

been or would be rejected for employment bya provider due to the hiring restrictions foundin section 660.317, RSMo.

(B) Department means the Department ofHealth and Senior Services.

(C) Determination means the decisionissued by the director of the Department ofHealth and Senior Services or the director’sdesignee based on the factual, procedural orcausal issues of the request for waiver.

(D) Director means the director of theDepartment of Health and Senior Services.

(E) Good Cause Waiver means a findingthat it is reasonable to believe that the restric-tions imposed by section 660.317, RSMo, onthe employment of an applicant may bewaived after an examination of the applicant’sprior work history and other relevant factorsis conducted and demonstrates that suchapplicant does not present a risk to the healthor safety of residents, patients or clients ifemployed by a provider.

(F) Provider means any person, corpora-tion or association who—

1. Is licensed as an operator pursuant toChapter 198, RSMo;

2. Provides in-home services under con-tract with the Department of Health andSenior Services;

3. Employs nurses or nursing assistantsfor temporary or intermittent placement inhealth care facilities;

4. Is an entity licensed pursuant toChapter 197, RSMo;

5. Is a public or private facility, day pro-gram, residential facility or specialized ser-vice operated, funded or licensed by theDepartment of Mental Health; or

6. Is a licensed adult day care provider.(G) Reference means a written statement

of character, qualification or ability issued onbehalf of the applicant by a person who is notrelated to or residing with the applicantrequesting a good cause waiver.

(H) Sponsor means the current or potentialemployer of the applicant, or a training pro-gram, agency or school in which the appli-cant is or was a student enrolled for the pur-pose of earning a professional license,certification or otherwise becoming qualifiedto perform the duties of an occupation.

(2) Any person who is not eligible foremployment by a provider due to the hiringrestrictions found in section 660.317, RSMo,may apply to the director for a good causewaiver. If the director, or the director’sdesignee, determines that the applicant hasdemonstrated good cause, such restrictionsprohibiting such persons from being hired bya provider shall be waived and such personsmay be so employed unless rejected foremployment on other grounds. Hiring restric-tions based on the Department of Health andSenior Services’ employee disqualificationlist established pursuant to section 660.315,RSMo, are not subject to a waiver.

(3) The director, or the director’s designee,shall accept an application for a good causewaiver only if the application—

(A) Is submitted in writing by the applicanton the form provided by the department;

(B) Is legible;(C) Is signed by the applicant;(D) Includes an indication of the type of

waiver that is being requested;(E) Includes a complete history of residen-

cy since the earliest disqualifying offense orincident;

(F) Includes a complete employment histo-ry since the age of eighteen (18) years;

(G) Includes an attached explanation writ-ten by the applicant as to why the applicantbelieves he or she no longer poses a risk tothe health, safety or welfare of residents,patients or clients;

(H) Includes an attached description writ-ten by the applicant of the events that result-ed in each disqualifying offense or incident;

(I) Includes attached documentation on theapplicant’s professional, vocational or occu-pational licensure, certification or registration


Secretary of State


history and current status, if any, in this stateand any other state;

(J) Includes at least one (1) reference letterfrom a sponsor. If the applicant is not able toobtain a sponsor, the applicant shall so state,shall identify those potential sponsors whohave been approached by the applicant, andshall submit three (3) reference letters fromindividuals knowledgeable of the applicant’scharacter or work history who are not relatedto or residing with the applicant;

(K) Includes a criminal history recordfrom the Missouri State Highway Patrol ifrequesting a waiver of disqualifying criminaloffenses;

(L) Includes a certified court documentfor each disqualifying criminal offense. Ifsuch document is not obtainable, a writtenand signed statement from the court indicat-ing that no such record exists must be sub-mitted;

(M) Includes certified investigative reportsfrom the Department of Social Services ifrequesting a waiver of child abuse or neglectfindings or a waiver of foster parent licensedenial, revocation, or involuntary suspen-sion;

(N) Includes certified investigative reportsor other documentation of the incident(s)which resulted in the applicant’s inclusion onall other lists in the Family Care Safety Reg-istry for which waiver is requested; and

(O) If in addition to the criminal offense(s)for which the applicant is requesting a waiv-er the applicant has any pending felony ormisdemeanor charges, includes a statementexplaining the circumstances and certifiedcopies of the charging documents for allpending criminal charges; and, in the case ofan applicant seeking a position with an in-home services provider agency or homehealth agency, if in addition to the circum-stances related to the listing on any of thebackground checklists of the Family CareSafety Registry for which the applicant isrequesting a waiver the applicant has anypending circumstances which if establishedwould lead to an additional listing on any ofthe background checklists of the Family CareSafety Registry, includes a statement explain-ing the circumstances and certified copies ofdocuments relating to those circumstances.

(4) The director, or the director’s designee,will not consider any application for a goodcause waiver unless it is fully completed,signed by the applicant, and contains allrequired attachments.

(5) Each completed application will bereviewed by a good cause waiver committeeof two (2) or more employees of the depart-

ment. The director shall determine the sizeof the committee and shall, from time totime, appoint members to serve on the com-mittee.

(A) If the applicant seeks a good causewaiver of placement on the disqualificationlist maintained by the Department of MentalHealth, the director shall appoint an employ-ee of the Department of Mental Health rec-ommended by the director of the Departmentof Mental Health to serve on the good causewaiver committee.

(B) A member of the good cause waivercommittee shall recuse himself or herself in agood cause waiver review in which the mem-ber’s impartiality might reasonably be ques-tioned, including but not limited to instanceswhere the committee member has a personalbias or prejudice concerning the applicant, orpersonal knowledge of evidentiary facts con-cerning the application for good cause waiv-er.

(6) The department may, at any time duringthe application process or review thereof,request additional information from the appli-cant. If the applicant fails to supply anyrequested additional information within thirty(30) calendar days of the date of the request,unless the applicant requests and the depart-ment grants an extension, the department willconsider the application for good cause waiv-er to be withdrawn by the applicant.

(7) The department may request the appli-cant, prior to the completion of the review, toappear in person to answer questions abouthis or her application. If the applicant isrequested to appear in person, the depart-ment, in its sole discretion, shall determinethe location for the appearance and may con-duct any such proceedings using electronicmeans, including but not limited to telephon-ic or video conferencing. The departmentshall review and may investigate the informa-tion contained in each application for com-pleteness, accuracy and truthfulness. Theburden of proof shall be upon the applicant todemonstrate that he or she no longer poses arisk to the health, safety or welfare of resi-dents, patients or clients. The following fac-tors shall be considered in determiningwhether a good cause waiver should be grant-ed:

(A) The applicant’s age at the time thecrime was committed or at the time the inci-dent occurred that resulted in the applicantbeing listed on the background checklists inthe Family Care Safety Registry;

(B) The circumstances surrounding thecrime or surrounding the incident that result-ed in the applicant being listed on the back-

ground checklists in the Family Care SafetyRegistry;

(C) The length of time since the convictionor since the occurrence of the incident thatresulted in the applicant being listed on thebackground checklists in the Family CareSafety Registry;

(D) The length of time since the applicantcompleted his or her sentence for the dis-qualifying conviction(s), whether or not theapplicant was confined, conditionallyreleased, on parole or probation;

(E) The applicant’s entire criminal historyand entire history of all incidents that result-ed in the applicant being listed on the back-ground checklists in the Family Care SafetyRegistry, including whether that historyshows a repetitive pattern of offenses or inci-dents;

(F) The applicant’s prior work history; (G) Whether the applicant had been

employed in good standing by a provider butsubsequently became ineligible for employ-ment due to the hiring restrictions in section660.317, RSMo;

(H) Whether the applicant has been con-victed or found guilty of, or pled guilty ornolo contendere to any offense displayingextreme brutality or disregard for human wel-fare or safety;

(I) Whether the applicant has omitted amaterial fact or misrepresented a materialfact pertaining to his or her criminal oremployment history or to his or her history ofincidents that resulted in his or her being list-ed on the background checklists in the Fami-ly Care Safety Registry;

(J) Whether the applicant has ever beenlisted on the Employee Disqualification Listmaintained by the department as provided insection 660.315, RSMo;

(K) Whether the applicant’s criminaloffenses were committed, or the incidentsthat resulted in the applicant being listed onthe background checklists in the Family CareSafety Registry occurred, during the time heor she was acting as a provider or as anemployee for a provider;

(L) Whether the applicant has, while dis-qualified from employment by a provider,obtained employment by fraud, deceit, decep-tion or misrepresentation, including misrep-resentation of his or her identity;

(M) Whether the applicant has ever had aprofessional or occupational license, certifi-cation, or registration revoked, suspended, orotherwise disciplined;

(N) Any other information relevant to theapplicant’s employment background or pastactions indicating whether he or she wouldpose a risk to the health, safety or welfare ofresidents, patients or clients; and



(O) Whether the applicant has supplied allinformation requested by the department.

(8) If, at the time of an application for a waiv-er, or during the waiver consideration pro-cess, the applicant has been charged orindicted for, but not convicted of, any of thecrimes covered under the provisions of sec-tion 660.317, RSMo, the division will holdthe request for waiver in abeyance while suchcharges are pending or until a court of com-petent jurisdiction enters a judgment or orderdisposing of the matter.

(9) Each applicant who submits a waiverapplication meeting the requirements of sec-tion (3) of this rule shall be notified in writ-ing by the director, or the director’s designee,as to whether his or her application hasresulted in a determination of good cause orno good cause. Such notification shall beeffective if sent to the applicant’s addressgiven on the application.

(10) Any good cause waiver granted to anapplicant applies only to:

(A) The specific disqualifying convic-tion(s), finding(s) of guilt, plea(s) of guilty ornolo contendere, as contained in the certify-ing copies of the court documents which arerequired in the application; and/or

(B) The incident(s) that resulted in theapplicant being listed on the backgroundchecklists in the Family Care Safety Registry,as contained in the investigative reports orother supporting documentation required inthe application or subsequently requested bythe department.

(11) Any good cause waiver granted to anapplicant applies only to those disqualifyingcriminal convictions on incidents that result-ed in the applicant being listed on the back-ground checklists in the Family Care SafetyRegistry, as covered under the provisions ofsection 660.317, RSMo, and shall not applyto any other hiring restriction or exclusionimposed by any other federal or state laws orregulations.

(12) The director, or the director’s designee,may withdraw a good cause waiver if itreceives information or finds that—

(A) The applicant has omitted a materialfact or misrepresented a material fact in seek-ing a good cause waiver;

(B) The applicant has been subsequentlyconvicted or found guilty of, or pled guilty ornolo contendere to any class A or B felonyviolation of Chapter 565, 566, or 569,RSMo, or any violation of subsection 3 of

section 198.070, RSMo, or section 568.020,RSMo, in this state or any other state;

(C) Such applicant is a prospective or cur-rent employee of an in-home servicesprovider or home health agency and has beensubsequently involved in an incident thatresults in the applicant being listed on any ofthe background checklists in the Family CareSafety Registry;

(D) The applicant has omitted, misrepre-sented or failed to disclose or provide any ofthe information required by section 660.317,RSMo, or the provisions of this rule; or

(E) There has been a material change inthe circumstances upon which the good causewaiver was granted.

(13) If the good cause waiver is withdrawn bythe department, the notice of such withdraw-al shall be mailed by the department to theapplicant’s last known address, with a copy ofthe notice sent to the applicant’s last knownemployer, if any.

(14) No applicant may be employed in adirect care or direct service position with aprovider during the pendency of a request forwaiver unless the applicant has been continu-ously employed by that provider prior toAugust 28, 2003. If an applicant is employedon or after August 28, 2003, he or she maybe employed following submission of a com-pleted waiver application on a conditionalbasis to provide in-home services or homehealth services to any in-home services clientor home health patient during the pendencyof that waiver application if:

(A) The disqualifying crime is not one thatwould preclude employment pursuant to sub-section 6 of section 660.317, RSMo; and

(B) The applicant is not listed on theDepartment of Health and Senior Services’employee disqualification list established pur-suant to section 660.315, RSMo.

(15) If a waiver is denied to an applicantemployed on or after August 28, 2003, on aconditional basis, the conditional employ-ment shall immediately terminate.

(16) Applicants who have been denied a goodcause waiver, or who have had their goodcause waivers withdrawn by the department,may reapply one (1) time every twelve (12)months, or whenever the circumstances relat-ed to the disqualifying conviction(s) havechanged.

(17) Each provider shall be responsible for—(A) Requesting criminal background

checks on all prospective employees, regard-less of waiver status, in accordance with the

provisions of sections 660.317 and 43.540,RSMo; and

(B) Contacting the department to confirmthe validity of a prospective employee’s goodcause waiver prior to hiring the prospectiveemployee if the prospective employee revealsthe existence of a good cause waiver orreveals the existence of an otherwise disqual-ifying circumstance.

(18) Each in-home services provider or homehealth provider shall also be responsible for—

(A) Requesting Family Care Safety Reg-istry background screenings on all prospec-tive employees, regardless of waiver status, inaccordance with the provisions of section660.317.7, RSMo; and

(B) Contacting the department to confirmthe validity of a prospective employee’s goodcause waiver prior to hiring the prospectiveemployee if the prospective employee revealsthe existence of a good cause waiver orreveals the existence of an otherwise disqual-ifying circumstance.

(19) All applications for good cause waiversand related documents shall become perma-nent records maintained by the department.

AUTHORITY: sections 660.017, RSMo 2000,660.050 and 660.317, RSMo Supp. 2003.*This rule was originally filed as 13 CSR 15-10.060. Emergency rule filed March 1, 1999,effective March 30, 1999, expired Jan. 10,2000. Original rule filed March 1, 1999,effective Sept. 30, 1999. Moved to 19 CSR30-82.060, effective Aug. 28, 2001. Emergen-cy amendment filed Oct. 15, 2003, effectiveOct. 26, 2003, expired April 22, 2004.Amended: Filed Oct. 15, 2003, effective April30, 2004.

*Original authority: 660.017, RSMo 1993, amended 1995;660.050, RSMo 1984, amended 1988, 1992, 1993, 1994,1995, 2001; and 660.317, RSMo 1996, amended 1997,1998, 2002, 2003.

19 CSR 30-82.070 Alzheimer’s Demonstra-tion Projects

PURPOSE: This rule is being promulgatedto describe the general requirements and pro-cess by which project participants will beselected in order to implement Alzheimer’sDemonstration Projects in accordance withsection 198.086, RSMo Supp. 1999.

PUBLISHER’S NOTE: The secretary of statehas determined that the publication of theentire text of the material which is incorpo-rated by reference as a portion of this rulewould be unduly cumbersome or expensive.


Secretary of State


Therefore, the material which is so incorpo-rated is on file with the agency who filed thisrule, and with the Office of the Secretary ofState. Any interested person may view thismaterial at either agency’s headquarters orthe same will be made available at the Officeof the Secretary of State at a cost not toexceed actual cost of copy reproduction. Theentire text of the rule is printed here. Thisnote refers only to the incorporated by refer-ence material.

(1) For the purposes of this rule, “Health carefacilities for persons with Alzheimer’s dis-ease or Alzheimer’s related dementia” meansfacilities that are specifically designed andoperated to provide elderly individuals whohave chronic confusion or dementia illness,or both, with a safe, structured but flexibleenvironment that encourages physical activitythrough a well-developed recreational andaging-in-place activity program.

(2) Participation in the Alzheimer’s Demon-stration Projects will be solicited by the Divi-sion of Aging by letter to all providers cur-rently licensed by the division and to allinterested parties who have advised the divi-sion of their interest. The solicitation letterwill advise all recipients of the criteria to beused in making the selection and will be sentin advance of the selection with sufficientmailing time allowed for the submission ofproposals by the date specified.

(3) Potential project participants mustrespond to the solicitation letter within thirty(30) days of the date received. The divisionmust receive proposals by the date specifiedin the solicitation letter in order for the pro-posals to be considered. Proposals mustaddress the criteria contained in the letter.

(4) The criteria utilized to select Alzheimer’sDemonstration Project participants will bedeveloped by a committee appointed by thedirector of the Division of Aging consistingof representatives of providers, consumersand professionals in the long-term care indus-try who possess knowledge of the provisionof treatment to individuals with Alzheimer’sdisease or other related dementias.

(5) Proposals submitted will be screened ini-tially for the ability of project applicants tocomply with the minimum requirements setforth in section 198.086, RSMo Supp. 1999.Such applicants must provide supportedassurances of their ability to achieve initialand continued compliance with all suchrequirements in order to be included in thefinal selection. Proposals from project appli-cants which are determined to not meet the

minimum requirements shall be removedfrom consideration.

(6) The proposals submitted by applicantswhich remain after the initial screening shallbe reviewed to determine whether allrequired components, as set forth in this rule,are addressed. Proposals which are deter-mined to have not addressed all requiredcomponents shall be removed from consider-ation.

(7) Proposals remaining shall be reviewed bythe director of the Division of Aging and ini-tial selections made. Selections for partici-pants will be finalized only after the applicantreasonably demonstrates the financial capaci-ty necessary to effectively implement andmaintain the facility and program describedin the proposal.

(8) Project participants selected for thedemonstration projects shall be notified bythe division within sixty (60) days from thedate by which proposals shall be submitted tothe division.

(9) All facilities selected to participate in thedemonstration projects shall demonstrate theability to comply with the following mini-mum requirements set forth in section198.086, RSMo Supp. 1999:

(A) Each health care facility for personswith Alzheimer’s disease or other relateddementias shall maintain substantial compli-ance with all regulations under which theyare licensed or certified. A facility mayrequest an exception to a state licensure reg-ulation in accordance with 13 CSR15-10.010(4);

(B) Facilities shall design and implementself-care, productive and leisure activity pro-grams for individuals with Alzheimer’s orother related dementias. These programsshall continually strive to promote the highestpracticable physical and mental abilities andfunctioning of each resident;

(C) The facility may admit to the demon-stration project facility only persons whohave been diagnosed with Alzheimer’s dis-ease or other related dementia and for whomit has been determined that the facility is ableto meet their needs. The determination ofwhether a facility is able to meet a resident’sneeds shall be made in consultation betweenthe resident’s physician, family members orhealth care advocates;

(D) Facilities shall designate a contiguousportion of the facility as the demonstrationproject site, unless such facility exclusivelyadmits individuals with Alzheimer’s or otherrelated dementias as part of the demonstra-tion project. All designated demonstration

project beds shall be located within this des-ignated contiguous portion of the facility;

(E) Facilities shall design and implementa resident environment which promotes themaintenance of the residents’ social abilitiesthrough daily and frequent opportunities forsocialization and appropriate activities. Theresidential environment shall be designed andutilized in such a way as to reflect the indi-vidual preferences of residents and to provideas much independence and opportunities forchoices throughout a day as possible;

(F) A Minimum Data Set (MDS) assess-ment shall be completed for any resident whooccupies a bed designated for demonstrationproject participants. The MDS must be com-pleted within fourteen (14) days of admissionand an MDS quarterly review assessmentmust be completed every ninety (90) daysthereafter. The MDS must also be completedwhenever a significant change in conditionoccurs. For the purposes of this rule, “signif-icant change” means a change in medicalcondition or in cognitive or psychosocialfunctioning which requires a change or mod-ification in services or treatments provided inorder to maintain the individual at the highestpracticable level of functioning.

(G) Facilities shall be staffed twenty-four(24) hours a day by the number and type oflicensed and unlicensed personnel sufficientto insure that all the needs of residents aremet throughout the day. Facilities mustremain in compliance with the staffing regu-lations in effect for the licensure category ofthe facility and as established by statute andmust provide any additional staffing requiredto insure that residents’ needs are met. Facil-ities shall determine appropriate staffing lev-els by utilizing current and updated MinimumData Set information to identify residents’needs and shall make a determination on adaily and as-needed basis regarding the num-ber of staff required to meet these needs;

(H) Facilities shall conduct a total of atleast twenty-four (24) hours of staff trainingfor all employees providing direct care todemonstration project residents within thefirst thirty (30) days of employment. Thistraining shall consist of at least six (6) hoursof classroom training and two (2) hours ofon-the-job training in the special needs, careand safety of individuals with Alzheimer’sdisease or related dementias;

(I) Additional training provided shalladdress the needs, preferences and choices ofthe individual demonstration project resi-dents, the degree of and the provision ofassistance required with activities of dailyliving, the initiation of appropriate activitiesfor residents and the promotion of each resi-dent’s rights, dignity and independence;



(J) Facilities shall utilize personal elec-tronic monitoring devices for any residentwhose physician recommends and orders theuse of the device. Such orders shall be doc-umented in the resident’s health care record;

(K) The facility shall be equipped with acomplete automated sprinkler system in-stalled and maintained in accordance with the1996 edition of the National Fire ProtectionAssociation (NFPA) 13, Standard for theInstallation of Sprinkler Systems, or the 1996edition of NFPA 13R, Sprinkler Systems inResidential Occupancies Up to and IncludingFour Stories in Height, which are herebyincorporated by reference in this rule. Thefacility shall also be equipped with a com-plete electrically supervised fire alarm systemand smoke barriers in accordance with theprovisions of the 1997 Life Safety Code forExisting Health Care Occupancy, which codeis hereby incorporated by reference in thisrule; and

(L) Buildings and furnishings shall bedesigned to provide for residents’ safety.Facilities shall have indoor and outdoor activ-ity areas, and electronically controlled exitsfrom the buildings and grounds to allow resi-dents the ability to explore while preventingthem from exiting the facility’s grounds unat-tended.

(10) All demonstration project facilities shallcomplete the Alzheimer’s Special CareUnit/Program Disclosure Form in accordancewith section 198.510, RSMo Supp. 1999,and develop an informational brochure inaccordance with section 198.515, RSMoSupp. 1999. These must be submitted to thedivision’s licensure unit prior to the admis-sion of any residents through the demonstra-tion project and as required for licensing pur-poses.

(11) In addition to the minimum require-ments, applicants will also be considered forselection based on their ability to provide thefollowing:

(A) A safe environment for individualswith Alzheimer’s disease and other relateddementias;

(B) Admission and discharge criteriawhich effectively identify those individualsfor whom the participant is able to effective-ly provide treatment services;

(C) The provision of services through asocial model for the residential environment;

(D) Staffing in sufficient numbers and byappropriately qualified staff in order to meetthe needs of all residents with Alzheimer’sdisease or other related dementias on anongoing basis;

(E) Specialized staff training relating tothe needs, care and safety of individuals with

Alzheimer’s disease or other related demen-tias;

(F) Housing arrangements designed to pro-vide for residents’ comfort and safety as wellas the provision of services;

(G) Supportive services ancillary to theprovision of treatment and which support thetreatment provided by the facility; and

(H) Adequate financial support of the facil-ity’s demonstration project.

AUTHORITY: section 198.534, RSMo Supp.1999.* This rule was originally filed as 13CSR 15-10.070. Emergency rule filed April14, 2000, effective April 24, 2000, expiredFeb. 1, 2001. Original rule filed April 14,2000, effective Nov. 30, 2000. Moved to 19CSR 30-82.070, effective Aug. 28, 2001.

*Original authority: 198.534, RSMo 1999.

19 CSR 30-82.080 Nursing Facility Qualityof Care Improvement Program

PURPOSE: This rule explains the require-ments for receiving funding from the NursingFacility Quality of Care (NFQC) Fund toimprove the quality of service the facility pro-vides to its residents.

(1) Definitions.(A) Qualified Facility—Any facility

licensed pursuant to Chapter 198, RSMo,that has received a Class I or UncorrectedClass II Notice of Noncompliance within thepast twelve (12) months in one (1) of the fol-lowing areas:

1. For Residential Care Facility I (RCFI) and Residential Care Facility II (RCF II):

A. Administrative, Personnel andResident Care (19 CSR 30-86.042);

B. Dietary (19 CSR 30-86.052); orC. Resident Rights (19 CSR 30-

88.010);2. For Skilled Nursing Facility (SNF)

and Intermediate Care Facility (ICF):A. Administration and Resident Care

(19 CSR 30-85.042)B. Dietary (19 CSR 30-85.052); orC. Resident Rights (19 CSR 30-

88.010).(B) Quality Improvement Project for Mis-

souri (QIPMO) consultation—Provides tech-nical assistance and support to nursing facili-ty staff throughout the state in order toimprove the quality of care in nursing facili-ties using the Minimum Data Set (MDS) andon-site clinical consultation.

(2) Selection of Qualified Facilities.(A) Qualified facilities may submit a writ-

ten request to the department for funds from

the Nursing Facility Quality of Care (NFQC)Fund to pay for QIPMO assistance and sup-port. The department will provide a writtenresponse to the qualified facility’s requestapproving or disapproving the use of NFQCfunding for QIPMO assistance. In theabsence of extraordinary circumstances, aqualified facility shall receive no more thanone thousand dollars ($1,000) per request. Aqualified facility which wishes to receivemore than one thousand dollars ($1,000) perrequest must separately justify reimburse-ment in excess of one thousand dollars($1,000) by setting forth the extraordinarycircumstances justifying reimbursement inexcess of one thousand dollars ($1,000). Thedepartment may, in its sole discretion,approve reimbursement in excess of one thou-sand dollars ($1,000).

(B) Qualified facilities may also submit tothe department proposals describing imple-mentation of a quality improvement program,in lieu of the QIPMO Program. Such propos-als shall address areas of noncompliance thathave been cited in the notice of noncompli-ance issued in the past twelve (12) months.Upon approval of the proposal by the depart-ment, the department may use funds in theNFQC Fund that have been collected fromstate civil money penalties to fund the quali-fied facility’s proposal. In the absence ofextraordinary circumstances, a qualifiedfacility shall receive no more than one thou-sand dollars ($1,000) per proposal. A quali-fied facility which wishes to receive morethan one thousand dollars ($1,000) per pro-posal must separately justify reimbursementin excess of one thousand dollars ($1,000) bysetting forth the extraordinary circumstancesjustifying reimbursement in excess of onethousand dollars ($1,000). The departmentmay, in its sole discretion, approve reim-bursement in excess of one thousand dollars($1,000).

(C) The department may impose upon aqualified facility a directed plan of correc-tion, as set forth in section 198.066, RSMo,which includes QIPMO consultation. Fund-ing for the QIPMO consultation may be takenfrom the NFQC Fund, not to exceed onethousand dollars ($1,000), unless the depart-ment, in its sole discretion, determines reim-bursement in excess of one thousand dollars($1,000) is justified by extraordinary circum-stances.

(3) The qualified facility will submit to thedepartment the paid invoice(s) for theQIPMO consultation or other qualityimprovement program. The department willreimburse the qualified facility for theamount granted.


Secretary of State


AUTHORITY: section 198.067.6, RSMoSupp. 2003.* Emergency rule filed Sept. 12,2003, effective Sept. 22, 2003, expired March19, 2004. Original rule filed Sept. 12, 2003,effective Feb. 29, 2004.

*Original authority: 198.067, RSMo 1979, amended1989, 1996, 1999, 2003.




Rules of


Division 30—Division of Regulation and LicensureChapter 83—Definition of Terms

Title Page

19 CSR 30-83.010 Definition of Terms............................................................................3

Title 19—DEPARTMENT OFHEALTH AND SENIOR SERVICES

Division 30—Division of Regulationand Licensure

Chapter 83—Definition of Terms

19 CSR 30-83.010 Definition of Terms

PURPOSE: This rule defines terms used inthe rules for long-term care facilities as setforth in chapters 19 CSR 30-85, 19 CSR 30-86, 19 CSR 30-87, and 19 CSR 30-88.

(1) Activities of daily living (ADL)—Shallmean one (1) or more of the following:

(A) Eating;(B) Dressing;(C) Bathing;(D) Toileting;(E) Transferring; and (F) Walking.

(2) Administrator—Shall mean an individualperson who is in general administrativecharge of a facility.

(3) Assisted living facility (ALF)—Shallmean any premises, other than a residentialcare facility, intermediate care facility, orskilled nursing care facility, that is utilized byits owner, operator, or manager to providetwenty-four (24) hour care and services andprotective oversight to three (3) or more res-idents who are provided with shelter, board,and who may need and are provided with thefollowing:

(A) Assistance with any activities of dailyliving and any instrumental activities of dailyliving;

(B) Storage, distribution or administrationof medications; and

(C) Supervision of health care under thedirection of a licensed physician, providedthat such services are consistent with a socialmodel of care.

(D) The term “assisted living facility” doesnot include a facility where all of the resi-dents are related within the fourth degree ofconsanguinity or affinity to the owner, opera-tor, or manager of the facility.

(4) Automated dispensing system—Shallmean a mechanical system that performsfunctions that may include, but are not limit-ed to, storing, packaging or dispensing med-ications, and that collects, controls and main-tains all transaction information.

(5) Certified-medication technician—Shallmean a nursing assistant who has completeda course in medication administration

approved by the Department of Health andSenior Services.

(6) Chemical restraint—Shall mean a psy-chopharmacologic medication that is used fordiscipline or convenience and not required totreat medical symptoms.

(7) Communicable disease—Any illness, dis-ease or condition reportable to the MissouriDepartment of Health and Senior Services asrequired by 19 CSR 20-20.010 and 19 CSR20-20.020 is considered, for the context ofthese rules, a communicable disease.

(8) Community based assessment—Shallmean documented basic information andanalysis provided by appropriately trainedand qualified individuals describing an indi-vidual’s abilities and needs in activities ofdaily living, instrumental activities of dailyliving, vision/hearing, nutrition, social par-ticipation and support, and cognitive func-tioning using an assessment tool approved bythe Department of Health and Senior Ser-vices (the department), that is designed forcommunity based services and that is not thenursing home minimum data set. The assess-ment tool may be one developed by thedepartment or one used by a facility whichhas been approved by the department.

(9) Control of medication—Shall meanassuming responsibility by the facility for allfacets of control of medication including, butnot limited to, acquisition, storage, securityand administration.

(10) Convenience—Shall mean any actiontaken by the facility to control resident behav-ior or maintain residents with a lesser amountof effort by the facility and not in the resi-dent’s best interest.

(11) Dementia—Shall mean a general termfor the loss of thinking, remembering, andreasoning so severe that it interferes with anindividual’s daily functioning, and may causesymptoms that include changes in personali-ty, mood, and behavior.

(12) Designee—Shall mean an individualwho has been designated in writing by a res-ident to handle matters and receive reportsrelated to his/her personal possessions andproperty.

(13) Discipline—Shall mean any action takenby the facility for the purpose of punishing orpenalizing residents.

(14) Emergency medical procedure—Shallmean those written policies and procedureswhich describe the types and degrees of acci-dents and injuries, how they will be treated,by whom, in which instances the resident’sphysician will be notified and how quickly.

(15) Emergency medication supply —Shallmean a limited number of dosage units ofprescription medications that may be admin-istered to a resident in an emergency situationor for initial doses of a necessary medicationwhen a pharmacy cannot provide a prescrip-tion for a resident within a reasonable timebased on the resident’s clinical needs at thetime.

(16) Existing or existing licensed facility—Shall mean a long-term care facility whichwas licensed and in operation or one whoseplans were approved prior to June 10, 1981for a skilled or intermediate care facility orprior to November 13, 1980 for residentialcare facilities and assisted living facilitiesexcept as otherwise indicated in 19 CSR 30-86.012, 19 CSR 30-86.022 and 19 CSR 30-86.032.

(17) Exit—Shall mean a door leading to theoutside or through a horizontal exit in a firewall to a fire-safe area in the building.

(18) Facility—Shall mean any residential carefacility, assisted living facility, intermediatecare facility or skilled nursing facilitylicensed by the department.

(19) Fire-resistant construction—For inter-mediate care facilities and skilled nursingfacilities, fire-resistant construction shallmean that a facility meets the specificationsfor Type II (222) or Type II (111) construc-tion as given in the National Fire ProtectionAssociation Code 220. Fire-resistant con-struction for residential care facilities andassisted living facilities is defined in 19 CSR30-86.022.

(20) Hazardous area—Shall mean furnacerooms other than electric forced air furnaces,laundries, kitchens, maintenance shops andstorage rooms of over one hundred (100)square feet and any areas which contain com-bustible materials which will be either easilyignited, burn with an intense flame or resultin the production of dense smoke and fumes.

(21) Home-like—means a self-containedlong-term care setting that integrates the psy-chosocial, organizational and environmentalqualities that are associated with being at


Chapter 83—Definition of Terms 19 CSR 30-83

home. Home-like may include, but is not lim-ited, to the following:

(A) A living room and common use areasfor social interactions and activities;

(B) Kitchen and family style eating area foruse by the residents;

(C) Laundry area for use by residents;(D) A toilet room that contains a toilet,

lavatory and bathing unit in each resident’sroom;

(E) Resident room preferences for resi-dents who wish to share a room, and for res-idents who wish to have private bedrooms;

(F) Outdoor area for outdoor activities andrecreation; and

(G) A place where residents can give andreceive affection, explore their interests,exercise control over their environment,engage in interactions with others and haveprivacy, security, familiarity and a sense ofbelonging.

(22) Individualized service plan (ISP)—Shallmean the planning document prepared by anassisted living facility which outlines a resi-dent’s needs and preferences, services to beprovided, and the goals expected by the resi-dent or the resident’s legal representative inpartnership with the facility.

(23) Instrumental activities of daily living(IADL)—Shall mean one (1) or more of thefollowing activities:

(A) Preparing meals;(B) Shopping for personal items;(C) Medication management;(D) Managing money;(E) Using the telephone;(F) Housework; and(G) Transportation ability.

(24) Intermediate care facility—Shall meanany premises, other than a residential carefacility, assisted living facility, or skillednursing facility, which is utilized by itsowner, operator, or manager to provide twen-ty-four (24) hour accommodation, board,personal care, and basic health and nursingcare services under the daily supervision of alicensed nurse and under the direction of alicensed physician to three (3) or more resi-dents dependent for care and supervision andwho are not related within the fourth degreeof consanguinity or affinity to the owner,operator or manager of the facility.

(25) Involuntary seclusion—Shall mean sepa-ration of a resident from other residents orfrom her/his room or confinement to her/hisroom (with or without roommates) againstthe resident’s will, or the will of the resi-dent’s legal representative. Emergency or

short term monitored separation from otherresidents will not be considered involuntaryseclusion and may be permitted if used for alimited period of time as a therapeutic inter-vention to reduce agitation until professionalstaff can develop a plan of care to meet theresident’s needs.

(26) Keeping residents in place—Shall meanmaintaining residents in place during a fire inlieu of evacuation where a building’s occu-pants are not capable of evacuation, whereevacuation has a low likelihood of success, orwhere it is recommended in writing by localfire officials as having a better likelihood ofsuccess and/or lower risk of injury.

(27) Level I medication aide—Shall mean anindividual who has completed a courseapproved by the department in medicationadministration in a residential care facility orassisted living facility.

(28) Long-term care facility—Shall mean afacility that is licensed either solely or incombination as a skilled nursing facility, anintermediate care facility, a residential carefacility, or assisted living facility.

(29) Long-term care services—Shall meanthe assistance and support that a residentreceives in a residential care facility, assistedliving facility, intermediate care facility, andskilled nursing care facility, to meet the resi-dent’s individual need for nursing care, pro-tective oversight, monitoring, medicationmanagement, social interactions, cooking,housekeeping, laundry, and recreational activ-ities.

(30) Major fraction thereof—Shall mean any-thing over fifty percent (50%) of the numberof occupied beds.

(31) Major remodeling—Shall mean anyremodeling of a long-term care facility whichinvolves the addition of resident-use rooms,which affects fire safety or the structure ofthe building.

(32) Multistory building—Shall mean anybuilding with more than one (1) floor entire-ly above the grade. A floor that is partiallybelow grade will be counted as the first storyto determine sprinkler requirements only if itcontains resident sleeping rooms.

(33) New or newly licensed facility—Shallmean a long-term care facility whose plansare approved or which is licensed after June10, 1981 for a skilled nursing or intermediatecare facility or after November 13, 1980 for

residential care facility or assisted livingfacility except as otherwise indicated in 19CSR 30-86.012, 19 CSR 30-86.022, and 19CSR 30-86.032.

(34) Nursing personnel—Shall include anyemployee, including a nurse’s aide or anorderly, who provides or assists in the provi-sion of direct resident health care services.

(35) Operator—Shall mean any personlicensed or required to be licensed under theprovisions of sections 198.003–198.096,RSMo, in order to establish, conduct, ormaintain a facility. The term person requiredto be licensed shall mean any person havingthe following, as determined by the depart-ment:

(A) Ultimate responsibility for making andimplementing decisions regarding the opera-tion of the facility;

(B) Ultimate financial control of the oper-ation of a facility; and

(C) Legal right to possession of thepremises on which a facility is located.

(36) Person—Shall mean any individual, orany entity, including, but not limited to, acorporation, limited liability company, part-nership, association, nonprofit organization,fraternal organization, church, or politicalsubdivision of the state of Missouri.

(37) Physical restraint—Shall mean any man-ual method or physical or mechanical device,material or equipment attached to or adjacentto the resident’s body that the individual can-not remove easily which restricts freedom ofmovement or normal access to one’s body.Physical restraints include, but are not limit-ed to, leg restraints, arm restraints, handmitts, soft ties or vests, lap cushions, and laptrays the resident cannot remove easily. Phys-ical restraints also include facility practicesthat meet the definition of a restraint, such asthe following:

(A) Using side rails that keep a residentfrom voluntarily getting out of bed;

(B) Tucking in or using Velcro to hold asheet, fabric, or clothing tightly so that a res-ident’s movement is restricted;

(C) Using devices in conjunction with achair, such as trays, tables, bars, or belts, thatthe resident cannot remove easily, that pre-vent the resident from rising;

(D) Placing the resident in a chair that pre-vents a resident from rising; and

(E) Placing a chair or bed so close to awall that the wall prevents the resident fromrising out of the chair or voluntarily gettingout of bed.


Secretary of State


(38) Physician—Shall mean an individuallicensed to practice medicine in the state ofMissouri under Chapter 334, RSMo.

(39) Premises—Shall mean any structuresthat are in close proximity one to the otherand which are located on a single piece ofproperty.

(40) Protective oversight—Shall mean anawareness twenty-four (24) hours a day of thelocation of a resident, the ability to interveneon behalf of the resident, supervision ofnutrition, medication, or actual provisions ofcare, and the responsibility for the welfare ofthe resident, except where the resident is onvoluntary leave.

(41) Qualified dietitian—Shall mean an indi-vidual who is registered by the AmericanDietetic Association or who is eligible forregistration.

(42) Qualified therapist—Shall mean an indi-vidual who is either registered or is eligiblefor registration by the national accreditingassociation for that therapy or, if applicable,is licensed by the state of Missouri for thepractice of the profession in which s/he isengaged.

(43) Qualified therapy assistant—Shall meanan individual who would be qualified as anoccupational therapy or physical therapistassistant as outlined in 42 CFR 484.4.

(44) Residential care facility (RCF)—Shallmean any premises, other than an assistedliving facility, intermediate care facility, orskilled nursing facility, which is utilized by itsowner, operator, or manager to provide twen-ty-four (24) hour care to three (3) or moreresidents, who are not related within thefourth degree of consanguinity or affinity tothe owner, operator, or manager of the facili-ty and who need or are provided with shelter,board, and with protective oversight, whichmay include storage and distribution oradministration of medications and care duringshort-term illness or recuperation, exceptthat, for purposes of eligible residents offacilities formerly licensed as residential carefacilities II receiving supplemental welfareassistance payments, any residential carefacility that was licensed as a residential carefacility II on or before August 27, 2006 thatcontinues to meet the licensure standards fora residential care facility II in effect onAugust 27, 2006 shall be considered a resi-dential care facility II for purposes of its eli-gible residents receiving the cash grant pay-ment amount allocated immediately prior toAugust 28, 2006 for residents of a residential

care facility II pursuant to section 208.030,RSMo.

(45) Responsible party—Shall mean an indi-vidual who has been designated in writing bythe resident to handle matters and receivereports related to his/her general condition.

(46) Self-administration of medication—Shallmean the act of actually taking or applyingmedication to oneself.

(47) Self-control of medication—Shall meanassuming immediate responsibility by a resi-dent for the storage and administration ofmedication for oneself while the facilityretains ultimate control of medication.

(48) Skilled nursing care—Shall mean ser-vices furnished pursuant to physicians’ orderswhich require the skills of licensed nursesand which are provided directly by or underthe on-site supervision of these personnel.Examples of skilled nursing care mayinclude, but are not limited to: administrationof levine tube or gastrostomy tube feedings;nasopharyngeal and tracheotomy aspiration;insertion of medicated or sterile irrigationsolutions and replacement of catheters;administration of parenteral fluids; inhalationtherapy treatments; administration of othertreatments requiring aseptic technique; andadministration of injectable medication otherthan insulin.

(49) Skilled nursing facility—Shall mean anypremises, other than a residential care facili-ty, assisted living facility, or an intermediatecare facility, which is utilized by its owner,operator, or manager to provide for twenty-four (24) hour accommodation, board andskilled nursing care and treatment services toat least three (3) residents who are not relat-ed within the fourth degree of consanguinityor affinity to the owner, operator, or manag-er of the facility. Skilled nursing care andtreatment services are those services com-monly performed by or under the supervisionof a registered professional nurse for individ-uals requiring twenty-four (24) hours a daycare by licensed nursing personnel includingacts of observation, care, and counsel of theaged, ill, injured, or infirm, the administra-tion of medications and treatments as pre-scribed by a licensed physician or dentist, andother nursing functions requiring substantialspecialized judgment and skill.

(50) Social model of care—means long-termcare services based on the abilities, desires,and functional needs of the individual deliv-ered in a setting that is more home-like than

institutional, that promote the dignity, indi-viduality, privacy, independence, and autono-my of the individual, that respects residents’differences and promotes residents’ choices.

(51) Voluntary leave—Shall mean an off-premises leave initiated by: a) a resident thathas not been declared mentally incompetentor incapacitated by a court; or b) a legalguardian of a resident that has been declaredmentally incompetent or incapacitated by acourt.

(52) Vulnerable person—Shall mean any per-son in the custody, care, or control of theDepartment of Mental Health that is receiv-ing services from an operated, funded,licensed, or certified program.

AUTHORITY: sections 198.009, RSMo 2000,and section 198.073, RSMo Supp. 2007.*Emergency rule filed Sept. 7, 1979, effectiveSept. 28, 1979, expired Jan. 24, 1980. Thisrule originally filed as 13 CSR 15-11.010.Original rule filed Sept. 7, 1979, effectiveJan. 12, 1980. Amended: Filed Dec. 10,1980, effective June 11, 1981. Amended:Filed Dec. 10, 1981, effective May 11, 1982.Rescinded and readopted: Filed July 13,1983, effective Oct. 13, 1983. Amended:Filed Nov. 9, 1983, effective Feb. 11, 1984.Emergency amendment filed Aug. 1, 1984,effective Aug. 13, 1984, expired Dec. 10,1984. Amended: Filed Sept. 12, 1984, effec-tive Dec. 13, 1984. Amended: Filed Aug. 1,1988, effective Nov. 11, 1988. Moved to 19CSR 30-83.010, effective Aug. 28, 2001.Emergency amendment filed Sept. 12, 2003,effective Sept. 22, 2003, expired March 19,2004. Amended: Filed Sept. 12, 2003, effec-tive Feb. 29, 2004. Amended: Filed Sept. 14,2004, effective March 30, 2005. Amended:Filed Aug. 23, 2006, effective April 30, 2007.Amended: Filed March 13, 2008, effectiveOct. 30, 2008.

*Original authority: 198.009, RSMo 1979, amended1993, 1995 and 198.073, RSMo 1979, amended 1984,1992, 1999, 2006, 2007.


Chapter 83—Definition of Terms 19 CSR 30-83


Rules of


Division 30—Division of Regulation and LicensureChapter 84—Training Program for

Nursing Assistants

Title Page

19 CSR 30-84.010 Nurse Assistant Training Program...........................................................3

19 CSR 30-84.020 Certified Medication Technician Training Program.......................................9

19 CSR 30-84.030 Level I Medication Aide .....................................................................12

19 CSR 30-84.040 Insulin Administration Training Program .................................................14


LicensureChapter 84—Training Program for

Nursing Assistants

19 CSR 30-84.010 Nurse Assistant TrainingProgram

PURPOSE: The Omnibus Nursing Home Actmandates in section 198.082, RSMo thatnursing assistants employed in skilled nursingand intermediate care facilities complete anapproved training program. This rule givesinformation regarding the purpose of thetraining program, required objectives andcurriculum content, designates what is theapproved course curriculum and indicates thetraining locations and testing which arerequired for a program to be consideredapproved.

(1) Definitions.(A) Basic course shall mean the seventy-

five (75) hours of classroom training, the onehundred (100) hours of on-the-job supervisedtraining and the final examination of theapproved Nurse Assistant Training course.

(B) Certifying agency shall mean a long-term care (LTC) association or other entityapproved by the division under subsection(11)(B) to issue certificates to nursing assis-tants.

(C) Challenge the final examination shallmean taking the final examination of the basiccourse without taking the entire basic course.

(D) Division shall mean the MissouriDivision of Aging.

(E) Long-term care association shall meanthe Missouri Health Care Association, theMissouri Association of Homes for the Aged,the League of Nursing Home Administratorsor the Missouri Assisted Living Association.

(F) Nursing service shall mean an agencyor organization, such as a Nursing PoolAgency or Hospice, which employs nursesand nursing assistants for temporary or inter-mittent placement in LTC facilities.

(G) Training agency shall mean the organi-zation which sponsors the approved trainingprogram. An approved training agency isapproved by the Division of Aging under sec-tion (7) of this rule.

(H) Program shall mean the NurseAssistance Training Program as required bythe Omnibus Nursing Home Act and section198.082, RSMo 1994.

(2) The purpose of the Nurse AssistantTraining Program shall be to prepare individ-uals for employment in a LTC facility. The

program shall be designed to teach skills inresident care which will qualify students toperform uncomplicated nursing proceduresand to assist licensed practical nurses or reg-istered professional nurses in direct residentcare.

(3) All aspects of the Nurse AssistantTraining Program included in this rule (thatis, qualified instructor, clinical supervisor,examiner, approved course curriculum,approved training agency, supervised on-the-job training, testing and student qualifica-tions) shall be met in order for a program tobe considered as approved.

(4) The program shall consist of a basiccourse consisting of a minimum of seventy-five (75) classroom hours of training on basicnursing skills, fire safety and disaster train-ing, resident safety and rights, social and psy-chological problems of residents, and themethods of handling and caring for mentallyconfused residents such as those withAlzheimer’s disease and related disorders;one hundred (100) hours of supervised on-the-job training (clinical practice); a finalexamination; and, following the basic course,continuing in-service training as provided forin 13 CSR 15-14.042(19) through (24).

(5) Curriculum content of the program shallinclude procedures and instructions on basicnursing skills in the following areas: basichygiene techniques; bedmaking; personalcare of residents; food service; charting;safety measures (including fire/safety anddisaster preparedness, and infection control);basic preventative and restorative care andprocedures; basic observation procedures,such as weighing and measuring; communi-cation skills; methods of handling and caringfor mentally confused residents; residents’rights; ethical and legal responsibilities;death and dying; and mental health and socialneeds.

(A) The course curriculum as outlined inthe manual entitled The Nurse Assistant in aLong-Term Care Facility, produced by theInstructional Materials Laboratory,University of Missouri-Columbia, 1987, cat-alogue number 50-5061-S shall be consideredan approved course curriculum. Other manu-als and course material may be used to sup-plement the curriculum. Instructors shall usethe companion instructor’s guide, cataloguenumber 50-5061-I.

(B) An orientation module consisting ofcertain topics identified as such in theapproved course curriculum shall be the firstmaterial covered in the course unless thecourse is taught in its entirety before nursing

assistants have resident contact. All studentsmust complete the nurse assistant orientationmodule prior to providing direct care to anyresident. For those students alreadyemployed by an intermediate care or skillednursing facility, the orientation module shallbe taught at the beginning of the course andbefore the nursing assistant is allowed to pro-vide direct care to residents independently.

1. The orientation module shall include,as a minimum, the following topics: hand-washing, gloving and infection control; emer-gency procedures and Heimlich Maneuver;residents’ rights; abuse and neglect reporting;safety (fire and accident); lifting; moving andambulation; answering signal lights; bedpan,urinal, commode and toilet; preparing resi-dents for and serving meals; feeding the help-less; bathing; dressing and grooming; mouthcare; bedmaking (occupied and unoccupied);promoting residents’ independence; commu-nication and interpersonal skills.

2. Students shall complete the orienta-tion module taught by a qualified instructoreven though they may be employed in a facil-ity that uses the approved course material fororientation as required by 13 CSR 15-14.042(20). The instructor, in that instance,may adjust the time required to cover thematerial or may integrate the material into thebasic course content.

(C) The suggested time schedule includedfor each curriculum topic in the approvedcourse cited in subsection (5)(A) may beadjusted by the instructor to meet the partic-ular learning abilities of the students provid-ing that the orientation module shall be taughtin at least sixteen (16) hours for Medicare- orMedicaid-certified facilities. Licensed-onlyfacilities shall provide at least twelve (12)hours of basic orientation approved by thedivision.

(D) The on-the-job supervised componentof one hundred (100) hours shall start afterthe student has enrolled and started thecourse curriculum and shall precede the finalexamination.

(E) Continuing in-service education shallbe offered in the intermediate care or skilled-nursing facility (ICF/SNF) to nursing assis-tants on a regular basis following their suc-cessful completion of the basic course asrequired in 13 CSR 15-14.042(20) through(23).

(6) Student Enrollment and Qualifications.(A) Any individual who is employable by

an ICF/SNF to be involved in direct residentcare shall be eligible to enroll in an approvedtraining agency course if—

1. The individual is at least eighteen(18) years of age and employable.Employable shall mean that the individual is


Chapter 84—Training Program for Nursing Assistants 19 CSR 30-84

not listed on the Missouri Division of AgingEmployee Disqualified List; who has notbeen found guilty of, pled guilty to, beenconvicted of, or nolo contendere to, a ClassA or B felony under Chapters 565, 566 or569, a Class D felony under section 568.020,RSMo 1994 or any violation of section198.070.3, RSMo 1994, unless a good causewaiver has been granted by the division; andwho meets requirements under 13 CSR15-14.042(32); or

2. The individual is at least sixteen (16)years of age providing he or she is—

A. Currently enrolled in a secondaryschool health services occupation program ora cooperative work education program of anarea vocational-technical school or compre-hensive high school;

B. Placed for work experience in anICF/SNF by that program; and

C. Under the direct supervision ofthe instructor or licensed nursing staff of thefacility, or both, while completing the clinicalportion of the course. A certified facility maynot employ a student in the facility who is notcertified within four (4) months of date ofhire. A licensed-only facility may onlyemploy a student in that facility for up to one(1) year from the date of hire prior to certifi-cation.

(B) All full or part-time employees of anICF/SNF who are involved with direct resi-dent care, and hired in that capacity afterJanuary 1, 1980, shall have completed theapproved Nurse Assistant Training Programor shall enroll in and begin study in theapproved training program within ninety (90)days of employment, except that the followingpersons shall be permitted to challenge thefinal examination:

1. Persons who were enrolled in a pro-fessional (RN) or practical (LPN) nursingeducation program for at least four (4)months or who are enrolled in this programand who have successfully completed theFundamentals of Nursing Course, includingclinical hours within the last five (5) years,may challenge the final examination of thecourse, as this training is deemed equivalentto the required classroom hours and on-the-job training;

2. Professional nursing or practicalnursing licensure candidates who have failedstate licensure examinations may challengethe final examination, as their training isdeemed equivalent to the required classroomhours and on-the-job training;

3. Persons from other states who areapproved to work as a nurse assistance in theother states may challenge the final examina-tion, as their training is deemed equivalent to

the required classroom hours and on-the-jobtraining;

4. Students who have completed a nurs-ing program outside the United States andwho are awaiting the licensure examination inthis country shall be required to apply to thedivision to take the challenge examination. Inaddition to a completed application, the stu-dent must also include: a copy of the out ofcountry license or certificate; a copy of theschool transcript translated to English; a copyof the out of country criminal backgroundcheck translated to English. Students shall berequired to complete the orientation moduleof the course as given in subsection (5)(B) ofthis rule and then may challenge the finalexamination, as their training is deemedequivalent to the other required classroomhours and on-the-job training;

5. Persons trained in acute care sectionsof hospitals as nursing assistants or personstrained as psychiatric aides shall complete theorientation module with special emphasis onthe geriatric residents’ needs, residents’rights and orientation to the facility and shallcomplete the one hundred (100) hours of on-the-job training in an LTC facility or LTC unitof a hospital and then they may challenge thefinal examination, as their training is deemedequivalent to the other required classroomhours and on-the-job training;

6. Persons trained in an LTC unit of ahospital and who have been employed in theLTC unit of the hospital for at least twelve(12) months and who submit a letter of rec-ommendation from the administrator ordirector of nursing documenting their trainingmay challenge the final examination aftercompleting the units on residents’ rights andcare of the confused resident. Such trainingshall be deemed equivalent to the otherrequired classroom hours and on-the-jobtraining; and

7. Any other persons whose back-ground, education and training in gerontolo-gy and health occupations includes the com-ponents of the approved training curriculummay be allowed to challenge the final exami-nation after taking those portions of thecourse as determined to be necessary basedon evaluation of their credentials by thesupervisor of health education of the Divisionof Aging.

(C) Those persons designated in para-graphs (6)(B)1.–7., who want to challengethe final examination shall submit a request inwriting to the division enclosing any applica-ble documentation. The division willrespond, in writing, either approving ordenying the request to challenge the finalexamination and, if approved, the letter fromthe division may be presented to an approved

training agency to challenge the examinationor complete the course or portions of thecourse as required and then challenge theexamination.

(D) Those persons permitted to challengethe final examination shall have madearrangements to do so within sixty (60) daysof employment as a nursing assistant andshall have successfully challenged the finalexamination prior to or within one hundredtwenty (120) days of employment. Permissionletters not utilized within the one hundredtwenty (120)-day period shall be consideredinvalid and reapplication for permission tochallenge shall be made to the division.

(E) Nursing assistants who are employedby a nursing service, or who are working ona private duty basis providing direct residentcare shall have completed the approved basiccourse, shall have a current certificate froman approved certifying agency and shall belisted on the Division of Aging CertifiedNurse Assistant Registry prior to functioningin an ICF/SNF.

(F) Allied health care personnel, such asemergency medical technicians, medical lab-oratory technicians, surgical technicians, cen-tral supply technicians and dental auxiliaries,shall not be considered qualified and shall notbe allowed to challenge the final examination.Individuals, if employed by an ICF/SNF toprovide direct patient care shall enroll in andsuccessfully complete an approved program.

(G) If a student drops the course due to ill-ness or incapacity, the student may reenroll ina course within six (6) months and make upthe course material missed without retakingthe entire course upon presenting proof ofattendance and materials covered in the orig-inal class.

(H) A student shall complete the entirebasic course (including passing the finalexamination) within one (1) year of employ-ment as a nursing assistant in an SNF/ICF,except that a nursing assistant employed by afacility certified under Title XVIII or TitleXIX shall complete the course and be certi-fied within four (4) months.

(I) A full or part-time employee of anICF/SNF who is employed as a nursing assis-tant after January 1, 1989 who has not com-pleted at least the classroom portion of thebasic course shall not provide direct residentcare until he or she has completed the sixteen(16)-hour orientation module and the twelve(12) hours of supervised practical orientationrequired in 13 CSR 15-14.042(20).

(J) All nursing assistants trained prior toJanuary 1, 1989 who were not trained usingthe course curriculum referenced in subsec-tion (5)(A) of this rule with at least seventy-five (75) hours of classroom instruction shall


Secretary of State


have attended a special four (4)-hour retrain-ing program which used the manual entitledLong-Term Care Nurse Assistant Update pro-duced by the Instructional MaterialsLaboratory, University of Missouri-Columbia, 1989, catalogue number 50-5062-I or 50-5062-S. Any nursing assistant whodid not attend this retraining program byAugust 31, 1989 shall no longer be consid-ered a trained nursing assistant and all previ-ous credentials issued by any source shall beconsidered invalid. To be certified as requiredby the provisions of this rule, a person shallsuccessfully complete the entire NursingAssistant Training Program.

(7) Training Agencies.(A) The following entities are eligible to

apply to the division to be an approved train-ing agency:

1. Area vocational technical schools andcomprehensive high schools offering healthservice occupation programs which have apractice classroom and equipment used indelivering health care and a written agree-ment of cooperation with one (1) or moreSNFs/ICFs or an LTC unit of a hospital intheir vicinity for the one hundred (100)-houron-the-job training component of the course;

2. Community junior colleges or privateagencies approved by the MissouriDepartment of Elementary and SecondaryEducation or accredited by a nationally rec-ognized accrediting agency or association onthe list published by the secretary of theDepartment of Education, pursuant to theHigher Education Act (20 USC Sections 295-4(2)(D), 42 USC Section 298(b)(6)) and theVeterans’ Readjustment Assistance Act (38USC Section 1775(a)) which have a practicelaboratory with one (1) or more bed units andequipment used in delivering health care andhave a written agreement of cooperation withone (1) or more SNFs/ICFs, or LTC units ofa hospital in their vicinity for the on-the-jobtraining component of the course; or

3. A licensed hospital, licensedSNF/ICF which has designated space suffi-cient to accommodate the classroom teachingportion of the course, and if the one hundred(100) hours of on-the-job training is not pro-vided on-site, has a written agreement ofcooperation with an LTC unit of a hospital orSNF/ICF to provide that portion.

(B) A school, agency, hospital or nursingfacility which wants to be approved by thedivision to teach the Nursing AssistantTraining Program shall file an applicationwith the division giving the name(s) of theinstructor(s) and clinical supervisor(s); and,if clinical training is not being done on-site, a

copy of an agreement with a nursing facilityfor the clinical portion of the course.

(C) In order to be approved, the applicantshall have an area which will be designatedduring training sessions as a classroom withsufficient space to allow fifteen (15) studentsto be seated with room for note-taking,appropriate equipment as needed for teachingthe course, approved instructors and clinicalsupervisors, and shall assure that the instruc-tor and each student has a manual for thestate-approved course. Any ICF/SNF whichhas received a Notice of Noncompliancerelated to administration and resident carefrom the division in the two (2)-year periodprior to application for approval shall not beeligible for approval and if this Notice isissued after approval, approval shall be with-drawn by the division within ninety (90) daysand the certifying agencies shall be notifiedof the withdrawal of approval. Studentsalready enrolled in a class in this facility,however, may complete their course if aNotice is issued after a course has begun.However, a noncompliant facility where anextended or partially extended survey hasbeen completed may apply in writing to thedivision requesting permission for approval totrain and test nurse assistants for certifica-tion. The approval for each separate classmay be granted to teach and test in the facil-ity but not by the facility staff. If approval isgranted for a waiver for a certified facility orexception for a licensed-only facility, the divi-sion shall require certain criteria to be met,depending on the issues such as time and dis-tance to other training agencies in the area.

(D) The division shall make an on-siteinspection of each approved training agency’spremises within two (2) years of approval todetermine the adequacy of space; equipmentand supplies; and, if clinical training is notdone on-site, verify that there is a currentcopy of an agreement with a nursing facilityfor the clinical portion of the course.

(E) Upon receipt of a fully completedapplication form, the division shall notify theapplicant in writing within ninety (90) days ofapproval or disapproval. If disapproved, thereasons why shall be given.

(F) Training agencies shall be approved fora two (2)-year period and shall submit a newapplication for approval thirty (30) days priorto the expiration of approval.

(8) Instructor/student ratio shall be a maxi-mum of one to fifteen (1:15) and it is recom-mended that the ratio be one to ten (1:10) orless.

(9) Qualifications of Instructors, ClinicalSupervisors and Examiners.

(A) Instructor.1. An instructor shall be a registered

professional nurse currently licensed inMissouri or shall have a temporary permitfrom the Missouri State Board of Nursing.The licensee shall not be subject of currentdisciplinary action, such as censure, proba-tion, suspension or revocation.

2. An instructor shall have had, at aminimum, two (2) years of nursing experi-ence and at least one (1) year of experience inthe provision of LTC facility services in thelast five (5) years. Other personnel from thehealth professions may assist the instructor;however, they must have at least one (1) yearof experience in their field.

3. An applicant to be an instructor, shallsubmit credentials (resume) and a copy ofhis/her current license renewal card or tem-porary permit to the Division of Aging. A let-ter shall be provided by the division to theapplicant indicating the status of the appli-cant’s qualifications and, if not qualified, thereasons and what additional requirements areneeded.

4. An applicant to be an instructor shallattend a seminar approved by the Division ofAging to learn the methodology of teachingthe course but only after his/her credentialshave been reviewed and approved by theDivision of Aging. The Division of Agingshall issue a final letter of approval to be aqualified instructor after the person has satis-factorily completed the seminar. The seminarshall be conducted either by an LTC associa-tion or the Missouri Department ofElementary and Secondary Education usingqualified teacher educators approved by theMissouri Department of Elementary andSecondary Education and the Division ofAging.

5. Any registered nurse approved by thedivision or the Department of Elementaryand Secondary Education as an instructor orexaminer prior to January 1, 1990, exceptthose involved in nurse assistant curriculumdevelopment with the division or who areemployed by a certifying agency, shall attenda training seminar on teaching the nurseassistant course conducted by a LTC associa-tion or the Department of Elementary andSecondary Education by July 1, 1993 in orderto maintain status as an approved instructor.Instructors approved prior to January 1, 1990who are exempt from attending the trainingseminar shall write the Division of Agingsubmitting documentation of classes and stu-dents taught. The division will issue thoseinstructors letters of approval so they will nothave to attend the new training seminar. AfterJuly 1, 1993 all credentials issued prior toJanuary 1, 1990 shall be void. Nurses who



attend the approved seminar shall be issuednew certificates and the division shall main-tain a list of all approved instructors, includ-ing those issued letters of approval.

(B) Clinical Supervisor (On-the-JobSupervisor). The clinical supervisor shall bea currently licensed registered professionalnurse or licensed practical nurse, whoselicense is not currently subject to disciplinaryaction such as censure, probation, suspensionor revocation. The clinical supervisor shallbe licensed in Missouri or shall have a tem-porary permit from the Missouri State Boardof Nursing. The clinical supervisor shall becurrently employed by the facility where thestudents are performing their duties or by theagency conducting the course and shall haveattended a seminar approved by the Divisionof Aging to learn methodology of supervisingthe on-the-job training. Upon successfulcompletion of the training seminar, the clini-cal supervisor shall be issued a certificate andthe division shall maintain a list of approvedclinical supervisors. The clinical supervisorshall be on the facility premises in which thestudents are performing their duties while thestudents are completing the on-the-job com-ponent of their training and shall directlyassist the students in their training andobserve their skills when checking their com-petencies. The clinical supervisor shall haveat least one (1) year of experience in LTC ifnot currently employed by an LTC facility.

(C) Examiner.1. The examiner shall be a registered

professional nurse currently licensed inMissouri or shall have a temporary permitfrom the Missouri State Board of Nursing,and shall not be currently subject of disci-plinary action such as censure, probation,suspension or revocation.

2. The examiner shall have taught a sim-ilar course or shall be qualified to teach asimilar course; but shall not have been theinstructor of the students being examined;and shall not be employed by the operatorwhose students are being examined. Theexaminer shall be specifically approved bythe Division of Aging to administer finalexaminations of the state-approved nurseassistant training curriculum and shall havesigned an agreement with the division to pro-tect and keep secure the final examinations.

3. The examiner shall have attended anexaminer’s seminar given by the Division ofAging to learn the methodology and sign anagreement.

(D) Causes for Disqualification. A personshall not be allowed to be an instructor, clin-ical supervisor or examiner if it is found thathe or she—

1. Knowingly acted or omitted any dutyin a manner which would materially oradversely affect the health, safety, welfare orproperty of a resident;

2. Defrauded a training agency or stu-dent by taking payment and not completing acourse, not administering the final examina-tion as required, or not being on-site whilestudents are being trained;

3. Failed to teach, examine or clinical-ly supervise in accordance with 13 CSR15-13.010, or taught students from the statetest, changed answers on the state test, losttest booklets, or recorded false informationon test materials or test booklets of the pro-gram; or

4. Failed to send documentation of acompleted course to a certifying agency with-in thirty (30) days.

(E) Notification of Disqualification.1. The division shall notify the individ-

ual that he or she is no longer eligible to bean instructor, clinical supervisor or examiner.

2. The division shall notify all approvedtraining and certifying agencies if it has beendetermined that an individual is no longerconsidered an approved instructor, clinicalsupervisor or examiner and that person’sname shall be removed from the lists main-tained by the division of approved instructors,clinical supervisors or examiners.

3. To be reinstated as a state-approvedinstructor, clinical supervisor or examiner theindividual shall submit a request in writing tothe division director stating the reasons whyreinstatement is warranted. The divisiondirector or the director’s designee shallrespond in writing to the request.

(10) Testing.(A) In order to be eligible for testing, a

student shall have either completed the state-approved training curriculum offered by anapproved training agency or shall have a let-ter from the Division of Aging grantingapproval to challenge the final examination.

(B) A student shall pass a minimum ofthree (3) written or oral tests throughout thecourse with an eighty (80) score or better oneach test in order to be eligible to take thefinal examination.

(C) The final examination shall be con-ducted by an approved examiner who may beassisted by the instructor using the followingprocedures:

1. The instructor will select an LTC res-ident to participate in the testing process andobtain approval for this activity from the res-ident;

2. The examiner shall verify the eligibil-ity of the students by reviewing records toestablish that the student has completed the

approved training program or possesses anapproval letter from the division grantingapproval to challenge the final examination.In the event that a qualified instructor for thenurse assistant LTC program did not signrecords of a student who successfully com-pleted the program, without justification ordue to resignation from his/her position, theadministrator of the approved training agencymay validate the training by signature.Evidence of successful completion of thebasic course (that is, test scores, class sched-ules and the like) shall be documented priorto a student taking the final examination;

3. The student shall successfully com-plete at least nine (9) procedures under theobservation of the instructor or a facilitylicensed nurse and examiner.

A. The nine (9) procedures shallalways include a type of bath, vital signs(temperature, pulse, respirations and bloodpressure), transfer techniques, feeding tech-niques, dressing and grooming, skin care,active or passive, range of motion to upperand lower extremities (unless contraindicatedby a physician’s order) and handwashing andgloving from the standardized curriculum.

B. The remainder shall be selectedaccording to the resident’s care needs at thetime of day that testing occurs.

C. The evaluation of the student shallinclude communication and interaction withthe resident, provision of privacy, workhabits, appearance, conduct and reportingand recording skills;

4. The student shall successfully answerforty (40) out of fifty (50) oral or writtenquestions presented by the examiner based onthe standardized curriculum and selectedfrom a specific test pool of questions whichare safeguarded by the Division of Aging;

5. Any person who fails the final exam-ination, except those who have been permit-ted to challenge the examination, shall havethe opportunity to retake the examinationtwice within ninety (90) days. The examinershall notify the division and obtain differentexaminations to be administered each time. Ifit is failed a third time, the entire course orselected sections, as determined by the exam-iner, must be retaken before another exami-nation can be given; and

6. Any person who is required by sec-tion 198.082, RSMo to enroll in the NurseAssistant Program, but who has been permit-ted to challenge the final examination andwho fails the examination, must immediatelyreenroll in and begin study in the next avail-able course and shall complete the basiccourse within one (1) year of employment.

(11) Records and Certification.


Secretary of State




(A) Records.1. The examiner shall complete and sign

the competency record sheet and the finalexamination score sheet which shall includescores and comments. The examiner shalladvise the individual that successful comple-tion of the evaluation will result in the addi-tion of his/her name to the State NursingAssistant Register.

2. After scoring, the examiner shallreturn all test materials, test booklets, answersheets, and any appendices to the division.The examiner shall also provide the trainingagency with documentation of the student’stest scores.

3. A copy of the student’s final recordsheets shall be provided to the student (exceptfor the answer sheets). If the course is notcompleted, records and documentationregarding the portions completed shall beprovided to the student, if requested, and tothe training agency.

4. The training agency shall maintain therecords of students trained. Records shall bemaintained for at least two (2) years.

(B) Certification and Entry of Names onState Register.

1. The training agency shall submitwithin thirty (30) days, the student’s finalrecord sheets to any one of the long-term careassociations or any other agency which isspecifically approved by the division to issuenursing assistant certificates and providenames to the division for entry on the nurseassistant register.

2. Each student shall obtain a certificatefrom a state-approved association or agencyvalidating successful completion of the train-ing program.

3. The Division of Aging shall maintaina list of long-term care associations or otheragencies approved to handle the issuance ofcertificates for the Nurse Assistant TrainingProgram. In order for a long-term care asso-ciation or agency to be approved by theDivision of Aging, it shall enter into anagreement of cooperation with the MissouriDivision of Aging which shall be renewableannually and shall effectively carry out thefollowing responsibilities:

A. Issue certificates to individualswho have successfully completed the course;

B. Provide the Division of Aging withthe names and other identifying data of thosereceiving certificates on at least a monthlybasis; and

C. Maintain accurate and completerecords for a period of at least two (2) years.

4. The certificate of any nurse assistantwho has not performed nursing services formonetary compensation for at least one (1)day in a twenty-four (24)-consecutive month

period shall be invalid and the person’s nameshall be removed from the Missouri nursingassistant register. This individual, however,may submit his/her credentials to theDivision of Aging at any time and if unem-ployed for less than five (5) years, s/he maybe authorized to challenge the final examina-tion. If s/he passes the examination, theexaminer shall submit the individual’srecords to a training agency so that s/he canbe issued a new certificate and his/her namecan be placed on the nurse assistant registeragain. If unemployed longer than five (5)years, the individual must successfully com-plete the entire course before s/he can berecertified and s/he is not eligible to chal-lenge the final examination.

AUTHORITY: sections 198.079 and 198.082,RSMo 1994.* This rule originally filed as 13CSR 15-13.010. Original rule filed Aug. 13,1982, effective Jan. 13, 1983. Amended:Filed March 10, 1983, effective June 11,1983. Amended: Filed Sept. 12, 1984, effec-tive Dec. 11, 1984. Amended: Filed Oct. 13,1987, effective Jan. 29, 1988. Emergencyamendment filed Dec. 16, 1988, effectiveJan. 1, 1989, expired April 5, 1989.Amended: Filed Jan. 19, 1989, effective April27, 1989. Amended: Filed June 16, 1992,effective Feb. 26, 1993. Amended: Filed May26, 1998, effective Jan. 30, 1999. Moved to19 CSR 30-84.010, effective Aug. 28, 2001.



Secretary of State


19 CSR 30-84.020 Certified MedicationTechnician Training Program

PURPOSE: Individuals who administer med-ications in intermediate care and skillednursing facilities are required by rule to havesuccessfully completed a medication adminis-tration training program approved by theDepartment of Health and Senior Services.This rule sets forth the requirements for theapproval of a medication technician trainingprogram designating the required course cur-riculum content, outlining the qualificationsrequired of students and instructors, desig-nating approved training facilities, outliningthe testing and certification requirements,and establishing an update course.


(1) Definitions. For the purpose of this rulethe following definitions shall apply.

(A) Cooperating agency—an intermediatecare facility (ICF) or skilled nursing facility(SNF) licensed by the Department of Healthand Senior Services (the department) whichhas entered into a written agreement with theeducational training agency to provide the set-ting for the clinical portion of the course.

(B) Course—the sixty (60) hours of class-room training, eight (8) hours of clinicalpractice, and a two (2)-part final examinationof the department-approved certified medica-tion technician course curriculum.

(C) Educational training agency—an areavocational-technical school, an area careercenter, a comprehensive high school, a com-munity college, or an approved four (4) yearinstitution of higher learning that is approvedby the department to conduct the CertifiedMedication Technician (CMT) Course. Along-term care facility cannot be a trainingagency.

(2) The CMT course shall be prescribed bythe department in order to prepare individu-als for employment as certified medicationtechnicians in intermediate care facilities andskilled nursing facilities (ICF/SNF). The pro-gram shall be designed to teach skills in med-

ication administration of nonparenteral medi-cations, which will qualify students to per-form this procedure to assist licensed practi-cal nurses (LPNs) or registered nurses (RNs)in medication therapy. All aspects of theCMT course included in this rule shall bemet in order for a program to be approved.

(3) If the CMT course is to be conducted inan ICF/SNF, the facility must enter into anagreement with an educational training agen-cy which is responsible to:

(A) Provide administration of the Test ofAdult Basic Education (TABE) and review ofthe student’s qualifications;

(B) Arrange for a department-approvedinstructor;

(C) Arrange for administration of the finalexamination; and

(D) Certify the students through a depart-ment-approved certifying agency which is anyone (1) of the long-term care associations orany other department-approved agency autho-rized to issue certificates.

(4) The objective of the CMT TrainingProgram shall be to ensure that the medica-tion technician will be able to do the follow-ing:

(A) Prepare, administer, and documentadministration of medications by all routesexcept those administered by the parenteralroute;

(B) Observe, report, and documentresponses of residents to medications admin-istered;

(C) Identify responsibilities associatedwith acquisition, storage, and security ofmedications;

(D) Identify appropriate medication refer-ence materials;

(E) Observe, report, and documentresponses of residents to medications;

(F) Identify lines of authority and areas ofresponsibility; and

(G) Identify what constitutes a medicationerror.

(5) The course shall consist of at least sixty(60) classroom hours of instruction taught bya department-approved CMT instructor orexaminer (instructor/examiner). The courseshall include an additional minimum eight (8)hours of clinical practice conducted in alicensed ICF or SNF under the direct super-vision of the CMT instructor/examiner orunder the direct supervision of an RNemployed by the cooperating agency and des-ignated by the educational training agency insection (9) of this rule. The instructor/exam-iner or the RN employed by the cooperatingagency may require the student to complete

more than the minimum eight (8) hours ofclinical practice based on each student’s mas-tery of course content. A final written exam-ination and a minimum two (2)-hour finalpracticum examination must be conducted inan ICF/SNF.

(A) For all courses beginning on or afterthe effective date of this rule, the studentmanual and course developed by theDepartment of Elementary and SecondaryEducation and the Missouri Center forCareer Education at University of CentralMissouri as outlined in the manual entitledCertified Medication Technician, (Revised2008), incorporated by reference in this ruleand available by Internet at: www.cmttest.orgshall be considered the approved course cur-riculum. This rule does not incorporate anysubsequent amendments or additions.

(B) For all courses beginning on or afterthe effective date of this rule, the approvedcourse curriculum instructor’s guide shall bethe companion Instructor’s Guide, (Revised2008), incorporated by reference in this rule,and accessed by Internet: www.cmttest.org.This rule does not incorporate any subse-quent amendments or additions.

(C) Students and instructors shall eachhave a copy of the approved course curricu-lum manual.

(D) The curriculum content shall includeprocedures and instructions in the followingareas:

1. Basic review of body systems andmedication effects on each;

2. Medical terminology;3. Infection control;4. Medication classifications;5. Medication dosages, measurements,

and forms;6. Acquisition, storage, and security;7. Problems of observations in medica-

tion therapy; and8. Administration by oral, rectal, vagi-

nal, otic, opthalmic, nasal, skin, topical,transdermal patches, and oral metered doseinhaler.

(E) A student shall not be allowed to inde-pendently administer medications until suc-cessfully completing the CMT course. TheCMT Course Evaluation Record may be usedas authorization to independently administermedications for up to sixty (60) days. Afterthis period the student must be listed on theMissouri CNA Registry as an active CMT.

(6) Student Qualifications.(A) Any individual employable in an

ICF/SNF who will be involved in direct res-ident care shall be eligible to enroll as a stu-dent in the course if the following criteria arealso met:



1. High school diploma or GeneralEducation Development (GED) Certificate;

2. A minimum score of 8.9 on bothVocabulary and Comprehension tests and aminimum score of 7.0 on MathematicsConcepts and Application tests on the D levelof the TABE. The tests shall be administeredby the educational training agency;

3. Six (6) months of employment as aCNA who is listed as active on the MissouriCNA Registry;

4. For an individual currently employedin a long-term care facility, a letter of recom-mendation submitted to the educational train-ing agency by the administrator or director ofnursing of the facility, or for an individual notcurrently employed in a long-term care facil-ity, a letter of recommendation submitted tothe educational training agency by a previouslong-term care facility employer;

5. The individual is not listed on thedepartment’s Employee Disqualification List(EDL) and does not have a Federal Indicatoron the Missouri CNA Registry or any otherstate’s CNA Registry that the educationaltraining agency has checked based on a beliefthat information on the individual may beincluded;

6. The individual has not been convict-ed of or entered a plea of guilty or nolo con-tendere to a crime in this state or any otherstate, which if committed in Missouri wouldbe a Class A or Class B felony violation ofChapters 565, 566, or 569, RSMo, or anyviolation of subsection 3 of section 198.070,or section 568.020, RSMo, unless a goodcause waiver has been granted by the depart-ment under the provisions of 19 CSR 30-82.060; and

7. The individual meets the employmentrequirements listed in 19 CSR 30-85.042(32).

(B) Students who drop the CMT coursedue to illness or incapacity may reenroll with-in six (6) months of the date the student with-drew from the course and make up the missedcourse material upon presenting proof ofprior attendance and materials covered ifallowed by the educational training agency’spolicy.

(C) Individuals seeking to challenge theCMT examination shall be listed as active onthe Missouri CNA Registry and shall meetthe criteria in paragraph (6)(A)6. of this rule.If not listed as active on the Missouri CNARegistry, the individual shall first apply tochallenge and successfully pass the CNAwritten and practicum examination. The fol-lowing individuals may qualify to challengethe final written and practicum CMT exami-nation:

1. A student enrolled in a professionalnursing school or in a practical nursing pro-

gram who has completed a medicationadministration course and who has a letter ofendorsement from the school or programdirector;

2. An individual who successfully com-pleted a professional or practical nursing pro-gram in the last five (5) years but who failedthe professional (RN) or practical (LPN)state licensure examination;

3. An individual who provides evidenceof successful completion of a department-approved CMT course while working as anaide at a facility operated by the MissouriDepartment of Mental Health who is listed asa CNA on the Missouri CNA Registry.

(D) An individual who provides evidenceof successful completion of a MissouriDepartment of Mental Health (DMH)-approved CMT course while working at afacility operated by the DMH but who is notlisted as a CNA on the department’s MissouriCNA Registry may challenge the CMT exam-ination. The CMT challenge may only bemade after first completing the orientationmodule of the department’s approved NurseAssistant Training Program and successfullychallenging the final CNA examination sothat the individual’s name appears on thedepartment’s Missouri CNA Registry.

(E) An individual who has successfullycompleted a department-approved medicationtechnician course in another state, who iscurrently listed as a CMT in good standing inthat state, and who submits a letter of recom-mendation to the department’s HealthEducation Unit from an administrator ordirector of nursing of a facility in which theindividual worked as a medication technician.

(7) Obtaining Approval to Challenge theCMT Examination.

(A) An individual wanting to challenge thewritten and practicum final examination shallsubmit a request in writing to the depart-ment’s Health Education Unit enclosing doc-umentation required by this rule. If approvedto challenge the examination, a letter so stat-ing will be sent from the department to bepresented to the educational training agency.The educational training agency shall reviewand maintain a copy of the letter in the agen-cy’s file prior to scheduling the individual fortesting. Challenge approval letters shall bevalid for one hundred twenty (120) days fromthe date of the department’s approval.

(B) An individual who has successfullycompleted a professional or practical nursingprogram and who has not yet taken orreceived the results of the state licensureexamination may request a qualifying letterfrom the department’s Health Education Unitallowing the individual to administer medica-

tion in a long-term care facility. The qualify-ing letter allows the individual to administermedications according to this regulation inlieu of a certificate or the individual beinglisted on the Missouri CNA Registry as anactive CMT. However, if more than ninety(90) days have lapsed since graduation orsince taking the Missouri State BoardExamination with no successful results con-firmed, the individual shall request depart-ment approval to challenge the final examina-tion for certification as a medication techni-cian.

(C) An individual shall not administermedications without the instructor presentuntil the individual has successfully complet-ed the challenge examination and holds anauthorized signed CMT Course EvaluationRecord. An authorized signed CMT CourseEvaluation Record is good for up to sixty (60)calendar days from the examination datepending receipt of the certificate or of listingon the Missouri CNA Registry as an activeCMT.

(8) CMT Course Examiner QualificationRequirements.

(A) In order to qualify as an instructor,examiner, or both, the individual:

1. Shall be currently licensed to practiceas an RN in Missouri or shall have a tempo-rary permit from the Missouri State Board ofNursing. The instructor/examiner shall notbe the subject of current disciplinary action,such as probation, suspension, or revocationof license;

2. Shall hold a current CertifiedMedication Technician teaching certificatefrom the Department of Elementary andSecondary Education, Division of CareerEducation;

3. Shall complete an instructor/examin-er program workshop and be listed as a qual-ified CMT instructor/examiner on the depart-ment’s Instructor/Examiner Registry;

4. Shall sign an agreement with thedepartment to protect and keep secure thefinal examination and the PIN used to elec-tronically access the Instructor Guide/TestBank;

5. May be an employee of the ICF/SNFin which training is conducted, but theICF/SNF must have a cooperative agreementwith an educational training agency;

6. Shall teach the course or facilitate thechallenge examination only as permitted bythe educational training agency; and

7. May be assisted by pharmacists asguest instructors in the areas of medicationsystems, regulations governing medications,medication actions, adverse reactions, medi-cation interactions, and medication errors.


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(B) CMT Instructor/Examiner Disqualifi-cation Criteria.

1. An individual shall not be approved tobe an instructor/examiner if he or she hasever been found to have knowingly acted oromitted any duty in a manner which wouldmaterially and adversely affect the health,safety, welfare, or property of a resident.

2. An individual who has been approvedto be an instructor/examiner shall have thatstatus revoked if, after an investigation by thedepartment, it is found that the individual:

A. Knowingly acted or omitted anyduty in a manner which materially andadversely affected the health, safety, welfare,or property of a resident;

B. Defrauded an educational agencyor student by taking payment and not com-pleting a course or following through withcertification documentation required by 19CSR 30-84.020;

C. Failed to teach, examine, or clini-cally supervise in accordance with 19 CSR30-84.020;

D. Falsified information on the CMTCourse Evaluation Record or any otherrequired documentation;

E. Failed to keep secure the automat-ed PIN access system;

F. Failed to keep secure the CMTweb-based, department-approved InstructorGuide/Test Bank;

G. Copied test questions or answerkeys; or

H. Prepared students directly fromthe exam or utilized unfair or subjective test-ing techniques.

(C) When an individual is no longer qual-ified to be an instructor/examiner, the depart-ment shall:

1. Notify the individual that he or she isno longer eligible to be an instructor/examin-er;

2. Notify all certifying agencies that theindividual is no longer considered anapproved instructor or examiner; and

3. Remove the individual’s name fromthe department’s Instructor/ExaminerRegistry.

(D) To be reinstated as an approvedinstructor/examiner the individual shall sub-mit a request in writing to the department’sHealth Education Unit stating the reasonswhy reinstatement is warranted. If the indi-vidual has not attended the Train-the-TrainerProgram Workshop within two (2) years ofthe date of request, the individual shall retakethe Train-the-Trainer Program Workshop.The Section for Long-Term Care administra-tor or designee shall respond in writing to therequest.

(9) Educational Training Agencies.(A) The following entities are eligible to

apply to the department’s Health EducationUnit to be an approved educational trainingagency: vocational-technical schools, com-prehensive high schools, community collegesor approved four (4)-year institutions of high-er learning.

(B) All classrooms shall contain sufficientspace, equipment and teaching aids to meetthe course objectives.

(C) A school requesting approval to teachthe CMT Training Course or facilitate chal-lenging the examination shall file an applica-tion with the department’s Health EducationUnit giving the names of the instructors andlisting the equipment and classroom spacethat will be used and shall provide a copy ofan agreement with the cooperating agencywhere the course, clinical practice, or finalpracticum examination of the program will beconducted and provide the names of the RNssupervising the clinical observation.Educational training agencies shall beapproved for a two (2)-year period and shallsubmit a new application thirty (30) daysprior to the expiration date.

(D) The cooperating agency in which clin-ical practice and the final practicum examina-tion are conducted shall allow students,instructors and examiners access to the med-ication room, supervised access to residentsand access to the medication documentationarea.

(E) There shall be a signed written agree-ment between the educational training agencyand each cooperating agency which specifiesthe rules, responsibilities, and liabilities ofeach party.

(F) The educational training agency isresponsible for sending the department’sHealth Education Unit a copy of the mostcurrent signed agreement with the cooperat-ing agency where any portion of the course orthe entire course will be conducted. Thedepartment shall review all signed agree-ments of cooperation. On-site inspections ofthe cooperating agency or the educationaltraining agency may be made by the depart-ment if problems occur or complaints arereceived. If requirements are not met, the sta-tus as an educational training agency may berevoked by the department.

(G) The classroom portion of the coursemay be taught in an ICF/SNF if there is anapproved educational training agency as asponsor.

(10) Certified Medication Technician CourseTesting.

(A) Prior to the student’s enrollment, theTABE shall be administered by qualified

examiners designated by the educationaltraining agency. See paragraph (6)(A)2. ofthis rule.

(B) To be eligible for the final courseexamination, students shall have achieved ascore of at least eighty percent (80%) on eachwritten examination in the course curriculum.

(C) Courses beginning on or after theeffective date of this rule require the instruc-tor/examiner to administer the department-approved written final examination accessedthrough the department’s website atwww.cmttest.org using a secure PIN system.The final examination shall include fifty (50)multiple choice questions based on courseobjectives. A score of at least eighty percent(80%) is required for passing.

(D) The practicum examination shallinclude preparing and administering all non-parenteral routes and documenting adminis-tration of medications administered to resi-dents. The practicum examination shall beconducted under the direct supervision of thedepartment-approved instructor/examiner andthe individual responsible for medicationadministered in the ICF/SNF. Testing onmedications not available in the ICF/SNFshall be done in a simulated classroom situa-tion.

(E) The final examination may be retakenone (1) time within ninety (90) days of thefirst fail date without repeating the course.

(F) A challenge examination may be takenone (1) time. If failed, the entire course shallbe taken.

(G) The instructor/examiner shall com-plete the CMT Course Evaluation Record,which includes competencies, scores, andother identifying information.

(11) Records and Certification.(A) Records.

1. The educational training agency shallmaintain records for at least two (2) years forthose individuals who have completed theCMT Course and shall submit to a depart-ment-approved certifying agency within thir-ty (30) calendar days from the examinationdate the following: the student’s legal name,Social Security number, class beginning dateand completion date, whether certified by achallenge or full course, and other identifyinginformation from the CMT CourseEvaluation Record.

2. The educational training agency shallprovide a copy of the CMT CourseEvaluation Record to the certified medicationtechnician.

3. The educational training agency mayrelease a transcript with written permissionfrom the student in accordance with the



provisions of the Family Education Rightsand Privacy Act, 20 U.S.C. section 1232g.

(B) Certification.1. The educational training agency shall

maintain the records of individuals who havebeen enrolled in the CMT course and shallsubmit to a department-approved certifyingagency, the legal name, date of birth, SocialSecurity number, certificate number, certifi-cation date, educational training agency andcooperating agency for all individuals whosuccessfully complete the course and finalexamination within thirty (30) calendar daysfrom the examination date. Upon receipt ofthe successful completion of the course, adepartment-approved certifying agency shallissue a certificate of completion to the studentthrough the educational training agency. Anyfinal examination documentation over sixty(60) days old shall be invalid.

2. Each week the certifying agency shallprovide the department’s Health EducationUnit with names and other identifying infor-mation of those receiving certificates.

3. The department shall maintain a listof certifying agencies approved to issue cer-tificates for the CMT Training Program. Inorder for a certifying agency to be approvedby the department, the agency shall enter intoan annually renewable agreement of coopera-tion with the department.

(12) Requirements for Hiring an Individual asa CMT.

(A) The department shall maintain a CNARegistry, which will list the names of CMTsand other relevant and identifying informa-tion.

(B) Any individual seeking employment inan ICF/SNF as a CMT must be employableas a CNA and be listed with active status asa CNA and CMT on the department’s CNARegistry.

(C) When employing an individual as aCMT, the facility shall contact the depart-ment’s website at www.dhss.mo.gov/cnareg-istry in order to verify current certificationstatus of the individual. Current registry sta-tus must be verified even though the individ-ual presents a CMT certificate.

AUTHORITY: section 198.079, RSMo Supp.2007.* This rule originally filed as 13 CSR15-13.020. Original rule filed Aug. 13, 1982,effective Jan. 13, 1983. Amended: Filed Oct.13, 1987, effective Jan. 29, 1988. Amended:Filed July 13, 1998, effective Feb. 28, 1999.Moved to 19 CSR 30-84.020, effective Aug.28, 2001. Amended: Filed March 13, 2008,effective Oct. 30, 2008.

*Original authority: 198.079, RSMo 1979, amended 2007.

19 CSR 30-84.030 Level I Medication Aide

PURPOSE: Individuals who administer med-ications in residential care facilities I and IIare required by 13 CSR 15-15.042(49) to beeither a physician, a licensed nurse, a certi-fied medication technician or a level I medi-cation aide. This rule sets forth the require-ments for approval of a Level I MedicationAide Training Program designating therequired course curriculum content, outliningthe qualifications required of students andinstructors, designating approved trainingfacilities and outlining the testing and certifi-cation requirements.


(1) The Level I Medication Aide TrainingProgram shall be administered by theDepartment of Health and Senior Services(the department) in order to prepare individ-uals for employment as level I medicationaides in residential care facilities (RCFs) andassisted living facilities (ALFs). The programshall be designed to teach skills in medicationadministration of nonparenteral medicationsin order to qualify students to perform thisprocedure only in RCFs and ALFs inMissouri.

(2) All aspects of the level I Medication AideTraining Program included in this rule shallbe met in order for a program to be consid-ered approved.

(3) The objective of the level I MedicationAide Training Program shall be to ensure thatthe medication aide will be able to—definethe role of a level I medication aide; prepare,administer and chart medications by nonpar-enteral routes; observe, report and recordunusual responses to medications; identifyresponsibilities associated with control andstorage of medications; and utilize appropri-ate drug reference materials.

(4) The course shall be an independent self-study course with a minimum of sixteen (16)hours of integrated formal instruction andpractice sessions supervised by an approved

instructor which shall include a final writtenand practicum examination.

(5) The curriculum content shall include pro-cedures and instructions in the followingareas: basic human needs and relationships;drug classifications and their implications;assessing drug reactions; techniques of drugadministration; medication storage and con-trol; drug reference resources; and infectioncontrol.

(6) The course developed by the MissouriDepartment of Elementary and SecondaryEducation and the Department of Health andSenior Services as outlined in the manualentitled Level I Medication Aide (50-6064-Sand 50-6064-I) 1993 edition, produced by theInstructional Materials Laboratory, Univer-sity of Missouri-Columbia, incorporated byreference in this rule and available throughthe Department of Health and SeniorServices, PO Box 570, Jefferson City, MO65102-0570, shall be considered the approvedcourse curriculum. This rule does not incor-porate any subsequent amendments or addi-tions to the materials incorporated by refer-ence. Students and instructors each shall havea copy of this manual.

(7) A student shall not administer medica-tions without the instructor present until s/hesuccessfully completes the course and obtainsa certificate.

(8) Student Qualifications.(A) Any individual employable by an RCF

or ALF to be involved in direct resident careshall be eligible to enroll as a student in thecourse. Employable shall mean an individualwho is at least eighteen (18) years of age; notlisted on the department’s EmployeeDisqualification List (EDL) and has not beenconvicted of, or entered a plea of guilty ornolo contendere to a crime in this state or anyother state, which if committed in Missouriwould be a class A or B felony violation ofChapters 565, 566, and 569, RSMo, any vio-lation of section 568.020, RSMo or any vio-lation of section 198.070.3, RSMo, unless agood cause waiver has been granted by thedepartment pursuant to the provisions of 19CSR 30-82.060.

(B) The following individuals may qualifyas level I medication aides by successfullychallenging the final examination: Individualseither enrolled in or who have been enrolledin a professional nursing school or in a prac-tical nursing program who have completed


Secretary of State


the medication administration or pharmacol-ogy course and who have letters of endorse-ment from the directors of their respectiveprograms.

(9) Those persons wanting to challenge thefinal examination shall submit a request inwriting to the department’s Section of LongTerm Care director enclosing applicable doc-umentation. If approved to challenge theexamination, a letter so stating will be sentfrom the division to present to an approvedinstructor so that arrangements can be madefor testing.

(10) Instructor Qualifications.(A) An instructor shall be currently

licensed to practice as either a registerednurse or practical nurse in Missouri or shallhold a current temporary permit from theMissouri State Board of Nursing. Thelicensee shall not be subject to current disci-plinary action such as censure probation, sus-pension or revocation. If the individual is alicensed practical nurse, the following addi-tional requirements shall be met:

1. Shall be a graduate of an accreditedprogram which has pharmacology in the cur-riculum.

2. This additional requirement shall notbe waived.

(B) In order to be qualified as an instruc-tor, the individual shall have had one (1)year’s experience working in a long-term care(LTC) facility licensed by the department orthe Department of Mental Health within thepast five (5) years; or shall be currentlyemployed in an LTC facility licensed by thedepartment or the Department of MentalHealth and shall have been employed by thatfacility for at least six (6) months; or shall bean instructor in a Health OccupationsEducation program; and shall have attended a“Train the Trainer” workshop to implementthe Level I Medication Aide Program con-ducted by a Missouri registered nurse presen-ter approved by the department.

(C) Upon completion of the workshop andreceipt of all credentials validating qualifica-tions, the presenter shall issue a certificateindicating that an instructor is approved toteach the level I medication aide course andshall submit the names of the approvedinstructors to the approved LTC association.

(D) A person who has been approved asan instructor shall have that status revoked if,after an investigation by the division, it isfound that the instructor:

1. Accepted money from a student anddid not follow through with the class or uponsuccessful completion of the class did not fol-low through with certification;

2. Falsified information on the finalscore sheet or any other required documenta-tion; or

3. Administered the final examinationincorrectly and not in accordance with sec-tion (12) of this rule.

(E) Once an instructor’s status is revokedonly the director of the division or his/herdesignee may reinstate the individual after theindividual requests reinstatement document-ing new circumstances. If the instructor’sstatus is revoked or reinstated, the divisionshall immediately notify all certifying agen-cies of the action.

(11) Sponsoring Agencies.(A) The following entities are eligible to

apply to the department to be an approvedtraining agency: an area vocational-technicalschool, a comprehensive high school, a com-munity college, an approved four (4) yearinstitution of higher learning or an RCF orALF licensed by the department or an LTCassociation.

(B) The sponsoring agency is responsiblefor obtaining an approved instructor, deter-mining the number of manuals needed for agiven program, ordering the manuals for thestudents and presenting a class schedule forapproval by an approved LTC association.The required information will include: thename of the approved instructor; the instruc-tor’s Social Security number, current addressand telephone number; the number of stu-dents enrolled; the name, address, telephonenumber, Social Security number and age ofeach student; the name and address of thefacility that employs the student, if applica-ble; the date and location of each class to beheld; and the date and location of the finalexamination. The LTC association whichapproved the course shall be notified inadvance if there are any changes in dates orlocations.

(C) Classrooms used for training shall con-tain sufficient space, equipment and teachingaids to meet the course objectives as deter-mined by an approved LTC association.

(D) If the instructor is not directlyemployed by the agency, there shall be asigned written agreement between the spon-soring agency and the instructor which shallspecify the role, responsibilities and liabili-ties of each party.

(12) Testing.(A) The final examination shall consist of

a written and a practicum examination admin-istered by the instructor.

1. The written examination shall includetwenty-five (25) questions based on thecourse objectives.

2. The practicum examination shall bedone in an LTC facility which shall includethe preparation and administration by nonpar-enteral routes and recording of medicationsadministered to residents under the directsupervision of the instructor and the personresponsible for medication administration inthe long-term care facility. Testing on medi-cations not available in the LTC facility shallbe done in a simulated classroom situation.

(B) A score of eighty percent (80%) isrequired for passing the final written exami-nation and one hundred percent (100%) accu-racy in the performance of the steps of proce-dure in the practicum examination.

(C) The final examination, if not success-fully passed, may be retaken within ninety(90) days one (1) time without repeating thecourse, however, those challenging the finalexamination must complete the course if theexamination is not passed in the challengeprocess.

(D) The instructor shall complete finalrecords and shall submit these and all testbooklets to the sponsoring agency.

(13) Records and Certification.(A) Records.

1. The sponsoring agency shall maintainrecords of all individuals who have beenenrolled in the Level I Medication AideProgram and shall submit to the LTC associ-ation which approved the course all test book-lets, a copy of the score sheets and a com-plete class roster.

2. A copy of the final record shall beprovided to any individual enrolled in thecourse.

3. A final record may be released onlywith written permission from the student inaccordance with the provisions of the PrivacyAct (PL 90-247).

(B) Certification.1. The LTC association which approved

the course shall award a Level I medicationaide certificate to any individual successfullycompleting the course upon receiving therequired final records and test booklets fromthe sponsoring agency.

2. The LTC association which approvedthe course shall submit to the department thenames of all individuals receiving certifi-cates.

(14) The department shall maintain a list ofLTC associations approved to handle theLevel I Medication Aide Training Program.In order for an LTC association to beapproved by the department the associationshall enter into an agreement of cooperationwith the department which shall be renewable




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annually and shall effectively carry out thefollowing responsibilities:

(A) Maintain a roster of approved instruc-tors;

(B) Approve sponsoring agencies, classschedules and classroom space;

(C) Distribute final examinations, reviewtest booklets, score sheets and class rosters;

(D) Award certificates to individuals whosuccessfully complete the course, provide thedepartment with the names of those receivingcertificates; and

(E) Maintain records.

(15) Maintaining Certification. (A) If the department, upon completion of

an investigation, finds that the Level I medi-cation aide has stolen or diverted drugs froma resident or facility or has had his/her nameadded to the employee disqualification list,the division shall delete such person’s namefrom the department’s Level I medicationaide listing. Such deletion shall render themedication aide’s certificate invalid.

AUTHORITY: sections 198.076, RSMo 2000and 198.005 and 198.073, RSMo Supp.2006.* This rule originally filed as 13 CSR15-13.030. Original rule filed May 14, 1985,effective Sept. 1, 1985. Amended: Filed Oct.16, 1985, effective Jan. 12, 1986. Amended:Filed May 26, 1998, effective Jan. 30, 1999.Moved to 19 CSR 30-84.030, effective Aug.28, 2001. Amended: Filed Aug. 23, 2006,effective April 30, 2007.

*Original authority: 198.005, RSMo 2006; 198.073,RSMo 1974, amended 1984, 1992, 1999, 2006; and198.076, RSMo 1979, amended 1984.

19 CSR 30-84.040 Insulin AdministrationTraining Program

PURPOSE: This rule sets forth the require-ments for approval of an insulin administra-tion training program, designates therequired course curriculum content, outlinesthe qualifications required of students andinstructors and outlines the testing andrecords requirements.

PUBLISHER’S NOTE: The secretary of statehas determined that the publication of theentire text of the material which is incorpo-rated by reference as a portion of this rulewould be unduly cumbersome or expensive.This material as incorporated by reference inthis rule shall be maintained by the agency atits headquarters and shall be made availableto the public for inspection and copying at nomore than the actual cost of reproduction.This note applies only to the reference mate-

rial. The entire text of the rule is printedhere.

(1) The Insulin Administration TrainingProgram shall be administered by theDepartment of Health and Senior Services(the department) in order to prepare medica-tion technicians in a skilled nursing facility(SNF) or intermediate care facility (ICF), ormedication aides in a residential care facility(RCF) or an assisted living facility (ALF) toadminister insulin. The program shall bedesigned to present information on diabetesas it relates to symptoms and implications ofproper or improper treatment, and to teachskills in insulin administration in order toqualify students to perform this procedure inlong-term care (LTC) facilities in Missouri.All aspects of the Insulin AdministrationTraining course included in this rule shall bemet in order for the program to be approved.

(2) The course shall consist of at least four(4) hours of classroom instruction by anapproved instructor and shall include a finalwritten and practicum examination. Thepracticum examination shall not be conductedin a simulated situation.

(3) The curriculum content shall include pro-cedures and instruction in the followingareas: diabetes and its treatment and compli-cations, types of insulin, technique of insulinadministration and methods of monitoringblood sugar levels.

(4) The manual entitled Insulin Administra-tion (50-6080-S and 50-6080-I), 2001 edi-tion, produced by the Instructional MaterialsLaboratory, University of Missouri-Colum-bia, which is incorporated by reference inthis rule, and available through theDepartment of Health and Senior Services,PO Box 570, Jefferson City, MO 65102-0570, shall be considered the approvedcourse curriculum. This rule does not incor-porate any subsequent amendments or addi-tions to the materials incorporated by refer-ence. Students and instructors shall each havea copy of the manual.

(5) A student shall not administer insulinwithout the instructor present until s/he hassuccessfully completed the course.

(6) Student Qualifications. (A) Any level I medication aide working in

an RCF or ALF, who is recommended inwriting for training by an administrator/man-ager or nurse with whom s/he has workedshall be eligible to enroll as a student in thiscourse.

(B) Any certified medication technicianwho is recommended in writing for trainingby the administrator or director of nursingwith whom s/he has worked shall be eligibleto enroll as a student in this course. The let-ter of recommendation shall be given to thetraining agency or instructor at enrollment.

(7) Instructor Qualifications. Only a regis-tered nurse who is an approved instructor forthe Level I Medication Aide Program,instructor/examiner for the Certified NurseAssistant Program or instructor for theCertified Medication Technician Programshall be considered qualified to teach theInsulin Administration Course.

(8) Testing. (A) The final examination shall consist of

a written and practicum examination adminis-tered by an approved instructor or examiner.

1. The written examination shall includeten (10) questions extracted from the list inthe instructor’s manual.

2. The practicum examination shallinclude the preparation, administration andrecording of administration of insulin to aresident(s) under the direct supervision of theinstructor/examiner.

(B) A score of eighty percent (80%) isrequired for passing the final written exami-nation and one hundred percent (100%) accu-racy in the performance of the steps of proce-dure in the practicum examination.

(C) The final examination, if not success-fully passed, may be retaken one (1) timewithin thirty (30) days without repeating thecourse.

(9) Records. (A) The instructor shall complete the final

record of the insulin administration courseand shall distribute copies in the followingmanner:

1. A copy shall be provided to each indi-vidual who successfully completes thecourse;

2. A copy shall be kept in the instruc-tor’s file; and

3. The original shall be sent to a certi-fying agency.

(B) Each student shall obtain a certificatefrom a state-approved certifying agency vali-dating successful completion of the trainingprogram.

(C) Records shall be retained by instructorsfor at least two (2) years.

(D) The department shall maintain a list ofapproved certifying agencies to handleissuance of certificates for the InsulinAdministration Program. In order for anagency to be approved by the department to

be a certifying agency, it shall enter into anagreement of cooperation with the depart-ment which shall be renewable annually andthe agency shall effectively carry out the fol-lowing responsibilities:

1. Review all documents submitted bythe instructor to assure that the instructor isqualified in accordance with section (7);

2. Assure that all program requirementshave been met as set forth in these rules or asstipulated in the agreement with the depart-ment;

3. Issue certificates to individuals whosuccessfully complete the course;

4. Provide the department with thenames of those receiving certificates on atleast a monthly basis; and

5. Maintain accurate and completerecords for a period of at least two (2) years.

AUTHORITY: sections 198.009 and198.076, RSMo 2000 and 198.005 and198.073, RSMo Supp. 2006.* This rule orig-inally filed 13 CSR 15-13.040. Original rulefiled Oct. 15, 1990, effective March 14,1991. Amended: Filed May 26, 1998, effec-tive Nov. 30, 1998. Moved to 19 CSR 30-84.040, effective Aug. 28, 2001. Amended:Filed Aug. 23, 2006, effective April 30, 2007.

*Original authority: 198.005, RSMo 2006; 198.009,RSMo 1979, amended 1993, 1995; 198.073, RSMo 1979,amended 1984, 1992, 1999, 2006 and 198.076, RSMo1979, amended 1984.




Rules of


Division 30—Division of Regulation and LicensureChapter 85—Intermediate Care and Skilled

Nursing Facility

Title Page

19 CSR 30-85.012 Construction Standards for New Intermediate Care and Skilled NursingFacilities and Additions to and Major Remodeling of Intermediate Careand Skilled Nursing Facilities ...............................................................3

19 CSR 30-85.022 Fire Safety Standards for New and Existing Intermediate Careand Skilled Nursing Facilities ...............................................................9

19 CSR 30-85.032 Physical Plant Requirements for New and Existing Intermediate Careand Skilled Nursing Facilities ..............................................................14

19 CSR 30-85.042 Administration and Resident Care Requirements for New and ExistingIntermediate Care and Skilled Nursing Facilities .......................................16

19 CSR 30-85.052 Dietary Requirements for New and Existing Intermediate Care andSkilled Nursing Facilities ...................................................................21


LicensureChapter 85—Intermediate Care and

Skilled Nursing Facility

19 CSR 30-85.012 Construction Standardsfor New Intermediate Care and SkilledNursing Facilities and Additions to andMajor Remodeling of Intermediate Careand Skilled Nursing Facilities

PURPOSE: This rule establishes constructionstandards for new intermediate care andskilled nursing facilities and additions to andremodeling of intermediate care and skillednursing facilities.

PUBLISHER’S NOTE: The secretary of statehas determined that the publication of theentire text of the material which is incorpo-rated by reference as a portion of this rulewould be unduly cumbersome or expensive.Therefore, the material which is so incorpo-rated is on file with the agency who filed thisrule, and with the Office of the Secretary ofState. Any interested person may view thismaterial at either agency’s headquarters orthe same will be made available at the Officeof the Secretary of State at a cost not toexceed actual cost of copy reproduction. Theentire text of the rule is printed here. Thisnote refers only to the incorporated by refer-ence material.

PUBLISHER’S NOTE: All rules relating tolong-term care facilities licensed by the Divi-sion of Aging are followed by a RomanNumeral notation which refers to the class(either class I, II or III) of standard as desig-nated in section 198.085.1, RSMo 1986.

(1) Plans and specifications shall be preparedfor the construction of all new intermediatecare and skilled nursing facilities and addi-tions to and remodeling of existing facilities.The plans and specifications shall be pre-pared in conformance with Chapter 327,RSMo, by a duly registered architect or reg-istered professional engineer. III

(2) The facility may submit schematic andpreliminary plans to the division showing thebasic layout of the building and the generaltypes of construction, mechanical and electri-cal systems. The facility may submit detailsbefore the larger and more complicated work-ing drawings and specifications so that neces-sary corrections can be easily made beforethe final plans are submitted. The facilityshall prepare and submit working drawings

and specifications, complete in all respects,for approval by the division. These plansshall cover all phases of the construction pro-ject, including site preparation; paving; gen-eral construction; mechanical work, includ-ing plumbing, heating, ventilating and airconditioning; electrical work; and all built-inequipment, including elevators, kitchenequipment and cabinet work. II/III

(3) Facilities shall begin construction onlyafter the plans and specifications havereceived the written approval of the division.Facilities shall then build in conformancewith the approved plans and specifications.The facility shall notify the division withinfive (5) days after construction begins. Ifconstruction of the project is not started with-in one (1) year after the date of approval ofthe plans and specifications are not complet-ed within a period of three (3) years, thefacility shall resubmit the plans to the divi-sion for its approval and shall amend them, ifnecessary, to comply with the then currentrules before construction work is started orcontinued. II/III

(4) The facility shall be located on an all-weather road and have easy access for vehic-ular traffic. III

(5) Facilities shall have access to local fireprotection. III

(6) The facility shall provide adequate roadsand walks within the lot lines to the mainentrance and service entrance. III

(7) In any new addition, an existing licensedfacility shall provide all required ancillaryservice areas, proportional to the number ofnew beds. However, for existing facilities,these support service areas may be reducedby the amount of existing areas that meet newfacility requirements. New support areasrequired in this project, whether they are toserve the new beds or the existing beds, shallcomply with the rules for new facilities. III

(8) Facilities shall have administrative andpublic areas as listed: business office, admin-istrator’s office (business office and adminis-trator’s office may be combined); director ofnurses’ office; lobby and waiting room (maybe combined); public restrooms for each sex;and public telephone. III

(9) The facility shall provide recreation,occupational therapy, activity and residents’dining space at a ratio of at least thirty (30)square feet for each resident. II

(10) Facilities shall provide a bulk storagearea consisting of a locked room, shelving,bins and large cans for storing long-term sup-plies of food and other dietary materialsabove the floor in a dry room with adequateventilation, cool, but not freezing. The bulkstorage area shall be one (1) square foot perbed, but in no case shall it be less than onehundred (100) square feet. III

(11) Facilities shall have dry short-term stor-age areas for daily food supplies and otherdietary materials. The dry short-term storagearea may include the space required for bulkstorage. III

(12) A facility shall provide a preparationarea for wrapping removal, vegetable clean-ing and peeling and meat cutting. III

(13) Facilities shall provide adequate cookingand baking areas. III

(14) A facility shall have a salad and sand-wich preparation area for the preparation ofcold foods. III

(15) Facilities shall provide a tray preparationand loading area for preparing trays for resi-dents’ food delivery and food cart loading. III

(16) A facility shall provide a pot and panwashing area consisting of a three (3)-com-partment sink with a double drainboard forthe washing of utensils during the food prepa-ration period. III

(17) Facilities shall have a dishwashing areaprovided with a soiled dish receiving counter,space for scraping with a garbage grinder,prerinse sink, counter for racking dishes,dishwasher, clean dish counter, dish rackstorage and an exhaust fan. II/III

(18) A facility shall have a dish storage areawith shelves adjacent to the tray preparationarea. III

(19) Facilities shall provide refrigerators ofadequate capacity in all kitchens and otherpreparation centers where perishable foodswill be stored. A minimum of two (2) sepa-rate sections or boxes shall be provided in themain kitchen; one (1) for meat and dairyproducts and one (1) for general storage. III

(20) The refrigerators’ compressors and evap-orators shall have sufficient capacity to main-tain temperatures of thirty-five degreesFahrenheit (35°F) in the meat and dairyboxes and forty degrees Fahrenheit (40°F) in


Chapter 85—Intermediate Care and Skilled Nursing Facility 19 CSR 30-85

the general storage boxes when the boxes arebeing used for those purposes. II

(21) These compressors shall be automatical-ly controlled. III

(22) Compressors, piping and evaporatorsshall be tested for leaks and capacity. Certifi-cation of these tests shall be made available tothe division. III

(23) A facility shall have an office area forplanning menus and food purchases next tothe dietary area. III

(24) Kitchen shall have handwashing sinks.III

(25) A facility shall have a janitor’s area,exposed or in a closet, in or near the kitchen,that contains a floor receptor or service sink.III

(26) A garbage removal area with garbageand trash cans located inconspicuously shallbe easily accessible from both the kitchen andthe service drive. III

(27) Housekeeping areas shall be provided aslisted: clean linen area, soiled linen area andlaundry area. II

(28) The facility shall have a designated phys-ical therapy area large enough to give reha-bilitative care to physically disabled resi-dents. This area shall be sized toaccommodate all equipment and activities inthe facility’s proposed physical therapy pro-gram. In no case shall this area be less thantwo hundred (200) square feet. III

(29) The facility shall provide the followingelements: treatment areas and equipment asdictated by the facility’s physical therapy pro-gram; a handwashing sink; an exercise area;storage for clean linen, supplies and equip-ment; a toilet room located in the physicaltherapy room or within the immediate area ofthe physical therapy department; and anoffice or sufficient space for the physicaltherapy director’s desk and file. The physicaltherapy area may be located adjacent to anoccupational therapy area and share any or allof the required elements providing that thesharing of elements conforms with the facili-ty’s therapy programs. III

(30) If there is a designated occupationaltherapy area, it shall be large enough toaccommodate all the equipment and activitiesin the facility’s proposed occupational thera-py program. When the facility locates physi-

cal therapy and occupational therapy in thesame area, there shall be a space that can beseparated from the rest of the area if ceram-ics, sculpture, minor woodwork and lightmechanical work are a part of the occupa-tional therapy program. III

(31) Facilities shall provide a maintenanceroom or area. II

(32) A facility shall provide an employees’dressing or locker room with separaterestrooms for each sex. III

(33) Facilities shall provide storage rooms aslisted: general storage—ten (10) square feetper bed for the first fifty (50) beds, plus eight(8) square feet per bed for the next twenty-five (25) beds, plus five (5) square feet perbed for any additional beds over seventy-five(75). No storage room shall be less than onehundred (100) square feet of floor space. Therequired residents’ clothes storage room andstorage for outdoor equipment may be includ-ed in the minimum area required for generalstorage. III

(34) A continuous system of unobstructedcorridors, referred to as required corridors,shall extend through the enclosed portion ofeach story of the building. These corridorswill connect all rooms and spaces with eachother and with all entrances, exit ways andelevators, with the following exceptions:work suites, such as the administrative suiteand dietary area, occupied primarily byemployed personnel may contain corridors oraisles as necessary, and will not be subject tothe rules applicable to required corridors.Areas may be open to this system as permit-ted by the 1985 edition of the Life SafetyCode, for those facilities with plans approvedon or before December 31, 1998. All facili-ties with plans submitted for approval on orafter January 1, 1999, shall comply with theprovisions of the 1997 Life Safety Code,incorporated by reference in this rule. II/III

(35) A facility shall provide a personal careroom with barber and beauty shop facilities.III

(36) There shall be an oxygen storage roomthat is surrounded by one (1)-hour rated con-struction with a powered or gravity vent tothe outside. II

(37) Facilities shall have one (1) or morenursing units. A nursing unit shall not exceeda maximum of sixty (60) resident beds. Eachnursing unit shall be a single floor continuousarea which does not require resident care

traffic to traverse other areas. A facility shallnot locate a resident room door more thanone hundred forty feet (140') from the nurs-es’ station and the dirty utility room. II

(38) Resident room area shall be a minimumof eighty (80) square feet per bed in multiplebed resident rooms, and one hundred (100)square feet per bed in one (1)-bed residentrooms. A continuous aisle not less than threefeet (3') wide shall be available around thefoot and along both sides of each bed. Facil-ities shall locate beds to avoid drafts, exces-sive heat and other residents discomforts.Typical minimum clear dimensions for thebed area in resident rooms shall be as fol-lows:1-Bed 10' 6" × 9' 3"2-Bed 10' 6" × 15' 6"3-Bed 10' 6" × 21' 9"4-Bed 18' 0" × 15' 6"

Heating units and handwashing sinks mayprotrude into this required space. II

(39) To provide for the isolation of a resi-dent(s) with a communicable disease(s), eachunit shall have at least two (2) private residentrooms provided with a separate roomequipped with a toilet and handwashing sinkto serve the isolation room only. III

(40) Each resident shall have a wardrobe,locker or closet. A clothes rod and shelf shallbe provided. III

(41) No room shall be occupied by more thanfour (4) beds. III

(42) No resident shall be housed in a room inwhich the outside grade line is more thanthree feet (3') above the floor level on thewindow side of the resident room for a dis-tance of at least fifteen feet (15') from theoutside wall of the resident room. The resi-dent rooms shall be outside rooms with min-imum window sizes as follows:

1-Bed 10 square feet2-Bed 16 square feet3-Bed 24 square feet4-Bed 32 square feet

These areas are for total window size includ-ing frames. III

(43) Each resident, without entering the gen-eral corridor area, shall have access to a toi-let room. III

(44) One (1) toilet room shall serve no morethan six (6) beds and no more than two (2)resident rooms. II/III

(45) The toilet room shall contain a watercloset and a lavatory. II


Secretary of State


(46) If each resident room contains a hand-washing sink, the may omit the handwashingsink from a toilet room that serves adjacentresident rooms. When a handwashing sink islocated within the same room as the toilet,the minimum area of a room shall be thirty(30) square feet. If the room contains only atoilet, the minimum area of the room shall beeighteen (18) square feet. III

(47) Each nursing unit shall have a centrallylocated nurses’ work station with a workcounter and storage space for charts. Theentire counter shall have a four foot (4') dis-tance between the wall located behind thecounter and the edge of the counter nearestthe wall. III

(48) Facilities shall provide a medicine prepa-ration room next to each nurses’ station thathas at least sixty (60) square feet of useablefloor space. Facilities shall provide a speciallocked medication cabinet for storage of theClass II medications inside the locked medi-cation cabinet. If the outer cabinets are notlocked, the facility must provide a closer andhardware that cannot be left unlocked on thedoor to the medicine room. A facility is alsorequired to have the following in the medicineroom: a work counter, handwashing sink,under cabinet storage, a medicine refrigera-tor, adequate lighting and provisions forproper temperature control. II/III

(49) Each nursing unit shall have a clean util-ity room accessible directly from the nursingunit corridor and near enough to the nurses’station to facilitate control by the nurses. Thefloor and walls shall have impervious sur-faces. The facility shall provide this roomwith adequate lighting and heating, a hand-washing sink and at least one (1) locking cab-inet. II/III

(50) Each nursing unit shall have a dirty util-ity room which is accessible directly fromthe nursing unit corridor. The floor shall havean impervious surface and the walls shallhave impervious surfaces to a minimumheight of five feet (5') above the floor. Theroom shall be provided with adequate lightingand heating, a double sink, clinic sink and atleast one (1) locking cabinet. III

(51) Each nursing unit shall contain one (1)training or handicapped toilet per sex, eachwith a floor area of at least five feet by sixfeet (5' × 6'). This toilet may be located inthe central bath. III

(52) Each nursing unit shall have a separatebathroom for each sex. II

(53) Tubs shall be institutional-type, freestanding with a minimum of three feet (3')clearance from the wall on each side and fourfeet (4') at the end. The shower shall be aminimum of four feet (4') wide and of amplelength for a wheelchair resident. Thirty-inchby sixty-inch (30" × 60") Americans withDisability Act (ADA)-approved showers willbe accepted. The facility may replacerequired institutional-type tub(s) withwhirlpool tubs or other types of bathing fix-tures. III

(54) The aggregate number of tubs or show-ers or both shall not be less than one for eachfifteen (1:15) beds on each floor. II/III

(55) The facility shall provide a locked cabi-net in or near each bathroom for the storageof cleaning supplies. III

(56) Centralized bathing facilities shall havefixed partitions or fire-resistant curtains toprovide a private compartment for each watercloset, bathtub and shower. Curtains or doorsshall be installed on access openings. III

(57) Clean linen storage with adequate shelv-ing is required in each nursing unit. III

(58) Each nursing unit must have a stretcherand wheelchair parking area. III

(59) Equipment and supply storage isrequired in each nursing unit. III

(60) Required corridors shall be at least eightfeet (8') wide and shall be wider at elevatorsand other points of traffic concentration. Nopart of the area of any required corridor oraisle shall be counted as part of the requiredarea of any space adjacent to the corridor oraisle. II/III

(61) The width of stairways shall not be lessthan three feet eight inches (3' 8"). The widthshall be measured between handrails wherehandrails project more than three and one-half inches (3 1/2"). II/III

(62) Doors from sleeping and treatment areasthrough which residents will pass shall be atleast forty-four inches (44") wide. Doors tocentralized toilets, bathrooms, hair caresalons and small day rooms shall be at leastthirty-six inches (36") wide. Doors to indi-vidual toilets adjacent to resident rooms shallbe at least thirty-two inches (32") wide. II

(63) Exit doors shall swing outward. Doors torooms shall swing into the rooms they serve.Doors to small toilet rooms may swing out-

ward into the next room and, if they swinginward, they shall be equipped for emergencyaccess. No doors shall swing into requiredcorridors or aisles except doors to janitors’closets, linen closets or doors to similar smallspaces that are open only temporarily. II

(64) Ceilings shall be at least eight feet (8').Ceilings in corridors, storage rooms, toiletrooms and other minor rooms shall not beless than seven feet six inches (7' 6"). Sus-pended tracks, rails and pipes located in thenormal traffic path shall be at least six feeteight inches (6' 8") above the floor. III

(65) Drinking fountains shall be located in ornear the lobby and recreation area and in eachnursing unit. The fountain shall be accessibleto residents in wheelchairs. III

(66) Facilities with plans approved on orbefore December 31, 1998, shall complywith the American National Standards Inst-itute (ANSI) publication A117.1, 1971, Mak-ing Buildings and Facilities Accessible to, andUseable by, the Physically Handicapped. Allnew facilities whose plans were submitted tothe division on or after January 1, 1999, shallcomply with ANSI A117.1, 1992, MakingBuildings and Facilities Accessible to, andUseable by, the Physically Handicapped,incorporated by reference in this rule. III

(67) Handrails shall be provided on bothsides of all corridors and aisles used by resi-dents. Corridor handrails shall have endsreturn to the wall. III

(68) All stairways shall have handrails onboth sides. II

(69) Facilities shall provide grab bars orhandrails, secured in proper positions tofacilitate the bodily movements of residents,next to all bathtubs, within all showers and onat least one (1) side of all toilets. II

(70) Lavatories shall be positioned to beaccessible to wheelchair residents and shallnot have cabinets underneath or any otherunnecessary obstruction to the maneuverabil-ity of wheelchairs. III

(71) The facility shall provide mirrors in eachresident’s room or adjoining toilet room.Mirrors shall be at least three feet (3') highwith the bottom edge located no more thanthree feet four inches (3' 4") above the flooror the facility may use framed tilting mir-ror(s). III



(72) Facilities shall provide fire-resistantdivider curtains attached to the ceiling orwalls in all resident rooms other than privateor single bedrooms. A facility shall placethese divider curtains to provide completeprivacy for each bed. III

(73) All new facilities and additions to allareas of existing facilities which undergomajor remodeling, shall be of sufficientstrength in all their parts to resist all stressesimposed by dead loads, live loads and lateralor uplift forces such as wind, without exceed-ing, in any of the structural materials, theallowable working stresses established forthese materials by generally accepted goodengineering practice. II

(74) The following unit live loads shall be theminimum distributed live loads acceptable forthe occupancies listed:

(A) Facility bedrooms and all adjoiningservice rooms which compose a typical nurs-ing unit (except solariums and corridors)—forty pounds per square foot (40 psf); II

(B) Solariums, corridors in nursing unitsand all corridors above the first floor, exami-nation and treatment rooms, laboratories, toi-let rooms and locker rooms—sixty (60) psf;II

(C) Offices, conference room, library,kitchen, corridors and other public areas onfirst the floor—eighty (80) psf; II

(D) Stairways, laundry, large rooms usedfor dining, recreation or assembly areas andworkshops—one hundred (100) psf; II

(E) Records file room, storage and sup-ply—one hundred twenty-five (125) psf; II

(F) Mechanical equipment room—onehundred fifty (150) psf; II

(G) Roofs (except use increased valuewhere snow and ice may occur)—twenty (20)psf; and II

(H) Wind—as required by local conditionsbut not less than fifteen (15) psf. II

(75) For live loads of one hundred (100)pounds or less per square foot, the design liveload on any member supporting one hundredfifty (150) square feet or more may bereduced at the rate of eight hundredths of apercent (0.08%) per square foot of area sup-ported by the member, except that no reduc-tions shall be made for roof live loads or forlive loads of areas to be occupied as places ofpublic assembly. The reduction shall exceedneither “R”, as determined by the followingformula nor sixty percent (60%): II

D + LR = 100 × _______________

4.33 L

where

R = reduction in percent;D = dead load per square foot of area sup-ported by the member; andL = design live load per square foot of areasupported by the member.

(76) For live loads exceeding one hundred(100) psf, no reduction shall be made, exceptthat the design live loads on columns may bereduced twenty percent (20%). II

(77) Floor areas where partition positions aresubject to change shall be designed to supporta uniformly distributed load of twenty-five(25) psf in addition to all other loads. II

(78) Foundations shall rest on natural solidground or properly compacted fill and shallbe carried to a depth of not less than one foot(1') below the estimated frost line or shallrest on leveled rock or load-bearing pileswhen solid ground is not encountered. Foot-ings, piers and foundation walls shall be ade-quately protected against deterioration fromthe action of groundwater. A facility shalltake reasonable care to establish proper soilbearing values for the building site soil. If thebearing capacity of a soil is in question, arecognized load test may be used to deter-mine the safe bearing value. II

(79) All facilities with plans approvedbetween June 10, 1981 and December 31,1998, shall comply with the 1985 edition ofthe Life Safety Code, and all new facilitieswith plans approved on or after January 1,1999, shall comply with the 1997 edition ofthe Life Safety Code (National Fire ProtectionAssociation NFPA 101), which are incorpo-rated by reference in this rule. No provisionof the 1997 code will be enforced if it is morerestrictive than the code of original planapproval. Facilities may only use the firesafety evaluation system found in the 1995NFPA 101A, incorporated by reference inthis rule, if necessary to justify variance fromthe text of the Life Safety Code and not as aguide for the total design of a new facility. II

(80) Facilities with plans approved on orbefore December 31, 1998, shall complywith the fire-resistant rating of structural ele-ments equal to those required by the 1985Life Safety Code (NFPA 101). Facilities withplans approved on or after January 1, 1999,shall comply with the fire-resistant rating ofstructural elements equal to those required bythe 1997 Life Safety Code (NFPA 101),incorporated by reference in this rule. Allfacilities shall meet the following additionalrequirement: exterior walls less than thirtyfeet (30') from an adjacent building, proper-

ty line or parallel wing shall have a two(2)-hour fire-resistant rating. This distancemay be reduced to fifteen feet (15') if a one(1)-hour rated wall is provided with sprinklerprotection for each window. II

(81) Doors between rooms and the requiredcorridors shall not have louvres or transoms.They shall be one and three-fourths inches (1 3/4") solid-core wood doors or metaldoors with equivalent or greater fire-resis-tance. II

(82) Laundry and trash chutes, where used,shall be of fire-resistant material and installedwith a flushing ring, vent to atmosphere andfloor drain in the basement. Facilities shallprovide an automatic sprinkler at the top ofeach laundry and trash chute. Each floor shallhave a self-closing one and one-half (1 1/2)-hour B-label fire door that shall not open to acorridor. II

(83) Hardware on toilet room doors shall beoperable from both the inside and the outside.II

(84) The floors of toilets, baths, bedpanrooms, pantries, utility rooms and janitors’closets shall have smooth, waterproof sur-faces which are wear-resistant. The floors ofresidents’ rooms shall be smooth and easilycleaned. The floors of kitchens and foodpreparation areas shall be waterproof, grease-proof, smooth and resistant to heavy wear.II/III

(85) The walls of all rooms where food anddrink are prepared, served or stored shallhave a smooth surface with painted or equal-ly washable finish. At the base, they shall bewaterproof and free from spaces which mayharbor ants and roaches. The walls ofkitchens, sculleries, utility rooms, baths,showers, dishwashing rooms, janitors’ closetsand spaces with sinks shall have waterproofpainted, glazed or similar finishes to a pointabove the splash and spray line. III

(86) The ceilings of all sculleries, kitchensand other rooms where food and drink areprepared shall be painted with washablepaint. III

(87) All floor construction shall be complete-ly of noncombustible material regardless ofthe construction type of the building. II

(88) All new floor covering installed and usedin new and existing licensed facilities on or


Secretary of State




after January 1, 1999, shall be Class I in non-sprinklered buildings and Class II in sprin-klered buildings. Class I has a critical radi-ant flux of zero point forty-five (0.45) ormore watts per square centimeter when test-ed according to the 1995 NFPA 253, incor-porated by reference in this rule. Class II hasa critical radiant flux of zero pointtwenty-two (0.22) or more watts per squarecentimeter when tested according to the 1995NFPA 253. Those facilities who installednew floor covering on or before December31, 1998, shall comply with the requirementsof the 1978 edition of the NFPA 253. III

(89) A facility shall furnish and install theheating system, steam system, boilers andventilation to meet all requirements of localand state codes and NFPA regulations. II/III

(90) The building shall be heated by a two(2)-pipe steam system, a forced hot water sys-tem, a forced hot air system, a system of elec-trical heating elements or a combination oftwo (2) or more of these systems. No open

flame space heaters or space heaters receiv-ing combustion air from the heated spaceshall be used. Facilities shall not dependupon fireplaces for required heating. III

(91) The heating system shall be capable ofheating resident-occupied areas to a tempera-ture of eighty degrees Fahrenheit (80°F)(27°C) at the winter design temperature. Inspaces where radiant panel heating is used,facilities may reduce the temperature asrequired to maintain an equivalent comfortlevel. III

(92) The heating system shall have automaticcontrols adequate to provide comfortableconditions in all portions of the building at alltimes. III

(93) Neither the heating nor the ventilatingsystem shall require the circulation of airthrough openings in the required corridorpartitions except for the delivery of ventilat-ing air from corridors through each room

door at a velocity of not more than two hun-dred fifty feet (250') per minute when thedoor is closed and the space under it is notover one inch (1") in height. No louvres shallbe installed in doors in required corridor par-titions. II/III

(94) A facility with plans approved on orafter January 1, 1999, shall install an air-con-ditioning system, or individual room air-con-ditioning units, that meet all the 1996 NFPA90A requirements, incorporated by referencein this rule. The systems or units must becapable of maintaining resident-use areas ateighty-five degrees Fahrenheit (85°F)(29.4°C) at the summer design temperature.Those facilities with plans approved on orbefore December 31, 1998, shall complywith the NFPA 90A requirements as refer-enced in the 1985 Life Safety Code. II/III

(95) Ventilation requirements given in TableI—Ventilation Requirements shall be met.II/III

TABLE I VENTILATION REQUIREMENTSMinimum Air

Pressure Changes of Outdoor Minimum Total Air All Air ExhaustedRelationship to Air Per Hour Changes Per Hour Directly to Air Returned From

Area Designation Adjacent Areas Supplied to Room Supplied to Room Outdoors This Room

Patient Area Corridor P Optional 2 Optional Optional

Physical Therapy N 2 4 Optional OptionalOccupational Therapy N 2 4 Optional OptionalSoiled Work Roomor Soiled Holding N 2 10 Yes No

*Toilet Room N Optional 6 Yes NoBathroom N Optional 6 Yes NoJanitors’ Closet(s) N Optional 6 Yes No

Linen and TrashChute Room N Optional 6 Yes No

Food PreparationCenter E 2 6 Yes Optional

Warewashing Room N Optional 6 Yes NoDietary Day Storage V Optional 2 Yes NoLaundry, General V 2 6 Yes NoSoiled Linen Sortingand Storage N Optional 10 Yes No

P = PositiveN = NegativeE = EqualV = Variable

*Up to 75 cubic feet per minute (cfm) of make-up air for each patient room toilet may be supplied to the corridor and need not be supplieddirectly to the room.

NOTE: In the interest of energy conservation, energy saving design innovations that are not in strict conformance with these requirements,which do not adversely affect direct patient care, will be acceptable if approved in writing by the Division of Aging.

(96) The entire plumbing system and itsmaintenance and operation shall comply withthe requirements of all applicable local andstate codes including the requirements setforth in this rule and with the requirements ofthe 1987 National Plumbing Code, which isincorporated by reference in this rule. II/III

(97) Plumbing fixtures that require hot waterand are resident-accessible shall be suppliedwith water thermostatically controlled to pro-vide a water temperature of between one hun-dred twenty degrees Fahrenheit (120°F)(49°C) and one hundred five degrees Fahren-heit (105°F) (41°C) at the fixture or faucet.I/II

(98) The hot water heating equipment shallhave sufficient capacity to supply five (5) gal-lons (19 l) of water at one hundred twentydegrees Fahrenheit (120°F) (49°C) per hourper bed for nursing home fixtures or faucets,and eight (8) gallons (30 l) of water at onehundred sixty degrees Fahrenheit (160°F)(71.1°C) per hour per bed for kitchen andlaundry. The division may accept lessercapacities following submission of the calcu-lation for the anticipated demand of all fix-tures and equipment in the building. II

(99) Pipes shall be sized to supply water to allfixtures with a minimum pressure of fifteenpounds per square inch (15 psi) (1.02 atmo-spheres) at the top floor fixture during maxi-mum demand periods. All plumbing fixturesexcept water closets, urinals and drinkingfountains shall have both hot and cold watersupplies. III

(100) Facilities shall protect every supplyoutlet or connection to a fixture or applianceagainst back flow as provided by the 1987National Plumbing Code, incorporated byreference in this rule. All faucets to whichhoses can be attached, all spray fittings andall other fittings that could deliver water topoints below overflow lines, shall beequipped with vacuum breakers. II/III

(101) Wherever the usage of fixtures or appli-ances will permit, water supplied to all fix-tures, open tanks and equipment shall beintroduced through a suitable air gap betweenthe water supply and the flood level of thefixture. II

(102) Hot water circulating mains and risersshall be run from the hot storage tank to apoint directly below the highest fixture at theend of each branch main. III

(103) Where the building is higher than three(3) stories, each riser shall be circulated. III

(104) Water pipe sizes shall be equal to orgreater than those prescribed by the 1987National Plumbing Code, incorporated byreference in this rule. III

(105) All fixtures and equipment shall beconnected through traps to soil and waste pip-ing and to the sewer and they shall all beproperly trapped and vented to the outside. II

(106) Courts, yards and drives which do nothave natural drainage from the building shallhave catch basins and drains to low ground,storm-water system or dry wells. III

(107) Facilities where gas-fired equipment isto be installed for use on or after January 1,1999, shall provide and install all gas piping,fittings, tanks and specialties in compliancewith the 1996 NFPA 54, Installation of GasAppliances and Gas Piping, the 1995 NFPA58, Storage and Handling of LiquefiedPetroleum Gases, incorporated by referencein this rule, and the instructions of the gassupplier, except where more strict require-ments are stated. Facilities which installedgas-fired equipment on or before December31, 1998, shall ensure that the installationwas in compliance with the instructions andrequirements outlined in the NFPA 54 andNFPA 58 as referenced in the 1985 Life Safe-ty Code. Where liquefied petroleum gas(LPG) is used, the Missouri Department ofAgriculture also requires compliance with itsrules. II

(108) Where gas piping enters the buildingbelow grade, it shall have an outside vent asfollows: A concrete box, eighteen inches byeighteen inches (18" × 18") with three-inch(3") thick walls, of a height to rest on top ofthe entering gas pipe, and top of the box tocome within six inches (6") of top grade. Thebox shall be filled with coarse gravel. A one-inch (1") upright vent line shall be to one-half(1/2) the depth of the box and extend twelveinches (12") above top grade with a screenedU-vent looking down. The vent line is to beanchored securely to the building wall. II

(109) Facilities shall not install gas-firedequipment in any resident bedroom exceptthat through-wall gas heating units may beused if vented directly to the outside, takecombustion air directly from the outside andprovide a complete separation of the combus-tion system from the atmosphere of the occu-pied area. II

(110) In facilities where oxygen systems areinstalled on or after January 1, 1999, thefacilities shall install the oxygen piping, out-lets, manifolds, manifold rooms and storagerooms in accordance with the requirements ofthe 1993 NFPA 99, incorporated by referencein this rule. In facilities where oxygen sys-tems were installed on or before December31, 1998, facilities shall ensure that theinstallation was in compliance with NFPA 99as required and referenced in the 1985 LifeSafety Code. I/II

(111) The building sanitary drain system maybe cast iron, steel, copper or plastic ifinstalled in compliance with the NationalPlumbing Code, current edition. III

(112) Each main, branch main, riser andbranch to a group of fixtures of the water sys-tem shall be valved. III

(113) To prevent condensation, facilities shallcover cold water mains in occupied spaceswith approved vapor-proof insulation. III

(114) To prevent freezing, facilities shallinsulate all pipes in outside walls. III

(115) Facilities shall test soil, waste, vent anddrain lines according to the requirements ofthe 1987 National Plumbing Code, incorpo-rated by reference in this rule. The facilityshall make certification of these tests avail-able to the division. III

(116) After installation and before the nurs-ing home is operating, the facility shall disin-fect the entire water distribution system, bothhot and cold, and all connecting equipmentby one (1) of the methods described in the1987 National Plumbing Code, incorporatedby reference in this rule. III

(117) Water softeners, if used, shall be con-nected to the hot water supply only or con-nected so that water used for cooking anddrinking is not softened. III

(118) Facilities with plans approved on orafter January 1, 1999, shall ensure that theentire electrical system and its maintenanceand operation comply with the 1996 Nation-al Electrical Code, which is incorporated byreference in this rule. Facilities whose planswere approved on or before December 31,1998, shall comply with the National Electri-cal Code as referenced in the 1985 Life Safe-ty Code. II/III


Secretary of State


(119) Facilities shall adequately light alloccupied areas as required by the duties per-formed in that space. II/III

(120) Residents’ bedrooms shall have a mini-mum general illumination of ten (10) foot-candles, a night-light and a resident’s readinglight. The outlets for general illumination andnight-lights shall be switched at the door. III

(121) Each single-bed resident room shallhave at least two (2) duplex receptacles. Allmulti-bed resident rooms shall have at leastone (1) duplex receptacle at the head of eachbed plus one (1) additional duplex receptacle.Facilities shall not place duplex receptacles ina manner to cause an electrical shock hazard.III

(122) Facilities shall furnish lighting fixturesof a type suitable for the space for all lightingoutlets. III

(123) If ceiling lights are used in residents’rooms, they shall be of a type which are shad-ed or globed to minimize glare. III

(124) Facilities shall provide an electrically-powered nurses’ call system with indicatorlights at the corridor entrance of each bed-room. Audible signals and indicating panelsshall be located in each nurses’ station andutility room. Facilities shall provide signalbuttons at the head of each resident bed, ineach toilet room and in each bathroom. III

(125) Facilities shall provide night-lights inhallways, individual toilet rooms, stairwaysand resident rooms or adjacent toilet rooms.II

(126) A qualified electrician shall test andcertify the entire electrical system as being incompliance with the 1996 National ElectricalCode, incorporated by reference in this rule.In facilities whose plans were approved on orbefore December 31, 1998, the electricianshall test the system according to the stan-dards of the National Electrical Code as ref-erenced in the 1985 Life Safety Code. Facil-ities shall make this test certification availableto the division. III

(127) Facilities shall provide a complete,electrically-operated door alarm system thatis audible in the nurses’ station for all resi-dent-accessible exterior doors. III

(128) A facility shall have emergency light-ing for exits, stairs, corridors and nurses’ sta-tions. Facilities may provide this emergencylighting using an emergency generator or bat-

tery-operated lights rated at least one andone-half (1 1/2) hours. In facilities withplans approved on or after January 1, 1999,an emergency generator shall supply emer-gency power to life support systems asrequired by the 1993 NFPA 99, Health CareFacilities, incorporated by reference in thisrule. In facilities where plans were approvedon or before December 31, 1998, the electri-cal system shall comply to the standards ofthe National Electrical Code as referenced inthe 1985 Life Safety Code. III

(129) The elevator installations shall complywith all local and state codes, AmericanStandards Association Specification A17.1,1993 Safety Code for Elevators and Escala-tors, the 1996 National Electrical Code,incorporated by reference in this rule, and theminimum general standards as set forth inthis rule. In facilities whose plans wereapproved on or before December 31, 1998,the elevators shall comply with applicablelocal and state codes and the requirements setforth in the ASAS A17.1, Safety Code forElevators and Escalators, and the NationalElectrical Code as referenced in the 1985 LifeSafety Code. II

(130) Any facility with residents on one (1)or more floors above the first floor shall haveat least one (1) hydraulic or electric motordriven elevator. Facilities with a bed capacityfrom sixty-one to two hundred (61–200)above the first floor shall not have less thantwo (2) elevators. II

(131) Facilities with a bed capacity of fromtwo hundred to three hundred fifty (200—350) above the first floor shall have not lessthan three (3) elevators—two (2) passengerand one (1) service. II

(132) Inside cab dimensions of elevators shallbe not less than five feet four inches by eightfeet (5' 4" × 8') with a capacity of threethousand five hundred pounds (3,500 lbs.).Cab and shaft doors shall have no less thanthree feet ten inches (3' 10") clear opening.Elevators for which operators will not beemployed shall have automatic push-buttoncontrols, signal controls or dual controls foruse with or without the operator. Where two(2) push-button elevators are located togetherand where one (1) elevator serves more thanthree (3) floors and basement, they shall havecollective or signal control. III

(133) Facilities with plans approved on orafter January 1, 1999, shall have overspeedtests conducted on all elevator machines.Elevators will be tested for speed and load,

with and without loads, in both directions ascovered by the 1993 Safety Code for Eleva-tors and Escalators, incorporated by refer-ence in this rule. Facilities whose plans wereapproved on or before December 31, 1998,shall conduct overspeed tests in accordancewith applicable local and state codes and therequirements set forth in the ASAS A17.1,Safety Code for Elevators and Escalators, asreferenced in the 1985 Life Safety Code.Facilities shall make this test certificationavailable to the division. III

AUTHORITY: section 198.009, RSMo Supp.1998.* This rule originally filed as 13 CSR15-14.012. Original rule filed July 13, 1983,effective Oct. 13, 1983. Amended: Filed Aug.1, 1988, effective Nov. 11, 1988. Amended:Filed May 11, 1998, effective Dec. 30, 1998.Emergency amendment filed May 12, 1999,effective May 22, 1999, expired Feb. 24,2000. Amended: Filed July 13, 1999, effec-tive Jan. 30, 2000. Moved to 19 CSR 30-85.012, effective Aug. 28, 2001.

*Original authority: 198.009, RSMo 1979, amended1993, 1995.

19 CSR 30-85.022 Fire Safety Standardsfor New and Existing Intermediate Careand Skilled Nursing Facilities

PURPOSE: This rule establishes fire-safetyrequirements for new and existing intermedi-ate care and skilled nursing facilities.


PUBLISHER’S NOTE: All rules relating tolong-term care facilities licensed by the Divi-sion of Aging are followed by a RomanNumeral notation which refers to the class(either class I, II or III) of standard as desig-nated in section 198.085.1, RSMo 1994.

(1) Definitions. For the purpose of this rule,the following definitions shall apply:

(A) Accessible spaces—shall include allrooms, halls, storage areas, basements,attics, lofts, closets, elevator shafts, enclosed



stairways, dumbwaiter shafts, and chutes;(B) Area of refuge—a space located in or

immediately adjacent to a path of travel lead-ing to an exit that is protected from theeffects of fire, either by means of separationfrom other spaces in the same building or itslocation, permitting a delay in evacuation. Anarea of refuge may be temporarily used as astaging area that provides some relative safe-ty to its occupants while potential emergen-cies are assessed, decisions are made, and ifapplicable, evacuation has begun; and

(C) Major renovation—shall include thefollowing:

1. Addition of any room(s), accessibleby residents, that either exceeds fifty percent(50%) of the total square footage of the facil-ity or exceeds four thousand five hundred(4,500) square feet; or

2. Repairs, remodeling, or renovationsthat involve more than fifty percent (50%) ofthe building; or

3. Repairs, remodeling, or renovationsthat involve more than four thousand fivehundred (4,500) square feet of a smoke sec-tion.

4. If the addition is separated by two (2)-hour fire-resistant construction, only theaddition portion shall meet the requirementsfor an NFPA 13, 1999 edition, sprinkler sys-tem, unless the facility is otherwise requiredto meet NFPA 13, 1999 edition.

(2) General Requirements.(A) All National Fire Protection Associa-

tion (NFPA) codes and standards cited in thisrule: NFPA 10, Standard for Portable FireExtinguishers, 1998 edition; NFPA 13, Stan-dard for the Installation of Sprinkler Systems,1999 edition; NFPA 96, Standard for Venti-lation Control and Fire Protection of Com-mercial Cooking Operations, 1998 edition;NFPA 99, Standard for Health Care Facili-ties, 1999 edition; NFPA 101, The Life Safe-ty Code, 2000 edition; NFPA 72, NationalFire Alarm Code, 1999 edition; NFPA 25,Standard for the Inspection, Testing, andMaintenance of Water-Based Fire ProtectionSystems, 1998 edition; NFPA 253, StandardMethod of Test of Surface Burning Charac-teristics of Building Materials, 2000 edition;NFPA 701, Standard Methods of Fire Testsfor Flame Propagation of Textiles and Films,1999 edition; NFPA 211, Chimneys, Fire-places, Vents and Solid Fuel-Burning Appli-ances, 2000 edition; and NFPA 101A, Guideto Alternative Approaches to Life Safety,2001 edition, are incorporated by reference inthis rule and available for purchase from theNational Fire Protection Agency, 1 Battery-march Park, Quincy, MA 02269-9101;www.nfpa.org; by telephone at (617) 770-

3000 or 1-800-344-3555. This rule does notincorporate any subsequent amendments oradditions to the materials listed above.

(B) This rule does not prohibit facilitiesfrom complying with standards set forth innewer editions of the incorporated by refer-ence material listed in subsection (2)(A) ofthis rule if approved by the department.

(C) The department shall have the right ofinspection of any portion of a building inwhich a licensed facility is located unless theunlicensed portion is separated by two (2)-hour fire-resistant construction. I/II

(D) Facilities shall not use space understairways to store combustible materials. I/II

(E) No section of the building shall presenta fire hazard. I/II

(F) All facilities shall notify the depart-ment immediately after the emergency isaddressed if there is a fire in the facility orpremises and shall submit a complete writtenfire report to the department within seven (7)days of the fire, regardless of the size of thefire or the loss involved. II/III

(G) Following the discovery of any fire, thefacility shall monitor the area and/or thesource of the fire for a twenty-four (24)-hourperiod. This monitoring shall include, at aminimum, hourly visual checks of the area.These hourly visual checks shall be docu-mented. I/II

(H) All electrical appliances shall beUnderwriters’ Laboratories (UL) or FactoryMutual (FM)-approved, shall be maintainedin good repair, and no appliances or electri-cal equipment shall be used which emitfumes or which could in any other way pre-sent a hazard to the residents. I/II

(3) All openings that could permit the passageof fire, smoke, or both, between floors shallbe fire-stopped with a suitable noncom-bustible material. II/III

(4) Hazardous areas shall be separated byconstruction of at least one (1)-hour fire-resistant construction. Hazardous areas maybe protected by an automatic sprinkler systemin lieu of a one (1)-hour rated fire-resistantconstruction. When the sprinkler option ischosen, the areas shall be separated fromother spaces by smoke-resistant partitions anddoors. The doors shall be self-closing orautomatic closing. II

(5) The department prohibits the storage ofany unnecessary combustible materials in anypart of a building in which a licensed facilityis located. No section of the building shallpresent a fire hazard. I/II

(6) Oxygen storage shall be in accordancewith NFPA 99, 1999 edition. Facilities shall

use permanent racks or fasteners to preventaccidental damage or dislocation of oxygencylinders. Safety caps shall remain intactexcept where a cylinder is in actual use orwhere the regulator has been attached and thecylinder is ready for use. Individual oxygencylinders in use or with an attached regulatorshall be supported by cylinder collars or bystable cylinder carts. II/III

(7) Each nursing unit may maintain only one(1) emergency-use oxygen tank in a readilyaccessible unit area. II

(8) Fire Extinguishers.(A) Fire extinguishers shall be provided at

a minimum of one (1) per floor, so that thereis no more than seventy-five feet (75') traveldistance from any point on that floor to anextinguisher. I/II

(B) All new or replacement portable fireextinguishers shall be ABC-rated extinguish-ers, in accordance with the provisions ofNFPA 10, 1998 edition. A K-rated extin-guisher or its equivalent shall be used in lieuof an ABC-rated extinguisher in the kitchencooking areas. II

(C) Fire extinguishers shall have a rating ofat least—

1. Ten pounds (10 lbs.), ABC-rated orthe equivalent, in or within fifteen feet (15')of hazardous areas as defined in 19 CSR 30-83.010; II and

2. Five pounds (5 lbs.), ABC-rated orthe equivalent, in other areas. II

(D) All fire extinguishers shall bear thelabel of the Underwriters’ Laboratories (UL)or the Factory Mutual (FM) Laboratories andshall be installed and maintained in accor-dance with NFPA 10, 1998 edition. Thisincludes the documentation and dating of amonthly pressure check. II/III

(9) Facilities shall provide every cookingrange with a range hood and approved rangehood extinguishing system installed, tested,and maintained in accordance with NFPA 96,1998 edition. The range hood and its extin-guishing system shall be certified at leasttwice annually in accordance with NFPA 96,1998 edition. II/III

(10) Complete Fire Alarm Systems.(A) Facilities shall have a complete fire

alarm system installed in accordance withNFPA 101, Section 18.3.4, 2000 edition.The complete fire alarm system shall auto-matically transmit to the fire department, dis-patching agency, or central monitoring com-pany. The complete fire alarm system shallinclude visual signals and audible alarms thatcan be heard throughout the building and a


Secretary of State


main panel that interconnects all alarm-acti-vating devices and audible signals in accor-dance with NFPA 72, 1999 edition. At aminimum, the complete fire alarm systemshall consist of manual pull stations at or neareach attendant’s station and each requiredexit and smoke detectors interconnected tothe complete fire alarm system. Specific min-imum requirements relating to the intercon-nected smoke detectors are found in subsec-tions (10)(I) and (10)(J) of this rule. I/II

(B) All facilities shall test and maintain thecomplete fire alarm system in accordancewith NFPA 72, 1999 edition. I/II

(C) All facilities shall have inspections andwritten certifications of the complete firealarm system completed by an approved qual-ified service representative in accordancewith NFPA 72, 1999 edition, at least annual-ly. I/II

(D) The complete fire alarm system shallbe activated by all of the following: sprinklersystem flow alarm, smoke detectors, heatdetectors, manual pull stations, and activationof the range hood extinguishment system.II/III

(E) Facilities shall test by activating thecomplete fire alarm system at least once amonth. II/III

(F) Facilities shall maintain a record of thecomplete fire alarm system tests, inspectionsand certifications required by subsections(10)(B), (10)(C), and (10)(E) of this rule. III

(G) Upon discovery of a fault with thecomplete fire alarm system, the facility shallpromptly correct the fault. I/II

(H) When a complete fire alarm system isto be out-of-service for more than four (4)hours in a twenty-four (24)-hour period, thefacility shall immediately notify the depart-ment and the local fire authority and imple-ment an approved fire watch in accordancewith NFPA 101, 2000 edition, until the firealarm system has returned to full service. I/II

(I) Facilities that have a sprinkler system inaccordance with NFPA 13, 1999 edition,shall have smoke detectors interconnected tothe complete fire alarm system in all corri-dors and spaces open to the corridor. Smokedetectors shall be no more than thirty feet(30') apart with no point on the ceiling morethan twenty-one feet (21') from a smokedetector. I/II

(J) Facilities that do not have a sprinklersystem in accordance with NFPA 13, 1999edition, shall have smoke detectors intercon-nected to the complete fire alarm system inall accessible spaces within the facility asrequired by NFPA 72, 1999 edition. Smokedetectors shall be no more than thirty feet(30') apart with no point on the ceiling morethan twenty-one feet (21') from a smoke

detector. Smoke detectors shall not beinstalled in areas where environmental influ-ences may cause nuisance alarms. Such areasinclude, but are not limited to, kitchens, laun-dries, bathrooms, mechanical air handlingrooms, and attic spaces. In these areas, heatdetectors interconnected to the complete firealarm system shall be installed. Bathroomsnot exceeding fifty-five (55) square feet andclothes closets, linen closets, and pantries notexceeding twenty-four (24) square feet areexempt from having any detection device ifthe wall and ceilings are surfaced with limit-ed-combustible or noncombustible materialas defined in NFPA 101, 2000 edition. Con-cealed spaces of noncombustible or limited-combustible construction are not required tohave detection devices. These spaces mayhave limited access but cannot be occupied orused for storage. I/II

(11) Sprinkler System.(A) All facilities shall have inspections and

written certifications of the sprinkler systemcompleted by an approved qualified servicerepresentative in accordance with NFPA 25,1998 edition. The inspections shall be inaccordance with the provisions of NFPA 25,1998 edition, with certification at least annu-ally by a qualified service representative. I/II

(B) All facilities licensed prior to August28, 2007, that do not have a complete sprin-kler system in accordance with NFPA 13shall have until December 31, 2012, to com-ply with NFPA 13, 1999 edition. I/II Excep-tions shall be granted to this requirement ifthe following conditions are met:

1. The water supply for an NFPA 13sprinkler system is unavailable, and thedepartment receives a statement in writingfrom a licensed engineer or a certified sprin-kler representative documenting the unavail-ability of water; or

2. The facility meets Chapter 33 ofNFPA 101, Life Safety Code, 2000 edition,and the evacuation capability of residentsmeets the standards in NFPA 101A, Guide toAlternative Approaches to Life Safety, 2001edition. I/II

(C) Facilities that have sprinkler systemsinstalled prior to August 28, 2007, shallinspect, maintain, and test these systems inaccordance with NFPA 13, 1999 edition, andNFPA 25, 1998 edition. I/II

(D) Facilities licensed on or after August28, 2007, and any facility performing majorrenovations to the facility, shall have a com-plete sprinkler system installed in accordancewith NFPA 13, 1999 edition. I/II

(E) When a sprinkler system is to be out-of-service for more than four (4) hours in atwenty-four (24)-hour period, the facility

shall immediately notify the department andthe local fire authority and implement anapproved fire watch in accordance withNFPA 101, 2000 edition, until the sprinklersystem has returned to full service. I/II

(12) All facilities shall submit, by July 1,2008, a plan for compliance to the state firemarshal showing how the facility meets therequirements of sections (10), (11), (28), and(29) of this rule. If the facility’s plan forcompliance does not meet the requirementsof sections (10), (11), (28), and (29) of thisrule, the facility shall provide the state firemarshal with a written plan to include, at aminimum, an explanation of how the require-ments of sections (10), (11), (28), and (29)will be met, when they will be met, and con-tact information in the event the plan does notevidence compliance with these require-ments. II

(A) To qualify for a sprinkler systemexception, the facility shall present evidenceto the state fire marshal in writing from a cer-tified sprinkler system representative orlicensed engineer that the facility is unable toinstall an approved National Fire ProtectionAssociation 13 system due to the unavailabil-ity of water supply requirements associatedwith this system or the facility meets the safe-ty requirements of Chapter 33 of existing res-idential board and care occupancies of NFPA101, Life Safety Code. II

(13) Each floor of an existing licensed facili-ty shall have at least two (2) unobstructedexits remote from each other. One (1) of therequired exits in an existing multi-story facil-ity must be an outside stairway or an enclosedstair that is separated by one (1)-hour con-struction from each floor and has an exitleading directly outside at grade level. One(1) exit may lead to a lobby with exit facili-ties to the ground level outside instead ofleading directly to the outside. The lobbyshall have at least a one (1)-hour fire-ratedseparation from the remainder of the exitingfloor. I/II

(14) If facilities have outside stairways, theyshall be substantially constructed to supportresidents during evacuation. These stairwaysshall be protected or cleared of ice and snow.Fire escapes added to existing buildings,whether interior or exterior, shall have atleast a minimum thirty-six-inch (36") width,eight-inch (8") maximum risers, a nine-inch(9") minimum tread, no winders, a maximumheight between landings of twelve feet (12'),minimum landing dimensions of forty-fourinches (44"), landings at each exit door, andhandrails on both sides. Stairways shall be ofsturdy construction using at least two-inch

CODE OF STATE REGULATIONS 11ROBIN CARNAHAN (4/30/09)*Secretary of State


(2") lumber and shall be continuous toground level. Exit(s) to fire escapes shall beat least thirty-six inches (36") wide, and thefire-escape door shall swing outward. Alltreads and risers shall be of the same heightand width throughout the entire stairway, notincluding landings. II/III

(15) Facilities with three (3) or more floorsshall comply with the provisions of Chapter320, RSMo, which requires that outsidestairways be constructed of iron or steel. II

(16) Door locks shall be of a type that can beopened from the inside by turning the knob oroperating a simple device that will release thelock, or shall meet the requirements of Sec-tion 19.2 of NFPA 101, 2000 edition. Onlyone (1) lock will be permitted on any one (1)door. I/II

(17) All exit doors in existing licensed facili-ties shall be at least thirty inches (30") wide.II

(18) All exit doors in new facilities shall be atleast forty-four inches (44") wide. II

(19) In all facilities, all exit doors andvestibule doors shall swing outward in thedirection of exit travel. II

(20) In all existing licensed facilities, all hor-izontal exit doors in fire walls and all doorsin smoke barrier partitions may swing ineither direction. These doors normally maybe open, but shall be automatically self-clos-ing upon activation of the fire alarm system.They shall be capable of being manuallyreleased to self-closing action. II/III

(21) Facilities shall maintain corridors to befree of obstruction or equipment or suppliesnot in use. Doors to resident rooms shall notswing into the corridor. II/III

(22) Facilities shall place signs bearing theword EXIT in plain, legible block letters ateach required exit, except at doors directlyfrom rooms to exit corridors or passageways.II

(23) Wherever necessary, the facility shallplace additional signs in corridors and pas-sageways to indicate the exit’s direction. Let-ters on these signs shall be at least six inches(6") high and principle strokes three-fourthsinch (3/4") wide, except that the letters ofinternally illuminated exit signs may be notless than four inches (4") high. III

(24) Facilities shall maintain all exit anddirectional signs to be clearly legible andelectrically illuminated at all times by accept-able means such as emergency lighting whenlighting fails. II

(25) Facilities shall have emergency lightingof sufficient intensity to provide for the safe-ty of residents and other people using anyexit, stairway, and corridor. The lighting shallbe supplied by an emergency service, anautomatic emergency generator or batterylighting system. This emergency lighting sys-tem shall be equipped with an automatictransfer switch. In an existing licensed facili-ty, battery lights, if used, shall be wet cellunits or other rechargeable-type batteries thatshall be UL-approved and capable of operat-ing the light for at least one and one-half (1½) hours. Battery-operated emergency light-ing shall be tested for at least thirty (30) sec-onds every thirty (30) days, and an annualfunction test shall be conducted for the fulloperational duration of one and one-half (1½) hours. Records of these tests shall bedocumented and maintained for review. II

(26) If existing licensed facilities have laun-dry chutes, dumbwaiter shafts, or other simi-lar vertical shafts, they shall have a fire resis-tance rating of at least one (1) hour if servingthree (3) or fewer stories. Enclosures servingfour (4) or more stories shall have at least atwo (2)-hour fire-rated enclosure. Thesechute or shaft doors shall be self-closing orshall have any other approved device that willguarantee separation between floors. II

(27) Existing licensed multistoried facilitiesshall provide a smoke separation barrierbetween the basement and the first floor andthe floors of resident-use areas. At a mini-mum, this barrier shall consist of one-halfinch (1/2") gypsum board, plaster, or equiv-alent. There shall be a one and three-fourthsinch (1 3/4") thick solid-core wood door, orequivalent, at the top or bottom of the stairs.If the door is glazed, it shall be glazed withwired glass. II

(28) Each floor accessed by residents shall bedivided into at least two (2) smoke sectionswith each section not exceeding one hundredfifty feet (150') in length or width. If thefloor’s dimensions do not exceed seventy-fivefeet (75') in length or width, a division of thethe floor into two (2) smoke sections will notbe required. II

(29) Each smoke section shall be separated byone (1)-hour fire-rated walls that are continu-ous from outside wall-to-outside wall and

from floor-to-floor or floor-to-roof deck. Alldoors in this wall shall be at least twenty(20)-minute fire rated or its equivalent, self-closing, and may be held open only if thedoor closes automatically upon activation ofthe fire alarm system. II

(30) Existing licensed facilities shall haveattached self-closing devices on all doors pro-viding separation between floors. If the doorsare to be held open, they shall have electro-magnetic hold-open devices that are intercon-nected with either a smoke alarm or withother smoke-sensitive fire extinguishment oralarm systems in the building. II/III

(31) Smoking shall be permitted only in des-ignated areas. Areas where smoking is per-mitted shall be directly supervised unless theresident has been assessed by the facility anddetermined capable of smoking unassisted.At least annually, the facility shall reassessthose residents the facility has determined tobe capable of smoking unsupervised and shallalso reassess such resident when changes inhis or her condition indicate the resident mayno longer be capable of smoking withoutsupervision. The facility shall document thisassessment in the resident’s medical record.II

(32) Designated smoking areas shall haveashtrays of noncombustible material and ofsafe design. The contents of ashtrays shall bedisposed of properly in receptacles made ofnoncombustible material. II/III

(33) Fire Drills and Evacuation Plans.(A) All facilities shall develop a written

plan for fire drills and other emergencies andevacuation and shall request consultation andassistance annually from a local fire unit. Ifthe consultation cannot be obtained, the facil-ity shall inform the state fire marshal imme-diately in writing and request assistance inreview of the plan. II/III

(B) The plan shall include, but is not lim-ited to—

1. A phased response ranging from relo-cation of residents within the facility to relo-cation to an area of refuge, if applicable, tototal evacuation. This phased response part ofthe plan shall be consistent with the directionof the local fire unit or state fire marshal andshall be appropriate for the fire or emergen-cy;

2. Written instructions for evacuation ofeach floor including evacuation to areas ofrefuge, if applicable, and floor plan showingthe location of exits, fire alarm pull stations,fire extinguishers, and any areas of refuge;

12 CODE OF STATE REGULATIONS (4/30/09)* ROBIN CARNAHAN

Secretary of State


3. Evacuating residents, if necessary,from an area of refuge to a point of safetyoutside the building;

4. The location of any additional watersources on the property such as cisterns,wells, lagoons, ponds, or creeks;

5. Procedures for the safety and comfortof residents evacuated;

6. Staffing assignments;7. Instructions for staff to call the fire

department or other outside emergency ser-vices;

8. Instructions for staff to call alterna-tive resource(s) for housing residents, if nec-essary;

9. Administrative staff responsibilities;and

10. Designation of a staff member to beresponsible for accounting for all residents’whereabouts. II/III

(C) The written plan shall be accessible atall times and an evacuation diagram shall beposted on each floor in a conspicuous placeso that employees and residents can becomefamiliar with the plan and routes to safety.II/III

(D) A minimum of twelve (12) fire drillsshall be conducted annually with at least one(1) every three (3) months on each shift. Atleast four (4) of the required fire drills mustbe unannounced to residents and staff,excluding staff who are assigned to evaluatestaff and resident response to the fire drill.The fire drills shall include a simulated resi-dent evacuation that involves the local firedepartment or emergency service at leastonce a year. II/III

(E) The fire alarm shall be activated duringall fire drills unless the drill is conductedbetween 9 p.m. and 6 a.m., when a facility-generated predetermined message is accept-able in lieu of the audible and visual compo-nents of the fire alarm. II/III

(F) The facility shall keep a record of allfire drills including the simulated residentevacuation. The record shall include the time,date, personnel participating, length of timeto complete the fire drill, and a narrativenotation of any special problems. III

(34) Fire Safety Training Requirements.(A) The facility shall ensure that fire safe-

ty training is provided to all employees: 1. During employee orientation; 2. At least every six (6) months; and3. When training needs are identified as

a result of fire drill evaluations. II/III(B) The training shall include, but is not

limited to, the following: 1. Prevention of fire ignition, detection

of fire, and control of fire development; 2. Confinement of the effects of fire;

3. Procedures for moving residents to anarea of refuge, if applicable;

4. Use of alarms;5. Transmission of alarms to the fire

department;6. Response to alarms;7. Isolation of fire;8. Evacuation of the immediate area and

building; 9. Preparation of floors and facility for

evacuation; and10. Use of the evacuation plan required

by section (33) of this rule. II/III

(35) The use of wood- or gas-burning fire-places will be permitted only if the fireplacesare built of firebrick or metal, enclosed bymasonry, and have metal or tempered glassscreens. The chimneys shall be of masonryconstruction with flue linings that have atleast eight inches (8") of masonry separatingthe flue lining and the fireplace from anycombustible material. All fireplaces shall beinstalled, operated, and maintained in a safemanner. Fireplaces not in compliance withthese requirements may be provided if theyare for decorative purposes only or if they areequipped with decorative-type electric logs orother electric heaters which bear the UL labeland are constructed of electrical componentscomplying with and installed in compliancewith the National Electrical Code, incorpo-rated by reference in this rule. Fireplacesmeeting standards set forth in NFPA 211,2000 edition, are considered in compliancewith this rule. II/III

(36) All electric or gas clothes dryers shall bevented to the outside and the lint trap cleanedregularly. II/III

(37) In existing licensed facilities, all walland ceiling surfaces shall be smooth and freeof highly-combustible materials. II/III

(38) All curtains in resident-use areas shall berendered and maintained flame-resistant inaccordance with NFPA 701, 1999 edition.II/III

(39) All new floor covering installed shall beClass I in nonsprinklered buildings and ClassII in sprinklered buildings in accordance withNFPA 253, 2000 edition. II/III

(40) Trash and Rubbish Disposal Require-ments.

(A) Only metal or UL- or Factory Mutual(FM)-approved wastebaskets shall be used forthe collection of trash. II

(B) The facility shall maintain the exteriorpremises in a manner as to provide for firesafety. II

(C) Trash shall be removed from thepremises as often as necessary to prevent firehazards and public health nuisance. II

(D) No trash shall be burned within fiftyfeet (50') of any facility except in an approvedincinerator. I/II

(E) Trash may be burned only in a mason-ry or metal container. The container shall beequipped with a metal cover with openings nolarger than one-half inch (1/2") in size. II/III

(41) Minimum staffing for safety and protec-tive oversight to residents shall be—

(A) In a fire-resistant or sprinklered build-ing—

Time Personnel Residents7 a.m. to 3 p.m. 1 3–10*(Day)

3 p.m. to 11 p.m. 1 3–15*(Evening)

11 p.m. to 7 a.m. 1 3–20*(Night)

*One (1) additional staff person for everyfraction after that; I/II or

(B) In a nonfire-resistant, nonsprinkleredbuilding—

Time Personnel Residents7 a.m. to 3 p.m. 1 3–10*(Day)

3 p.m. to 11 p.m. 1 3–15*(Evening)

11 p.m. to 7 a.m. 1 3–15*(Night)

*One (1) additional staff person for everyfraction after that. I/II

AUTHORITY: sections 198.074 and 198.079,RSMo Supp. 2008.* This rule originally filedas 13 CSR 15-14.022. Original rule filed July13, 1983, effective Oct. 13, 1983. Amended:Filed Sept. 12, 1984, effective Dec. 13, 1984.Amended: Filed Aug. 1, 1988, effective Nov.11, 1988. Amended: Filed May 11, 1998,effective Dec. 30, 1998. Emergency amend-ment filed May 12, 1999, effective May 22,1999, expired Feb. 24, 2000. Amended: FiledJuly 13, 1999, effective Jan. 30, 2000. Movedto 19 CSR 30-85.022, effective Aug. 28,2001. Emergency amendment filed Nov. 24,2008, effective Dec. 4, 2008, expired June 1,2009. Amended: Filed Nov. 24, 2008, effec-tive May 30, 2009.




19 CSR 30-85.032 Physical Plant Require-ments for New and Existing IntermediateCare and Skilled Nursing Facilities

PURPOSE: This rule establishes the require-ments necessary in new and existing interme-diate care and skilled nursing facilities.


AGENCY NOTE: All rules relating to long-term care facilities licensed by the Division ofAging are followed by a Roman Numeralnotation which refers to the class (either classI, II or III) of standard as designated in sec-tion 198.085.1, RSMo.


tion (NFPA) codes and standards cited in thisrule: NFPA 54, National Fuel Code, 1999edition; NFPA 58, Liquefied Petroleum GasCode, 1999 edition; NFPA 70, National Elec-tric Code, 1999 edition; NFPA 99, HealthCare Facilities, 1999 edition; and NFPA 101,The Life Safety Code, 2000 edition, areincorporated by reference in this rule andavailable for purchase from the National FireProtection Agency, 1 Batterymarch Park,Quincy, MA 02269-9101; www.nfpa.org; bytelephone at (617) 770-3000 or 1-800-344-3555. This rule does not incorporate any sub-sequent amendments or additions to the mate-rials listed above.

(B) This rule does not prohibit facilitiesfrom complying with standards set forth innewer editions of the incorporated by refer-ence material listed in subsection (1)(A) ofthis rule where approved by the Departmentof Health and Senior Services (the depart-ment).

(2) The building shall be substantially con-structed and shall be maintained in goodrepair. New facilities shall comply with therequirements in accordance with the provi-sions found in 19 CSR 30-85.012. Existinglicensed facilities shall meet and maintain thefacility’s physical plant in accordance withthe construction standards in effect at the

time of initial licensing, unless there is a spe-cific rule governing the subject cited in thissection or in 19 CSR 30-85.022, except thatthose facilities licensed between 1957 and1965 shall not increase the capacity of anyroom or the total capacity of the facility with-out meeting new construction requirements.Existing licensed facilities with plansapproved after April 8, 1972 and prior to Jan-uary 1, 1999, shall comply as ExistingHealth Care Occupancies with NFPA 101,2000 edition. Facilities whose physical plantrequirement plans are approved on or afterJanuary 1, 1999, shall comply as New HealthCare Occupancies with NFPA 101, 2000 edi-tion. II/III

(3) In an existing facility licensed prior toJuly 1, 1965, the number of persons in anyroom or area used as sleeping quarters shallnot exceed the proportion of one (1) adult foreach sixty (60) square feet. In facilitieslicensed on or after July 1, 1965, adult resi-dent rooms shall be a minimum of eighty (80)square feet per bed in multi-bed residentrooms and one hundred (100) square feet forprivate rooms. This square footage caninclude all useable floor spaces such as clos-ets, entryways, and areas with moveableitems or furniture that do not impact the safe-ty or welfare of the resident, used for resi-dents’ belongings or if related to their care.Only the area of a room with a ceiling heightof at least seven feet (7') can be includedwhen calculating the square footage. II/III

(4) An existing facility licensed prior to July1, 1965 shall not use a private room less thansixty (60) square feet in size as sleeping quar-ters for residents under seventeen (17) yearsof age. In multi-bed resident rooms, the fol-lowing ratios shall apply: thirty (30) squarefeet per bed for beds four feet (4') or less inlength, forty (40) square feet per bed for bedsfour feet through five feet (4'–5') in lengthand sixty (60) square feet per bed for bedsover five feet (5') in length. In facilitieslicensed on or after July 1, 1965, rooms shallbe a minimum of thirty-five (35) square feetper bed for beds four feet (4') or less inlength; forty-five (45) square feet per bed forbeds four feet through five feet (4'–5') inlength; eighty (80) square feet per bed overfive (5) square feet in length in multiple bed-rooms; and one hundred (100) square feet forprivate rooms. II/III

(5) A facility may not house a resident in aroom which has an outside grade of morethan three feet (3') above the floor level onthe window side of the resident’s room for a

distance of at least fifteen feet (15') from theoutside wall of the resident’s room. II/III

(6) Facilities initially licensed after July 1,1965 shall have no more than four (4) bedsper room. II/III

(7) The facility shall provide sleeping quar-ters, separate from resident bedrooms for theadministrator or employees and their familieswho reside there. III

(8) A facility shall conspicuously and unmis-takably identify each room or ward or resi-dent-use area with a number or room namesecurely fastened to, or plainly painted on theentrance of the room or ward. III

(9) Each resident room shall have an outsidewindow with an area equivalent to not lessthan ten percent (10%) of the required floorarea. The facility shall maintain windows sothat they may be readily opened and closed.II/III

(10) Facilities shall ensure that every windowin resident-use areas has shades, curtains ordrapes. III

(11) The facility shall make provisions for aroom(s) which can be used for isolation of aresident(s) with communicable diseases.Facilities licensed after July 1, 1965 andprior to June 11, 1981 shall have at least two(2) private rooms with a toilet room equippedwith toilet and handwashing sink. Rooms des-ignated as isolation rooms may be occupiedby residents provided there is a written agree-ment on file indicating the resident’s willing-ness to relocate without prior notice if theroom is needed for isolation purposes. III

(12) Every facility shall provide a living roomor community room for the sole use of resi-dents. Sufficient chairs and tables shall befurnished. Under no circumstances may theliving room be used as a bedroom. A livingroom must be well-lighted, ventilated, andeasily accessible to residents. II

(13) Facilities shall ensure that gas-burningequipment and appliances are approved bythe American Gas Association and installedin compliance with NFPA 54, 1999 edition.Where liquefied petroleum gas (LPG) isused, facilities shall comply with the rules ofthe Missouri Department of Agriculture andNFPA 58, 1999 edition. Facilities that werecomplying prior to the effective date of thisrule with prior editions of the NFPA 54 andNFPA 58 referenced in this rule shall be per-mitted to continue to comply with the earlier


Secretary of State




editions, as long as there is not an imminentdanger to the health, safety, or welfare of anyresident or a substantial probability that deathor serious physical harm would result asdetermined by department. Gas-fired waterheaters shall be properly vented and all waterheaters shall be equipped with a temperatureand pressure relief valve. II

(14) Oxygen cylinders for medical use shallbe labeled “Oxygen.” All facilities shall haveoxygen systems, oxygen piping, outlets, man-ifold rooms, and storage rooms installed inaccordance with the requirements of theNFPA 99, 1999 edition. I/II

(15) Facilities shall provide adequate storageareas for food, supplies, linen, equipmentand residents’ personal possessions. II/III

(16) Toilet rooms shall be easily accessible,conveniently located, well-lighted and prop-erly ventilated. Doors to toilet rooms whichmay be locked from the inside, shall beequipped with a special lock which may beopened from the outside. II/III

(17) Existing licensed facilities shall provideone (1) toilet for each ten (10) residents orfraction of ten. II/III

(18) The facility shall provide separate toiletfacilities for each sex. Where urinals are pro-vided for men, a facility shall provide one (1)toilet and urinal for each fifteen (15) males orfraction of fifteen. III

(19) Facilities shall provide grab bars on atleast one (1) side of all toilets, in proper posi-tions to facilitate bodily movement of resi-dents. II

(20) Existing licensed facilities shall providehandwashing facilities consisting of a hand-washing sink in each toilet room for each fif-teen (15) residents or fraction of fifteen. Thehandwashing sink may be omitted from a toi-let room which serves adjacent residentrooms if each room contains a handwashingsink. II/III

(21) The facility shall provide one (1) showeror tub for each fifteen (15) residents or frac-tion of fifteen. II/III

(22) Facilities shall have metal grab barssecurely mounted for bathtubs, shower stallsand toilets. The facility shall also providerubber or similar type nonskid mats or stripsin tubs and showers to reduce or prevent slip-ping accidents and hazardous conditions. II

(23) Facilities shall provide fixed partitions orcurtains in bathrooms and toilet areas toensure privacy. III

(24) The facility shall ensure that plumbingfixtures that supply hot water and are acces-sible to the residents, shall be thermostatical-ly controlled so the water temperature at thefixture does not exceed one hundred twentydegrees Fahrenheit (120°F) (49°C). Thewater shall be at a temperature range of onehundred five degrees Fahrenheit to onehundred twenty degrees Fahrenheit(105°F–120°F) (41°C–49°C). I/II

(25) Facilities shall provide adequate spaceand locations for the proper cleansing, disin-fection, sterilization, and storage of nursingsupplies and equipment. This area shall bespecifically designated as a clean utility area.There shall be a separate area designated as adirty utility area, and neither area shall belocated in or open into a kitchen, diningroom, or a bathroom. The facility shall haveutility areas that are easily available to per-sonnel and located conveniently for the nurs-ing station staff. Utility areas shall be well-ventilated and well-lighted. II/III

(26) The facility shall provide either a nurs-ing station or a nurses’ work area on eachfloor of a multistory facility. This area shallhave chart storage space on current residents.Facilities licensed or with plans approved onor after July 1, 1965, shall have a nurses’ sta-tion for every sixty (60) beds. Handwashingfacilities at or near the nurses’ station shall beavailable for physicians, nurses and other per-sonnel attending residents. II/III

(27) The facility shall be equipped with a callsystem that consists of an electrical intercom-munication system, a wireless pager system,a buzzer system, or hand bells for each resi-dent bed, toilet room, and bathroom. The callsystem shall be audible in the attendant’swork area and be in compliance with 19 CSR30-85.012(124). II/III

(28) The heating of the building shall berestricted to steam, hot water, permanentlyinstalled electric heating devices or warm airsystems employing either central heatingplants with installation so as to safeguard theinherent fire hazard or outside wall heaterswith approved installation. Portable heateruse is prohibited. Facilities shall provide ade-quate guards to safeguard residents wherepotential burn hazards exist. I/II

(29) The facility shall heat all resident-acces-sible areas to ensure that the air temperature

is not lower than sixty-eight degrees Fahren-heit (68°F). These areas shall be capable ofbeing heated to not less than eighty degreesFahrenheit (80°F). At all times the reason-able comfort needs of residents shall be met.I/II

(30) The facility shall cool resident-accessi-ble areas when air temperatures exceedeighty-five degrees Fahrenheit (85°F). Theseareas shall be capable of being cooled to atleast seventy-one degrees Fahrenheit (71°F).At all times the reasonable comfort needs ofresidents shall be met. I/II

(31) Electrical Wiring Requirements.(A) Electrical wiring and equipment shall

be installed and maintained in accordancewith the NFPA 70, 1999 edition. Facilitiesthat were complying prior to the effectivedate of this rule with prior editions of theNFPA 70 referenced in this rule shall be per-mitted to continue to comply with the earliereditions, as long as there is not an imminentdanger to the health, safety, or welfare of anyresident or a substantial probability that deathor serious physical harm would result asdetermined by the department. II/III

(B) Every two (2) years, a qualified elec-trician will be required to certify in writingthat the electrical system is being maintainedand operated in accordance with the stan-dards outlined by the NFPA 70, 1999 editionor the earlier NFPA 70 edition with which thefacility was complying prior to the effectivedate of this rule. II/III

(32) Lighting in hallways, bathrooms, recre-ational, dining, and all resident-use areasshall be provided with a minimum intensityof ten (10) footcandles and shall be sufficientto meet the residents’ and staff needs. III

(33) Facilities shall use night-lights in hall-ways, resident rooms, toilet rooms or bath-rooms and on stairways. II

(34) The facility shall ensure that a readinglight is provided for each resident whodesires to read. III

(35) To prevent direct glare to residents’ eyes,facilities shall ensure that lights in resident-use areas have a shade or dome. III

(36) If elevators are used, their installationand maintenance shall comply with all localand state codes and NFPA 70, 1999 edition.II

(37) If extension cords are used, they must beUnderwriters Laboratories (UL)-approved or

shall comply with other recognized electricalappliance approval standards and sized tocarry the current required for the applianceused. Only one (1) appliance shall be con-nected to one (1) extension cord. Only two(2) appliances may be served by one (1)duplex receptacle. Extension cords shall notbe placed under rugs, through doorways, orlocated where they are subject to physicaldamage. II/III

(38) The facility shall maintain furniture andequipment in good condition and shallreplace it if broken, torn, heavily soiled ordamaged. Rooms shall be designed and fur-nished so that the comfort and safety of theresidents are provided for at all times. II/III

(39) Rooms shall be neat, orderly andcleaned daily. II/III

(40) The facility shall ensure that each resi-dent shall be provided an individual bed, sin-gle or twin, in good repair of rigid type. Bedsshall be at least thirty-six inches (36") wide.Double beds of satisfactory construction maybe provided for married couples. Rollaway,metal cots or folding beds shall not be used.II/III

(41) A minimum of three feet (3') shall beavailable between parallel beds. III

(42) Mattresses shall be clean, in good repair,sized to fit the bed and a minimum of fourinches (4") in thickness to provide comfort.II/III

(43) The facility shall ensure that each bedhas at least one (1) clean comfortable pillow.Extra pillows shall be available to meet theneeds of the residents. III

(44) Multi-bed resident rooms shall havescreens or curtains, either portable or perma-nently affixed, available and used to provideprivacy as needed or as requested. III

(45) Facilities shall provide each residentwith an individual locker or other suitablespace for storage of clothing and personalbelongings. III

(46) The facility shall provide residents withan individual rack for towels and washclothsunless they are provided with clean wash-cloths or towels for use each time needed. III

(47) A comfortable chair shall be availablefor each resident’s use. III

(48) Only activities necessary to the adminis-tration of the facility shall be contained in any

building used as a long-term care facilityexcept as follows:

(A) Related activities may be conducted inbuildings subject to prior written approval ofthese activities by the department. Examplesof these activities are home health agencies,physician’s office, pharmacy, ambulance ser-vice, child day care, food service, and outpa-tient therapy for the elderly or disabled in thecommunity;

(B) Adult day care may be provided forfour (4) or fewer participants without priorwritten approval of the department if thelong-term care facility meets the followingstipulations:

1. The operation of the adult day carebusiness shall not interfere with the care anddelivery of services to the long-term care res-idents;

2. The facility shall only accept partici-pants in the adult day care program appropri-ate to the level of care of the facility andwhose needs can be met;

3. The facility shall not change the phys-ical layout of the facility without prior writtenapproval of the department;

4. The facility shall provide a privatearea for adult day care participants to nap orrest;

5. Adult day care participants shall notbe included in the census, and the numbershall not be more than four (4) above thelicensed capacity of the facility; and

6. The adult day care participants, whileon-site, are to be included in the determina-tion of staffing patterns for the long-term carefacility; and

(C) An associated adult day health careprogram may be operated without prior writ-ten approval if the provider of the adult dayhealth care services is certified in accordancewith 13 CSR 70-92.010. II/III

AUTHORITY: section 198.079, RSMo Supp.2007.* This rule originally filed as 13 CSR15-14.032. Original rule filed July 13, 1983,effective Oct. 13, 1983. Emergency amend-ment filed Nov. 9, 1983, effective Nov. 19,1983, expired March 18, 1984. Amended:Filed Nov. 9, 1983, effective Feb. 11, 1984.Amended: Filed Sept. 12, 1984, effectiveDec. 13, 1984. Amended: Filed Aug. 1,1988, effective Nov. 11, 1988. Amended:Filed May 11, 1998, effective Dec. 30, 1998.Emergency amendment filed Feb. 1, 1999,effective Feb. 11, 1999, expired Aug. 9, 1999.Amended: Filed Feb. 1, 1999, effective July30, 1999. Moved to 19 CSR 30-85.032, effec-tive Aug. 28, 2001. Amended: Filed March13, 2008, effective Oct. 30, 2008.

*Original authority: 198.079, RSMo 1979, amended 2007.

19 CSR 30-85.042 Administration and Res-ident Care Requirements for New andExisting Intermediate Care and SkilledNursing Facilities

PURPOSE: This rule establishes standardsfor administration and resident care in anintermediate care or skilled nursing facility.

Editor’s Note: All rules relating to long-termcare facilities licensed by the Division ofAging are followed by a Roman Numeralnotation which refers to the class (eitherClass I, II or III) of standard as designated insection 198.085.1, RSMo.

(1) The operator shall designate a person asadministrator who holds a current license asa nursing home administrator in Missouri. II

(2) The facility shall post the administrator’slicense. III

(3) The operator shall be responsible toassure compliance with all applicable lawsand rules. The administrator shall be fullyauthorized and empowered to make decisionsregarding the operation of the facility andshall be held responsible for the actions of allemployees. The administrator’s responsibili-ties shall include the oversight of residents toassure that they receive appropriate nursingand medical care. II/III

(4) The administrator shall be employed inthe facility and serve in that capacity on afull-time basis. An administrator cannot belisted or function as an administrator in morethan one (1) licensed facility at the sametime, except that one (1) administrator mayserve as the administrator of more than one(1) licensed facility if all facilities are on thesame premises. II/III

(5) The licensed administrator shall not leavethe premises without delegating the necessaryauthority in writing to a responsible individ-ual. If the administrator is absent from thefacility for more than thirty (30) consecutivedays, the person designated to be in adminis-trative charge shall be a currently licensednursing home administrator. Such thirty (30)consecutive-day absences may only occuronce within any consecutive twelve (12)-month period. I/II

(6) The facility shall not knowingly admit orcontinue to care for residents whose needscannot be met by the facility directly or incooperation with outside resources. Facilitieswhich retain residents needing skilled nursing


Secretary of State




care shall provide licensed nurses for theseprocedures. I/II

(7) When outside resources are used to pro-vide services to the resident, the facility shallenter into a written agreement with eachresource. III

(8) Persons under seventeen (17) years of ageshall not be admitted as residents to the facil-ity unless the facility cares primarily for res-idents under seventeen (17) years of age. III

(9) The facility shall not care for more resi-dents than the number for which the facilityis licensed. II

(10) The facility’s current license shall bereadily visible in a public area within thefacility. Notices provided to the facility by theDivision of Aging granting exceptions to reg-ulatory requirements shall be posted with thefacility’s license. III

(11) Regular daily visiting hours shall beestablished and posted. Relatives orguardians and clergy, if requested by the res-ident or family, shall be allowed to see criti-cally ill residents at any time unless the physi-cian orders otherwise in writing. II/III

(12) A supervising physician shall be avail-able to assist the facility in coordinating theoverall program of medical care offered in thefacility. II

(13) The facility shall develop policies andprocedures applicable to its operation toinsure the residents’ health and safety and tomeet the residents’ needs. At a minimum,there shall be policies covering personnelpractices, admission, discharge, payment,medical emergency treatment procedures,nursing practices, pharmaceutical services,social services, activities, dietary, housekeep-ing, infection control, disaster and accidentprevention, residents’ rights and handlingresidents’ property. II/III

(14) A pharmacist currently licensed in Mis-souri shall assist in the development of writ-ten policies and procedures regarding phar-maceutical services in the facility. II/III

(15) All personnel shall be fully informed ofthe policies of the facility and of their duties.II/III

(16) All persons who have any contact withthe residents in the facility shall not know-ingly act or omit any duty in a manner whichwould materially and adversely affect the

health, safety, welfare or property of a resi-dent. I

(17) Effective August 28, 1997, each facilityshall, not later than two (2) working days ofthe date an applicant for a position to havecontact with residents is hired, request acriminal background check, as provided insections 43.530, 43.540 and 610.120,RSMo. Each facility must maintain in itsrecord documents verifying that the back-ground checks were requested and the natureof the response received for each suchrequest. The facility must ensure that anyapplicant who discloses prior to the check ofhis/her criminal records that he/she has beenconvicted of, plead guilty or nolo contendereto, or has been found guilty of any A or Bfelony violation of Chapter 565, 566 or 569,RSMo, or any violation of subsection 3 ofsection 198.070, RSMo, or of section568.020, RSMo, will not be allowed to workin contact with patients or residents until andunless a check of the applicant’s criminalrecord shows that no such convictionoccurred. II/III

(18) The facility must develop and implementwritten policies and procedures which requirethat persons hired for any position which is tohave contact with any patient or resident havebeen informed of their responsibility to dis-close their prior criminal history to the facil-ity as required by section 660.317.5, RSMo.The facility—

(A) Shall also develop and implement poli-cies and procedures which ensure that thefacility does not knowingly hire, after August28, 1997, any person who has or may havecontact with a patient or resident, who hasbeen convicted of, plead guilty or nolo con-tendere to, in this state or any other state, orhas been found guilty of any A or B felonyviolation of Chapter 565, 566 or 569, RSMo,or any violation of subsection 3 of section198.070, RSMo, or of section 568.020,RSMo, unless the person has been granted agood cause waiver by the division;

(B) May consider for employment, in posi-tions which have contact with resident orpatients, any person who has been granted agood cause waiver by the division in accor-dance with the provisions of section 660.317,RSMo Supp. 1999 and 13 CSR 15-10.060;and;

(C) Shall contact the division to confirmthe validity of an applicant’s good causewaiver prior to hiring the applicant. II/III

(19) No person who is listed on the employ-ee disqualification list maintained by the divi-sion as required by section 198.070, RSMo

shall work or volunteer in the facility in anycapacity whether or not employed by theoperator. II

(20) The facility shall develop and offer anin-service orientation and continuing educa-tional program for the development andimprovement of skills of all the facility’s per-sonnel, appropriate for their job function.Facilities shall begin providing orientation onthe first day of employment for all personnelincluding licensed nurses and other profes-sionals. At a minimum, this shall cover pre-vention and control of infection, facility poli-cies and procedures including emergencyprotocol, job responsibilities and lines ofauthority, confidentiality of resident informa-tion and preservation of resident dignityincluding protection of the resident’s privacyand instruction regarding the property rightsof residents. Nursing assistants who have notsuccessfully completed the classroom portionof the state-approved training program priorto employment shall not provide direct resi-dent care until they have completed the six-teen (16)-hour, orientation module and atleast twelve (12) hours of supervised practi-cal orientation. This shall include, in addi-tion to the topics covered in the general ori-entation for all personnel, special focus onfacility protocols as well as practical instruc-tion on the care of the elderly and disabled.This orientation shall be supervised by alicensed nurse who is on duty in the facilityat the time orientation is provided. II/III

(21) Nursing assistants who have not success-fully completed the state-approved trainingprogram shall complete a comprehensive ori-entation program within sixty (60) days ofemployment. This may be part of a nursingassistant training program taught by anapproved instructor in the facility. It shallinclude, at a minimum, information on com-municable disease, handwashing and infec-tion control procedures, resident rights,emergency protocols, job responsibilities andlines of authority. II/III

(22) The facility must ensure there is a sys-tem of in-service training for nursing person-nel which identifies training needs related toproblems, needs, care of residents and infec-tion control and is sufficient to ensure staff’scontinuing competency. II/III

(23) Facilities shall conduct at least annualin-service education for nursing personnelincluding training in restorative nursing. Thistraining by a registered nurse or qualifiedtherapist shall include: turning and position-ing for the bedridden resident, range of

motion (ROM) exercises, ambulation assis-tance, transfer procedures, bowel and bladderretraining and self-care activities of daily liv-ing. II/III

(24) A registered nurse shall be responsiblefor the planning and then assuring the imple-mentation of the in-service education pro-gram for nursing personnel. II

(25) Facilities shall maintain records whichindicate the subject of, and attendance at, allin-service sessions. III

(26) All authorized personnel shall haveaccess to the legal name of each resident,name and telephone number of physician andnext of kin or responsible party of each resi-dent to contact in the event of emergency.II/III

(27) The facility must develop and imple-ment policies and procedures which ensureemployees are screened to identify communi-cable diseases and ensure that employeesdiagnosed with communicable diseases donot expose residents to such diseases. Thefacility’s policies and procedures must com-ply with the Missouri Department of Health’sregulations pertaining to communicable dis-eases, specifically 19 CSR 20-20.010 through19 CSR 20-20.100, as amended. II

(28) The administrator shall maintain on thepremises an individual personnel record oneach employee of the facility which shallinclude: the employee’s name and address;Social Security number; date of birth; date ofemployment; experience and education; ref-erences, if available; the result of backgroundchecks required by section 660.317, RSMo; acopy of any good cause waiver, granted by thedivision, if applicable; position in the facili-ty; record that the employee was instructedon resident’s rights; basic orientationreceived; and reason for termination, if appli-cable. Documentation shall be on file of alltraining received within the facility in addi-tion to current copies of licenses, transcripts,certificates or statements evidencing compe-tency for the position held. Facilities shallretain personnel records for at least one (1)year following termination of employment.III

(29) Facilities shall maintain written docu-mentation on the premises showing actualhours worked by each employee. III

(30) All persons who have or may have con-tact with residents shall at all times when onduty or delivering services wear an identifi-

cation badge. The badge shall give theirname, title and, if applicable the status oftheir license or certification as any kind ofhealth care professional. This rule shall applyto all personnel who provide services to anyresident directly or indirectly. III

(31) Employees other than nursing personnelshall be at least sixteen (16) years of age.II/III

(32) Nursing personnel shall be at least eigh-teen (18) years of age except that a personbetween the ages of seventeen (17) years ofage and eighteen (18) years of age may pro-vide direct resident care if he/she has suc-cessfully completed the state-approved nurs-ing assistant course and has been certifiedwith his/her name on the state nursing assis-tant register. He/she must work under thedirect supervision of a licensed nurse and willnever be left responsible for a nursing unit.II/III

(33) All nurses employed by the facility shallbe currently licensed in Missouri. II

(34) All facilities shall employ a director ofnursing on a full-time basis who shall beresponsible for the quality of patient care andsupervision of personnel rendering patientcare. II

(35) Licensed Nursing Requirements; SkilledNursing Facility.

(A) The director of nursing shall be a reg-istered nurse. II

(B) A registered nurse shall be on duty inthe facility on the day shift. Either a licensedpractical nurse (LPN) or a registered profes-sional nurse (RN) shall be on duty in thefacility on both the evening and night shifts.II

(C) A registered nurse shall be on call dur-ing the time when only an LPN is on duty. II

(36) Licensed Nursing Requirements; Inter-mediate Care Facilities.

(A) The director of nursing shall be eitheran RN or an LPN. II

(B) When the director of nursing is anLPN, an RN shall be employed as consultanta minimum of four (4) hours per week to pro-vide consultation to the administrator and thedirector of nursing in matters relating to nurs-ing care in the facility. II

(C) An LPN or RN shall be on duty and inthe facility on the day shift. II

(D) An LPN or RN shall be on call twen-ty-four (24) hours a day, seven (7) days aweek. I/II

(37) All facilities shall employ nursing per-sonnel in sufficient numbers and with suffi-cient qualifications to provide nursing andrelated services which enable each resident toattain or maintain the highest practicablelevel of physical, mental and psychosocialwell-being. Each facility shall have alicensed nurse in charge who is responsiblefor evaluating the needs of the residents on adaily and continuous basis to ensure there aresufficient, trained staff present to meet thoseneeds. I/II

(38) Nursing personnel shall be on duty at alltimes on each resident-occupied floor. II

(39) Nursing assistants employed after Jan-uary 1, 1980, shall have completed mandato-ry training as required by section 198.082,RSMo, or be enrolled in the course and func-tioning under the supervision of a stateapproved instructor of clinical supervisor aspart of the one hundred (100) hours of on-the-job training. The person enrolled shall havesuccessfully completed the course andbecome certified within one (1) year ofemployment with a licensed-only facility orwithin four (4) months of employment with afacility certified under Title XVIII or TitleXIX if he or she is to remain employed in thefacility as a nursing assistant. II

(40) Nursing personnel in any facility withmore than twenty (20) residents shall not rou-tinely perform non-nursing duties. II/III

(41) Nursing personnel in facilities withtwenty (20) residents or less shall performnon-nursing duties only if acceptable infec-tion control measures are maintained. II/III

(42) Each facility resident shall be under themedical supervision of a Missouri-licensedphysician who has been informed of the facil-ity’s emergency medical procedures and iskept informed of treatments or medicationsprescribed by any other professional lawfullyauthorized to prescribe medications. I/II

(43) Facilities shall ensure that at the timethe resident is admitted, the facility obtainsfrom a physician the resident’s primary diag-nosis along with current medical findings andthe written orders for the immediate care ofthe resident. II/III

(44) The facility shall ensure that the resi-dent’s private physician, the physician’sdesignee, the facility’s supervising physicianor an alternate physician shall examine theresident at least annually, and shall examine


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the resident as often as necessary to ensureproper medical care. I/II

(45) For each medical examination, thephysician must review the resident’s care,including medications and treatments; write,sign and date progress notes; and sign anddate all orders. The facility shall establish apolicy requiring the physician to sign ordersand to complete all other documentationrequired if the physician does not visit theresident routinely. II/III

(46) No medication, treatment or diet shallbe given without a written order from a per-son lawfully authorized to prescribe such andthe order shall be followed. No restraint shallbe applied except as provided in 13 CSR 15-18.010, Resident Rights. I/II

(47) There shall be a safe and effective sys-tem of medication distribution, administra-tion, control and use. I/II

(48) Verbal and telephone orders for medi-cation or treatment shall be given only tothose individuals licensed or certified toaccept orders. Orders shall be immediatelyreduced to writing and signed by that indi-vidual. If a telephone order is given to a cer-tified medication technician, an initial dose ofmedication or treatment shall not be givenuntil the order has been reviewed by tele-phone or in person by a licensed nurse orpharmacist. The review shall be documentedby the reviewer co-signing the telephoneorder. II

(49) Medications shall be administered onlyby a licensed physician, a licensed nurse or amedication technician who has successfullycompleted the state-approved course for med-ication administration. II

(50) Injectable medication, other thaninsulin, shall be administered only by alicensed physician or a licensed nurse.Insulin injections may be administered by acertified medication technician who has suc-cessfully completed the state-approved coursefor insulin administration. II

(51) Self-administration of medication is per-mitted only if approved in writing by the res-ident’s physician and it is in accordance withthe facility’s policy and procedures. II

(52) All medication errors and adverse reac-tions shall be reported immediately to thenursing supervisor and the resident’s physi-cian and, if there was a dispensing error, tothe issuing pharmacist. II/III

(53) At least monthly a pharmacist or a reg-istered nurse shall review the drug regimen ofeach resident. Irregularities shall be report-ed in writing to the resident’s physician, theadministrator and the director of nurses.There must be written documentation whichindicates how the reports were acted upon.II/III

(54) All prescription medications shall besupplied as individual prescriptions. Allmedications, including over-the-counter med-ications, shall be packaged and labeled inaccordance with applicable professionalpharmacy standards and state and federaldrug laws and regulations. The United StatesPharmacopoeia (USP) labeling shall includeaccessory and cautionary instructions as wellas the expiration date, when applicable, andthe name of the medication as specified in thephysician’s order. Over-the-counter medica-tions for individual residents shall be labeledwith at least the resident’s name. II/III

(55) If the resident brings medications to thefacility, they shall not be used unless the con-tents have been examined, identified and doc-umented by a pharmacist or a physician.II/III

(56) Facilities shall store all external andinternal medications at appropriate tempera-tures in a safe, clean place and in an orderlymanner apart from foodstuffs and dangerouschemicals. A facility shall secure all medica-tions, including those refrigerated, behind atleast one (1) locked door or cabinet. Facili-ties shall store containers of discontinuedmedication separately from current medica-tions. II/III

(57) Facilities shall store Schedule II medica-tions, including those in the emergency drugsupply, under double lock separately fromnoncontrolled medication. Schedule II med-ications may be stored and handled with othernoncontrolled medication if the facility has asingle unit dose drug distribution system inwhich the quantity stored is minimal and amissing dose can be readily detected. II

(58) Upon discharge or transfer, a residentmay be given medications with a writtenorder from the physician. Instructions for theuse of those medications will be provided tothe resident or the resident’s designee. III

(59) All non-unit doses and all controlledsubstances which have been discontinuedmust be destroyed on the premises withinthirty (30) days. Outdated, contaminated ordeteriorated medications and non-unit dose

medications of deceased residents shall bedestroyed within thirty (30) days. Unit dosemedications returnable to the pharmacy shallbe returned within thirty (30) days. II/III

(60) Medications shall be destroyed in thefacility by a pharmacist and a licensed nurseor by two (2) licensed nurses. III

(61) Facilities shall maintain records of med-ication destroyed in the facility. Recordsshall include: the resident’s name; the date;the name, strength and quantity of the medi-cation; the prescription number; and the sig-natures of the participating parties. III

(62) The facility shall maintain records ofmedication released to the family or residentupon discharge or to the pharmacy. Recordsshall include: the resident’s name; the date;the name, strength and quantity of the medi-cation; the prescription number; and the sig-nature of the persons releasing and receivingthe medication. III

(63) The facility must establish a system ofrecords of receipt and disposition of all con-trolled drugs in sufficient detail to enable anaccurate reconciliation. The system mustenable the facility to determine that drugrecords are in order and that an account of allcontrolled drugs is maintained and recon-ciled. II/III

(64) Facilities shall make available to allnursing staff up-to-date reference material onall medications in use in the facility. III

(65) The facility shall develop policies toidentify any emergency stock supply of pre-scription medications to be kept in the facili-ty for resident use only. This emergency drugsupply must be checked at least monthly by apharmacist to ensure its safety for use andcompliance with facility policy. A facilityshall have the emergency drug supply readilyavailable to medical personnel and use ofmedications in the emergency drug supplyshall assure accountability. III

(66) Each resident shall receive twenty-four(24)-hour protective oversight and supervi-sion. For residents departing the premises onvoluntary leave, the facility shall have, at aminimum, a procedure to inquire of the resi-dent or resident’s guardian of the resident’sdeparture, of the resident’s estimated lengthof absence from the facility, and of the resi-dent’s whereabouts while on voluntary leave.I/II


Secretary of State


(67) Each resident shall receive personalattention and nursing care in accordance withhis/her condition and consistent with currentacceptable nursing practice. I/II

(68) Each resident shall be clean, dry andfree of body and mouth odor that is offensiveto others. I/II

(69) Taking into consideration the resident’spreferences, residents shall be well-groomedand dressed appropriately for the time of day,the environment and any identified medicalconditions. II/III

(70) Residents who are physically or mental-ly incapable, or both, of changing their ownpositions shall have their positions changed atleast every two (2) hours and shall be provid-ed supportive devices to maintain good bodyalignment. I/II

(71) The facility must provide each residentthe opportunity to access sufficient fluids tomaintain proper hydration in accordance withthe resident’s medical condition and goals oftreatment as documented in the medicalrecord. I/II

(72) All residents who require assistance atmealtimes, whether it be preparation of thefood items or actual feeding, shall be provid-ed the assistance upon delivery of the tray.Facilities shall provide dining room supervi-sion during meals. II/III

(73) Facilities shall provide each resident,according to his/her needs, with restorativenursing to encourage independence, activityand self-help to maintain strength and mobil-ity. Each resident shall be out of bed asdesired unless medically contraindicated. II

(74) Each resident shall have skin careincluding the application of oil, lotion andcream as needed to prevent dryness and scal-ing of skin. II/III

(75) Facilities shall keep residents free fromavoidable pressure sores, taking measurestoward prevention. If sores exist, staff shallgive adequate treatment. I/II

(76) Facility staff shall check residentsrequiring restraints every thirty (30) minutesand exercise the residents every two (2)hours. II/III

(77) Facilities shall not use locked restraints.I

(78) Residents shall be cared for by usingacceptable infection control procedures toprevent the spread of infection. The facilityshall make a report to the division withinseven (7) days if a resident is diagnosed ashaving a communicable disease, as deter-mined by the Missouri Department of Healthand listed in the Code of State Regulationspertaining to communicable diseases, specif-ically 19 CSR 20-20.020, as amended. I/II

(79) In the event of accident, injury or sig-nificant change in the resident’s condition,facility staff shall notify the resident’s physi-cian in accordance with the facility’s emer-gency treatment policies which have beenapproved by the supervising physician. I/II

(80) In the event of accident, injury or sig-nificant change in the resident’s conditions,facility staff shall immediately notify the per-son designated in the resident’s record as thedesignee or responsible party. III

(81) Staff shall inform the administrator ofaccidents, injuries and unusual occurrenceswhich adversely affect, or could adverselyaffect, the resident. The facility shall devel-op and implement responsive plans of action.III

(82) Facilities shall ensure that each residentis provided individual personal care itemsnecessary for good grooming. Items shall bestored and maintained in a clean mannerwithin the resident’s room. III

(83) Facilities shall provide equipment andnursing supplies in sufficient number to meetthe needs of the residents. II/III

(84) Facilities shall keep all utensils andequipment in good condition, effectively san-itized, sterilized, or both, and stored to pre-vent contamination. II/III

(85) Staff shall ensure that bedpans, com-modes and urinals are covered after use,emptied promptly and thoroughly cleanedafter use. II/III

(86) Facilities shall provide and use a suffi-cient supply of clean bed linen, includingsheets, pillow cases, blankets and mattresspads to assure that resident beds are keptclean, neat, dry and odor free. II/III

(87) Staff shall use moisture proof covers asnecessary to keep mattresses and pillowsclean, dry and odor free. II/III

(88) Facilities shall provide each residentwith fresh bath towels, hand towels and wash-cloths as needed for individual usage. II/III

(89) In addition to rehabilitative or restora-tive nursing, all facilities shall provide ormake arrangements for providing rehabilita-tion services to all residents according totheir needs. If a resident needs rehabilitationservices, a qualified therapist shall performan evaluation on written order of the resi-dent’s physician. II/III

(90) Facilities shall ensure that rehabilitationservices are provided by or under the on-sitesupervision of a qualified therapist or a qual-ified therapy assistant who works under thegeneral supervision of a qualified therapist.I/II

(91) Staff shall include the following in doc-umentation of rehabilitation services: physi-cian’s written approval for proposed plan ofcare; progress notes at least every thirty (30)days by the therapist; daily record of the pro-cedure(s) performed; summary of therapywhen rehabilitation has been reached and, ifapplicable, recommendations for mainte-nance procedures by restorative nursing. III

(92) The facility shall designate a staff mem-ber to be responsible for the facility’s socialservices program. The designated staff per-son shall be capable of identifying social andemotional needs, knowledgeable of methodsor resources, or a combination of these, touse to meet them and services shall be pro-vided to residents as needed. II/III

(93) The facility shall designate an employ-ee to be responsible for the activity program.The designated person shall be capable ofidentifying activity needs of residents,designing and implementing programs tomaintain or increase, or both, the resident’scapability in activities of daily living. Facil-ities shall provide activity programs on a reg-ular basis. Each resident shall have a plannedactivity program which includes individual-ized activities, group activities and activitiesoutside the facility as appropriate to his/herneeds and interests. II/III

(94) The facility shall provide and use ade-quate space and equipment within the facilityfor the identified activity needs of residents.II/III

(95) The facility shall establish and maintaina program for informing all residents inadvance of available activities, activity loca-tion and time. III



(96) Facility staff shall include the followinggeneral information in admission records:resident’s name; prior address; age (birthdate); sex; marital status; Social Securitynumber; Medicare and Medicaid numbers;date of admission; name, address and tele-phone number of responsible party; name,address and telephone number of attendingphysician; height and weight on admission;inventory of resident’s personal possessionsupon admission; and names of preferred den-tist, pharmacist and funeral director. II/III

(97) Facility staff shall include physicianentries in the medical record with the follow-ing information: admission diagnosis, admis-sion physical and findings of subsequentexaminations; progress notes; orders for allmedications and treatment; orders for extentof activity; orders for restraints includingtype and reason for restraint; orders for diet;and discharge diagnosis or cause of death.II/III

(98) Residents admitted to a facility on refer-ral by the Department of Mental Health shallhave an individualized treatment plan or indi-vidualized habilitation plan on file which isupdated annually. III

(99) Facilities shall ensure that the clinicalrecord contains sufficient information to—

(A) Identify the resident;(B) Reflect the initial and ongoing assess-

ments and interventions by each disciplineinvolved in the care and treatment of the res-ident; and

(C) Identify the discharge or transfer desti-nation. II/III

(100) Facilities shall ensure that the resident’sclinical record must contain progress notesthat include, but are not limited to:

(A) Response to care and treatment;(B) Change(s) in physical, mental and psy-

chosocial condition;(C) Reasons for changes in treatment; and(D) Reasons for transfer or discharge.

II/III

(101) The facility must safeguard clinicalrecord information against loss, destructionor unauthorized use. III

(102) The facility must keep all informationconfidential that is contained in the resident’srecords regardless of the form or storagemethod of the records, including video-,audio- or computer-stored information. III

(103) The facility must maintain clinicalrecords on each resident in accordance with

accepted professional standards and prac-tices. These records shall be complete, accu-rately documented, readily accessible oneach nursing unit and systematically orga-nized. II/III

(104) Facilities must retain clinical recordsfor the period of time required by state law orfive (5) years from the date of discharge whenthere is no requirement in state law. III

(105) Facilities shall retain all financialrecords related to the facility operation forseven (7) years from the end of the facility’sfiscal year. III

(106) In the event the resident is transferredfrom the facility, the resident shall be accom-panied by a copy of the medical history,transfer forms which include the physicalexam report, nursing summary and report oforders physicians prescribed. II/III

AUTHORITY: sections 198.006, RSMo Supp.2003 and 198.079, RSMo 2000.* This ruleoriginally filed as 13 CSR 15-14.042. Origi-nal rule filed July 13, 1983, effective Oct. 13,1983. Emergency amendment filed Nov. 9,1983, effective Nov. 19, 1983, expired March18, 1984. Amended: Filed Nov. 9, 1983,effective Feb. 11, 1984. Amended: Filed Sept.12, 1984, effective Dec. 13, 1984. Amended:Filed Aug. 1, 1988, effective Nov. 10, 1988.Amended: Filed Jan. 3, 1992, effective Aug.6, 1992. Amended: Feb. 13, 1998, effectiveSept. 30, 1998. Amended: Filed Feb. 15,2000, effective Aug. 30, 2000. Moved to 19CSR 30-85.042, effective Aug. 28, 2001.Emergency amendment filed Sept. 12, 2003,effective Sept. 22, 2003, expired March 19,2004. Amended: Filed Sept. 12, 2003, effec-tive Feb. 29, 2004.

*Original authority: 198.006, RSMo 1979, amended1984, 1987, 2003; 198.079, RSMo 1979.

19 CSR 30-85.052 Dietary Requirementsfor New and Existing Intermediate Careand Skilled Nursing Facilities

PURPOSE: This rule establishes dietaryrequirements for new and existing intermedi-ate care and skilled nursing facilities.


(1) Each resident shall be served nutritiousfood, properly prepared and appropriatelyseasoned, taking into consideration residentfood preferences, to provide an adequate dietin accordance with the physician’s order andas recommended by the National ResearchCouncil. Nutritional needs of residents shallbe met and shall be based on the individual’scircumstances, medical condition and goalsof treatment as determined and justified bythe physician. A qualified professional, suchas a dietitian or registered nurse, shall regu-larly assess these needs and shall keep thephysician informed of the nutritional status ofthe resident. I/II

(2) At least three (3) substantial meals orother equivalent shall be served daily at reg-ular hours with supplementary feedings asnecessary. At least two (2) meals shall behot.II/III

(3) Foods shall be prepared and served usingmethods that conserve nutritive value, flavorand appearance. II/III

(4) Special attention shall be given to the tex-ture of food given to residents who havechewing difficulty. II/III

(5) Provision shall be made to assure that hotfood is served hot and cold food is servedcold. II

(6) If a resident refuses food served, appro-priate substitutes of similar nutritive valueshall be offered. II/III

(7) Bedtime snacks of nourishing quality shallbe offered to all residents unless medicallycontraindicated. III

(8) Tray service and dining room service forresidents shall be attractive and each residentshall receive appropriate table service. III

(9) Each resident who is served meals in bedor in a chair not within the dining area shallbe provided with either a table, an overbedtable or an overbed tray of sturdy construc-tion which is positioned so that the residentcan eat comfortably. III

(10) A time schedule for service of meals toresidents shall be established. Meals shall beserved approximately four to five (4–5) hoursapart and not longer than fourteen (14) hoursfrom a substantial evening meal to breakfast.II/III

(11) A minimum of thirty (30) minutes shallbe given for eating meals. Residents who eat


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slowly or who need assistance shall be givenas much time to eat as necessary. II/III

(12) An identification system shall be estab-lished to assure that each resident receives thediet as ordered. II/III

(13) If the residents have objectionable tablemanners, an alternate method of meal serviceshall be provided. III

(14) There shall be sufficient personnel prop-erly trained in their duties to assure adequatepreparation and serving of food. II

(15) All facilities shall employ a food servicesupervisor who shall have overall superviso-ry responsibility for dietary services. II

(16) Menus for special prescribed diets shallbe reviewed and approved in writing by eithera qualified dietitian, a registered nurse or aphysician. II/III

(17) If food preparation, service, or both,within the facility is handled through a con-tractual arrangement, all regulations govern-ing sanitation (13 CSR 15-17), dietary ser-vice and contractual personnel shall be metand maintained. II/III

(18) If it is determined by the Division ofAging that due to the complexity of pre-scribed diets or that the food service supervi-sor is unable to assure compliance with thedietary requirements, the facility shall berequired to employ, for specified periods oftime, a qualified dietitian to serve as a con-sultant and until the food service managementimproves to assure that the residents’ needsare being met. II

(19) A current record of purchased food shallbe kept to show the kind and amount of foodpurchased each month. III

(20) Supplies of staple food for a minimum ofa one (1)-week period and of perishable foodsfor a minimum of a three (3)-day period shallbe maintained on the premises. II

(21) Menus for all diets shall be planned atleast two (2) weeks in advance. If cyclemenus are used, the cycle must cover a mini-mum of three (3) weeks and must be differ-ent each day of the week. Menus showing thefoods and amounts of food to be served eachday during the current week shall be postedwhere seen readily as food is prepared andserved. Each day’s menu shall show the dateit was actually used and shall be kept on file

for thirty (30) days. A list of substitutionsshall be kept for thirty (30) days. III

(22) A file of standardized recipes shall beused. III

(23) A diet manual approved by the Divisionof Aging shall be readily available to attend-ing physicians, nursing and dietary person-nel. III

AUTHORITY: section 198.009, RSMo 1986.*This rule originally filed as 13 CSR 15-14.052. Original rule filed July 13, 1983,effective Oct. 13, 1983. Amended: Filed Aug.1, 1988, effective Nov. 10, 1988. Amended:Filed Jan. 3, 1992, effective Aug. 6, 1992.Moved to 19 CSR 30-85.052, effective Aug.28, 2001.

*Original authority: 198.009, RSMo 1979.


Rules of


Division 30—Division of Regulation and LicensureChapter 86—Residential Care Facilities and

Assisted Living Facilities

Title Page

19 CSR 30-86.012 Construction Standards for Assisted Living Facilities and Residential Care Facilities....................................................................3

19 CSR 30-86.022 Fire Safety Standards for Residential Care Facilitiesand Assisted Living Facilities ...............................................................4

19 CSR 30-86.032 Physical Plant Requirements for Residential Care Facilitiesand Assisted Living Facilities ..............................................................10

19 CSR 30-86.042 Administrative, Personnel and Resident Care Requirements for New andExisting Residential Care Facilities .......................................................12

19 CSR 30-86.043 Administrative, Personnel and Resident Care Requirements for FacilitiesLicensed as a Residential Care Facility II on August 27, 2006 thatWill Comply with Residential Care Facility II Standards .............................19

19 CSR 30-86.045 Standards and Requirements for Assisted Living Facilities Which ProvideServices to Residents with a Physical, Cognitive, or Other Impairmentthat Prevents the Individual from Safely Evacuating the Facility withMinimal Assistance ..........................................................................23

19 CSR 30-86.047 Administrative, Personnel and Resident Care Requirements for Assisted Living Facilities ...................................................................24

19 CSR 30-86.052 Dietary Requirements for Residential Care Facilities andAssisted Living Facilities ...................................................................33


Division 30—Division of Regulationand Licensure

Chapter 86—Residential Care Facilitiesand Assisted Living Facilities

19 CSR 30-86.012 Construction Standardsfor Assisted Living Facilities and Residen-tial Care Facilities

PURPOSE: This rule establishes constructionstandards for Residential Care Facilities andAssisted Living Facilities.


AGENCY NOTE: All rules relating to long-term care facilities licensed by the depart-ment are followed by a Roman Numeral whichrefers to the class (either class I, II or III) ofstandard as designated in section 198.085.1,RSMo 2000.

(1) These standards apply to assisted livingfacilities and residential care facilities as indi-cated in the rule.

(2) A facility shall submit a copy of plans ofproposed new construction, additions to ormajor remodeling of an existing facility to theSection for Long Term Care of the Depart-ment of Health and Senior Services (here-inafter—the department). If the facility is tobe licensed for more than nine (9) residents,a registered architect or registered profes-sional engineer shall prepare the plans andspecifications for new construction or addi-tions to an existing facility in conformancewith Chapter 327, RSMo. III

(3) Construction of facilities shall begin onlyafter the plans and specifications havereceived the written approval of the depart-ment. Facilities shall then be built in confor-mance with the approved plans and specifica-tions. The facility shall notify the departmentwhen construction begins. If construction ofthe project is not started within one (1) yearafter the date of approval of the plans and

specifications and completed within a periodof three (3) years, the facility shall resubmitplans to the department for its approval andshall amend them, if necessary, to complywith the then current rules before construc-tion work is started or continued. III

(4) If the facility employs more than fifteen(15) people, it shall conform with section 504of the Rehabilitation Act of 1973. Any facili-ty that houses handicapped residents shallhave the first floor rooms and living areasdesigned to be accessible to these residents.III

(5) Facilities shall not house residents on alevel where the outside grade line is morethan three feet (3') above the floor level onthe window side of the room. II

(6) Facilities whose plans were approved afterDecember 31, 1987, shall provide a mini-mum of seventy (70) square feet per residentin private and multiple occupancy bedrooms.This square footage calculation shall includethe floor space used for closets and built-infurniture and equipment if these are for resi-dent use and the closet space does not exceedfive (5) square feet per resident. Private bed-rooms in existing facilities that are requiredto comply with the requirements of 19 CSR30-86.043 or 19 CSR 30-86.047, and multi-ple occupancy bedrooms in facilities licensedbetween November 13, 1980 and December31, 1987, shall have a minimum of sixty (60)square feet of floor space per resident. II

(7) Ceilings in bedrooms shall be a minimumof seven feet (7') in height or if a room withsloping ceiling is used, only the area wherethe ceiling height is at least seven feet (7')can be used to meet the required minimumsquare footage per resident. II

(8) Facilities shall provide bedrooms with atleast one (1) functional outside window withscreen. Window size shall be not less thanone-twentieth (1/20) or five percent (5%) ofthe required floor area. II

(9) Facilities shall provide resident roomswith a full nonlouvered door that swings intothe room. Facilities formerly licensed as res-idential care facilities II and existing prior toNovember 13, 1980, are exempt from thisrequirement. II

(10) Facilities shall permit no more than four(4) beds per bedroom, regardless of the roomsize. Facilities formerly licensed as residen-tial care facilities II and existing prior to

November 13, 1980, are exempt from thisrequirement. II

(11) One (1) tub or shower bath shall be pro-vided for each twenty (20) residents or majorfraction of twenty (20). Facilities exceedingtwenty (20) residents shall have separatebathing facilities for each sex. II

(12) One (1) toilet and lavatory shall be pro-vided for each six (6) residents or major frac-tion of six (6). Facilities formerly licensed asresidential care facilities II and in operationor whose plans were approved prior toNovember 13, 1980 are required to provideone (1) toilet for each ten (10) beds or majorfraction of ten (10) and one (1) lavatory forevery fifteen (15) residents or major fractionof fifteen (15). II

(13) Separate toilet rooms shall be providedfor each sex if common rooms with multi-stalls and stools are provided. II

(14) Bath and toilet facilities shall be conve-niently located so that residents can reachthem without passing through the kitchen,another bedroom, or auxiliary service areas.Facilities formerly licensed as residential carefacilities II and in operation or whose planswere approved prior to November 13, 1980are exempt from this requirement. III

(15) Bath and toilet facilities shall be venti-lated. III

(16) Facilities whose plans were approved orwere initially licensed after December 31,1987, shall have a community living and din-ing area separate from resident bedroomswith at least twenty-five (25) square feet perresident. The community living and diningarea may be combined with footage requiredfor another long-term care facility when thefacility is on the same premises as anotherlicensed facility. Facilities that are required tocomply with the requirements of 19 CSR 30-86.043 licensed prior to November 13, 1980,must have a living room area but they areexempt from minimum size requirements.Facilities licensed between November 13,1980 and December 31, 1987, shall have acommunity living area with twenty (20)square feet per resident for the first twenty(20) residents and an additional fifteen (15)square feet per resident over a census oftwenty (20). II

(17) Facilities shall provide the following inthe dietary area: a kitchen, dishwashing,refrigeration, and garbage disposal facilities.The facility shall arrange the kitchen andequipment to efficiently and sanitarily enable


Chapter 86—Residential Care Facilities and Assisted Living Facilities 19 CSR 30-86

the storage, preparation, cooking and servingof food and drink to residents. II

(18) Residential care facilities and assistedliving facilities shall provide a designatedattendant’s working area which includes: astorage space for records; locked storagespace for medications; a handwashing sinkwith hot and cold running water, a soap dis-penser and paper towels; and a telephoneconveniently located to the area. Facilitieslicensed for twelve (12) or fewer residents areexempt from a separate working area. III

(19) Facilities shall have a laundry area in aseparate room for storing, sorting, washing,drying and distributing linen and personalclothing. Laundry facilities of a licensedlong-term care facility located on the samepremises may be used. Facilities licensed fortwelve (12) or fewer residents will be exemptfrom having a separate room for laundry butthe laundry room shall be separate from thekitchen and shall not be located in a roomused by residents. III

(20) All newly licensed facilities shall be ofsturdy construction with permanent founda-tions. III

(21) In buildings built prior to September 28,1979, corridors shall have a minimum widthof thirty-six inches (36"). First-floor residentroom doors shall be a minimum of thirty-twoinches (32") wide. Resident room doors ofthese buildings on the second floor and aboveshall be a minimum of thirty inches (30")wide. II/III

(22) In newly licensed buildings constructedon or after September 28, 1979, all residentroom doors shall be a minimum of thirty-twoinches (32") wide on all floors. Corridorsshall be a minimum of forty-eight inches(48") wide and interior stairs shall be at leastthirty-six inches (36") wide. II/III

(23) Exit doors in newly licensed facilitiesshall be at least thirty-six inches (36") wide,at least seventy-two inches (72") high andshall swing outward. II/III

(24) Residential care facilities that acceptdeaf residents, shall have appropriate assis-tive devices to enable each deaf person tonegotiate a path to safety, including, but notlimited to, visual or tactile alarm systems.II/III

(25) Residential care facilities and facilitiesformerly licensed as residential care facilitiesII whose plans were initially approved

between December 31, 1987 and December31, 1998, shall have at least one (1) hydraulicor electric motor-driven elevator if there aremore than twenty (20) residents with bed-rooms above the first floor. The elevatorinstallation(s) shall comply with all local andstate codes, American Society for Mechani-cal Engineers (ASME) A17.1, Safety Codefor Elevators, Dumbwaiters, and Escalators,and the National Fire Protection Associa-tion’s applicable codes. All facilities withplans approved on or after January 1, 1999,shall comply with all local and state codes,ASME A17.1, 1993 Safety Code for Eleva-tors and Escalators, and the 1996 NationalElectrical Code. These references are incor-porated by reference in this rule and availableat: American Society for Mechanical Engi-neers, Three Park Avenue, New York, NY10016-5990; and The American NationalStandards Institute, 11 West 42nd Street, 13thFloor, New York, NY 10036. This rule doesnot incorporate any additional amendmentsor additions. II

(26) Facilities whose plans were approved orwhich were initially licensed after December31, 1987, shall provide an air-conditioningsystem, or individual room air-conditioningunits, capable of maintaining resident-useareas at eighty-five degrees Fahrenheit(85°F) (29.4°C) at the summer design tem-perature. II

(27) Home-Like Requirements with Respectto Construction Standards.

(A) Any assisted living facility formerlylicensed as a residential care facility shall bemore home-like than institutional withrespect to construction and physical plantstandards. II

(B) Any assisted living facility licensed asa residential care facility II prior to August28, 2006, shall qualify as being more home-like than institutional with respect to con-struction and physical plant standards. II

(C) Any assisted living facility that is builtor has plans approved on or after August 28,2006, shall be more home-like than institu-tional with respect to construction and physi-cal plant standards. II

AUTHORITY: sections 198.073 and 198.076,RSMo Supp. 2007.* This rule originally filedas 13 CSR 15-15.012. Original rule filed July13, 1983, effective Oct. 13, 1983. Emergen-cy amendment filed Aug. 1, 1984, effectiveAug. 13, 1984, expired Dec. 10, 1984.Amended: Filed Sept. 12, 1984, effectiveDec. 13, 1984. Amended: Filed May 13,1987, effective Aug. 13, 1987. Amended:Filed Aug. 1, 1988, effective Nov. 10, 1988.

Amended: Filed May 11, 1998, effective Dec.30, 1998. Moved to 19 CSR 30-86.012, effec-tive Aug. 28, 2001. Amended: Filed Nov. 15,2004, effective May 30, 2005. Amended:Filed Aug. 23, 2006, effective April 30, 2007.Amended: Filed March 13, 2008, effectiveOct 30, 2008.

*Original authority: 198.073, RSMo 1979, amended1984, 1992, 1999, 2006, 2007, and 198.076, RSMo 1979,amended 1984, 2007.

19 CSR 30-86.022 Fire Safety Standardsfor Residential Care Facilities and AssistedLiving Facilities

PURPOSE: This rule establishes fire safetystandards for residential care facilities andassisted living facilities.


Editor’s Note: All rules relating to long-termcare facilities licensed by the department arefollowed by a Roman Numeral notation whichrefers to the class (either class I, II or III) ofstandard as designated in section 198.085.1,RSMo Supp. 1999.


(A) Accessible spaces—shall include allrooms, halls, storage areas, basements, attics,lofts, closets, elevator shafts, enclosed stair-ways, dumbwaiter shafts, and chutes.

(B) Area of refuge—a space located in orimmediately adjacent to a path of travel lead-ing to an exit that is protected from theeffects of fire, either by means of separationfrom other spaces in the same building or itslocation, permitting a delay in evacuation.An area of refuge may be temporarily used asa staging area that provides some relativesafety to its occupants while potential emer-gencies are assessed, decisions are made,and, if applicable, evacuation has begun.

(C) Major renovation—shall include thefollowing:

1. Addition of any room(s), accessibleby residents, that either exceeds fifty percent


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(50%) of the total square footage of the facil-ity or exceeds four thousand five hundred(4,500) square feet; or

2. Repairs, remodeling, or renovationsthat involve structural changes to more thanfifty percent (50%) of the building; or

3. Repairs, remodeling, or renovationsthat involve structural changes to more thanfour thousand five hundred (4,500) squarefeet of a smoke section; or

4. If the addition is separated by two (2)-hour fire-resistant construction, only theaddition portion shall meet the requirementsfor NFPA 13, 1999 edition, sprinkler system,unless the facility is otherwise required tomeet NFPA 13, 1999 edition.

(D) Fire-resistant construction—type ofconstruction in residential care and assistedliving facilities in which bearing walls,columns, and floors are of noncombustiblematerial in accordance with NFPA 101, 2000edition. All load-bearing walls, floors, androofs shall have a minimum of a one (1)-hourfire-resistant rating.


tion (NFPA) codes and standards cited in thisrule: NFPA 10, Standard for Portable FireExtinguishers, 1998 edition; NFPA 13R,Installation of Sprinkler Systems, 1996 edi-tion; NFPA 13, Installation of Sprinkler Sys-tems, 1976 edition; NFPA 13 or NFPA 13R,Standard for the Installation of Sprinkler Sys-tems in Residential Occupancies Up to andIncluding Four Stories in Height, 1999 edi-tion; NFPA 13, Standard for the Installationof Sprinkler Systems, 1999 edition; NFPA 96,Standard for Ventilation Control and FireProtection of Commercial Cooking Opera-tions, 1998 edition; NFPA 101, The LifeSafety Code, 2000 edition; NFPA 72, Nation-al Fire Alarm Code, 1999 edition; NFPA72A, Local Protective Signaling Systems,1975 edition; NFPA 25, Standard for theInspection, Testing, and Maintenance ofWater-Based Fire Protection Systems, 1998edition; and NFPA 101A, Guide to Alterna-tive Approaches to Life Safety, 2001 edition,with regard to the minimum fire safety stan-dards for residential care facilities and assist-ed living facilities are incorporated by refer-ence in this rule and available for purchasefrom the National Fire Protection Agency, 1Batterymarch Park, Quincy, MA 02269-9101; www.nfpa.org; by telephone at (617)770-3000 or 1-800-344-3555. This rule doesnot incorporate any subsequent amendmentsor additions to the materials listed above.This rule does not prohibit facilities fromcomplying with the standards set forth innewer editions of the incorporated by refer-

ence material listed in this subsection of thisrule, if approved by the department.

(B) Facilities that were complying prior tothe effective date of this rule with prior edi-tions of the NFPA provisions referenced inthis rule shall be permitted to continue tocomply with the earlier editions, as long asthere is not an imminent danger to the health,safety, or welfare of any resident or a sub-stantial probability that death or serious phys-ical harm would result as determined by thedepartment.

(C) All facilities shall notify the depart-ment immediately after the emergency isaddressed if there is a fire in the facility orpremises and shall submit a complete writtenfire report to the department within seven (7)days of the fire, regardless of the size of thefire or the loss involved. II/III

(D) The department shall have the right ofinspection of any portion of a building inwhich a licensed facility is located unless theunlicensed portion is separated by two (2)-hour fire-resistant construction. No section ofthe building shall present a fire hazard. I/II

(E) Following the discovery of any fire, thefacility shall monitor the area and/or thesource of the fire for a twenty-four (24)-hourperiod. This monitoring shall include, at aminimum, hourly visual checks of the area.These hourly visual checks shall be docu-mented. I/II

(F) The facility shall maintain the exteriorpremises in a manner as to provide for firesafety. II

(G) Residential care facilities that acceptdeaf residents shall have appropriate assistivedevices to enable each deaf person to negoti-ate a path to safety, including, but not limit-ed to, visual or tactile alarm systems. II/III

(H) Facilities shall not use space understairways to store combustible materials. I/II

(3) Fire Extinguishers.(A) Fire extinguishers shall be provided at

a minimum of one (1) per floor, so that thereis no more than seventy-five feet (75') traveldistance from any point on that floor to anextinguisher. I/II

(B) All new or replacement portable fireextinguishers shall be ABC-rated extinguish-ers, in accordance with the provisions ofNFPA 10, 1998 edition. A K-rated extin-guisher or its equivalent shall be used in lieuof an ABC-rated extinguisher in the kitchencooking areas. II

(C) Fire extinguishers shall have a rating ofat least:

1. Ten pounds (10 lbs.), ABC-rated orthe equivalent, in or within fifteen feet (15')of hazardous areas as defined in 19 CSR 30-83.010; and

2. Five pounds (5 lbs.), ABC-rated orthe equivalent, in other areas. II

(D) All fire extinguishers shall bear thelabel of the Underwriters’ Laboratories (UL)or the Factory Mutual (FM) Laboratories andshall be installed and maintained in accor-dance with NFPA 10, 1998 edition. Thisincludes the documentation and dating of amonthly pressure check. II/III

(4) Range Hood Extinguishing Systems.(A) In facilities licensed on or before July

11, 1980, or in any facility with fewer thantwenty-one (21) beds, the kitchen shall pro-vide either:

1. An approved automatic range hoodextinguishing system properly installed andmaintained in accordance with NFPA 96,1998 edition; or

2. A portable fire extinguisher of at leastten pounds (10 lbs.) ABC-rated, or the equiv-alent, in the kitchen area in accordance withNFPA 10, 1998 edition. II/III

(B) In licensed facilities with a total oftwenty-one (21) or more licensed beds andwhose application was filed after July 11,1980, and prior to October 1, 2000:

1. The kitchen shall be provided with arange hood and an approved automatic rangehood extinguishing system unless the facilityhas an approved sprinkler system. Facilitieswith range hood systems shall continue tomaintain and test these systems; and

2. The extinguishing system shall beinstalled, tested, and maintained in accor-dance with NFPA 96, 1998 edition. II/III

(C) The range hood and its extinguishingsystem shall be certified at least twice annu-ally in accordance with NFPA 96, 1998 edi-tion. II/III

(5) Fire Drills and Evacuation Plans.(A) All facilities shall develop a written

plan for fire drills and other emergencies andevacuation and shall request consultation andassistance annually from a local fire unit. Ifthe consultation cannot be obtained, the facil-ity shall inform the state fire marshal in writ-ing and request assistance in review of theplan. II/III

(B) The plan shall include, but is not lim-ited to, the following:

1. A phased response ranging from relo-cation of residents within the facility to relo-cation to an area of refuge, if applicable, tototal evacuation. This phased response part ofthe plan shall be consistent with the directionof the local fire unit or state fire marshal andappropriate for the fire or emergency;

2. Written instructions for evacuation ofeach floor including evacuation to areas ofrefuge, if applicable, and a floor plan showing



the location of exits, fire alarm pull stations,fire extinguishers, and any areas of refuge;

3. Evacuating residents, if necessary,from an area of refuge to a point of safetyoutside the building;

4. The location of any additional watersources on the property such as cisterns,wells, lagoons, ponds, or creeks;

5. Procedures for the safety and comfortof residents evacuated;

6. Staffing assignments;7. Instructions for staff to call the fire

department or other outside emergency ser-vices;

8. Instructions for staff to call alterna-tive resource(s) for housing residents, if nec-essary;

9. Administrative staff responsibilities;and

10. Designation of a staff member to beresponsible for accounting for all residents’whereabouts. II/III

(C) The written plan shall be accessible atall times and an evacuation diagram shall beposted on each floor in a conspicuous placeso that employees and residents can becomefamiliar with the plan and routes to safety.II/III

(D) A minimum of twelve (12) fire drillsshall be conducted annually with at least one(1) every three (3) months on each shift. Atleast four (4) of the required fire drills mustbe unannounced to residents and staff,excluding staff who are assigned to evaluatestaff and resident response to the fire drill.The fire drills shall include a resident evacu-ation at least once a year. II/III

(E) The facility shall keep a record of allfire drills. The record shall include the time,date, personnel participating, length of timeto complete the fire drill, and a narrativenotation of any special problems. III

(F) The fire alarm shall be activated duringall fire drills unless the drill is conductedbetween 9 p.m. and 6 a.m., when a facility-generated predetermined message is accept-able in lieu of the audible and visual compo-nents of the fire alarm. II/III

(6) Fire Safety Training Requirements.(A) The facility shall ensure that fire safe-

ty training is provided to all employees: 1. During employee orientation; 2. At least every six (6) months; and3. When training needs are identified as

a result of fire drill evaluations. II/III(B) The training shall include, but is not

limited to, the following: 1. Prevention of fire ignition, detection

of fire, and control of fire development; 2. Confinement of the effects of fire;

3. Procedures for moving residents to anarea of refuge, if applicable;

4. Use of alarms;5. Transmission of alarms to the fire

department;6. Response to alarms;7. Isolation of fire;8. Evacuation of immediate area and

building; 9. Preparation of floors and facility for

evacuation; and10. Use of the evacuation plan as

required by section (5) of this rule. II/III

(7) Exits, Stairways, and Fire Escapes.(A) Each floor of a facility shall have at

least two (2) unobstructed exits remote fromeach other. I/II

1. For a facility whose plans wereapproved on or before December 31, 1987,or a facility licensed for twenty (20) or fewerresidents, one (1) of the required exits from amulti-story facility shall be an outside stair-way or an enclosed stairway that is separatedby one (1)-hour rated construction from eachfloor with an exit leading directly to the out-side at grade level. Existing plaster or gyp-sum board of at least one-half inch (1/2")thickness may be considered equivalent toone (1)-hour rated construction. The otherrequired exit may be an interior stairwayleading through corridors or passageways tooutside or to a two (2)-hour rated horizontalexit as defined by paragraph 3.3.61 of the2000 edition NFPA 101. Neither of therequired exits shall lead through a furnace orboiler room. Neither of the required exitsshall be through a resident’s bedroom, unlessthe bedroom door cannot be locked. I/II

2. For a facility whose plans wereapproved after December 31, 1987, for morethan twenty (20) residents, the required exitsshall be doors leading directly outside, one(1)-hour enclosed stairs or outside stairs or atwo (2)-hour rated horizontal exit as definedby paragraph 3.3.61 of 2000 edition NFPA101. The one (1)-hour enclosed stairs shallexit directly outside at grade. Access to theseshall not be through a resident bedroom or ahazardous area. I/II

3. Only one (1) of the required exits maybe a two (2)-hour rated horizontal exit. I/II

(B) In facilities with plans approved afterDecember 31, 1987, doors to resident userooms shall not be more than one hundredfeet (100') from an exit. In facilities equippedwith a complete sprinkler system in accor-dance with NFPA 13 or NFPA 13R, 1999edition, the exit distance may be increased toone hundred fifty feet (150'). Dead-end cor-ridors shall not exceed thirty feet (30') inlength. II

(C) In residential care facilities and facili-ties formerly licensed as residential carefacilities II, floors housing residents whorequire the use of a walker, wheelchair, orother assistive devices or aids, or who areblind, must have two (2) accessible exits tograde or such residents must be housed nearaccessible exits as specified in 19 CSR 30-86.042(33) for residential care facilities and19 CSR 30-86.043(31) for facilities formerlylicensed as residential care facilities II unlessotherwise prohibited by 19 CSR 30-86.045 or19 CSR 30-86.047, facilities equipped witha complete sprinkler system, in accordancewith NFPA 13 or NFPA 13R, 1999 edition,with sprinklered attics, and smoke partitions,as defined by subsection (10)(I) of this rule,may house such residents on floors that donot have accessible exits to grade if eachrequired exit is equipped with an area ofrefuge as defined and described in subsec-tions (1)(B) and (7)(D) of this rule. I/II

(D) An “area of refuge” shall have: 1. An area separated by one (1)-hour

rated smoke walls, from the remainder of thebuilding. This area must have direct accessto the exit stairway or access the stair througha section of the corridor that is separated bysmoke walls from the remainder of the build-ing. This area may include no more than two(2) resident rooms;

2. A two (2)-way communication orintercom system with both visible and audiblesignals between the area of refuge and thebottom landing of the exit stairway, atten-dants’ work area, or other primary locationas designated in the written plan for fire drillsand evacuation;

3. Instructions on the use of the areaduring emergency conditions that are locatedin the area of refuge and conspicuously post-ed adjoining the communication or intercomsystem;

4. A sign at the entrance to the roomthat states “AREA OF REFUGE IN CASEOF FIRE” and displays the internationalsymbol of accessibility;

5. An entry or exit door that is at least aone and three-fourths inch (1 3/4") solid corewood door or has a fire protection rating ofnot less than twenty (20) minutes with smokeseals and positive latching hardware. Thesedoors shall not be lockable;

6. A sign conspicuously posted at thebottom of the exit stairway with a diagramshowing each location of the areas of refuge;

7. Emergency lighting for the area ofrefuge; and

8. The total area of the areas of refugeon a floor shall equal at least twenty (20)square feet for each resident who is blind or


Secretary of State


requires the use of wheelchair or walkerhoused on the floor. II

(E) If it is necessary to lock exit doors, thelocks shall not require the use of a key, tool,special knowledge, or effort to unlock thedoor from inside the building. Only one (1)lock shall be permitted on each door. Delayedegress locks complying with section7.2.1.6.1 of the 2000 edition NFPA 101 shallbe permitted, provided that not more than one(1) such device is located in any egress path.Self-locking exit doors shall be equipped witha hold-open device to permit staff to reenterthe building during the evacuation. I/II

(F) If it is necessary to lock resident roomdoors, the locks shall not require the use of akey, tool, special knowledge, or effort tounlock the door from inside the room. Onlyone (1) lock shall be permitted on each door.Every resident room door shall be designedto allow the door to be opened from the out-side during an emergency when locked. Thefacility shall ensure that facility staff have themeans or mechanisms necessary to open res-ident room doors in case of an emergency.I/II

(G) All stairways and corridors shall beeasily negotiable and shall be maintained freeof obstructions. II

(H) Outside stairways shall be constructedto support residents during evacuation andshall be continuous to the ground level. Out-side stairways shall not be equipped with acounter-balanced device. They shall be pro-tected from or cleared of ice or snow. II/III

(I) Facilities with three (3) or more floorsshall comply with the provisions of Chapter320, RSMo which requires outside stairwaysto be constructed of iron or steel. II

(J) Fire escapes constructed on or afterNovember 13, 1980, whether interior orexterior, shall be thirty-six inches (36") wide,shall have eight-inch (8") maximum risers,nine-inch (9") minimum tread, no winders,maximum height between landings of twelvefeet (12'), minimum dimensions of landingsof forty-four inches (44"), landings at eachexit door, and handrails on both sides and beof sturdy construction, using at least two-inch(2") lumber. Exit doors to these fire escapesshall be at least thirty-six inches (36") wideand the door shall swing outward. II/III

(K) If a ramp is required to meet residents’needs under 19 CSR 30-86.042, the rampshall have a maximum slope of one to twelve(1:12) leading to grade. II/III

(8) Exit Signs.(A) Signs bearing the word EXIT in plain,

legible letters shall be placed at each requiredexit, except at doors directly from rooms toexit passageways or corridors. Letters of all

exit signs shall be at least six inches (6") highand principle strokes three-fourths of an inch(3/4") wide, except that letters of internallyilluminated exit signs shall not be less thanfour inches (4") high. II

(B) Directional indicators showing thedirection of travel shall be placed in corri-dors, passageways, or other locations wherethe direction of travel to reach the nearest exitis not apparent. II/III

(C) All required exit signs and directionalindicators shall be positioned so that bothnormal and emergency lighting illuminatesthem. II/III

(9) Complete Fire Alarm Systems.(A) Facilities that did not have a complete

fire alarm system prior to August 28, 2007,shall have a complete fire alarm systeminstalled in accordance with NFPA 101, Sec-tion 18.3.4, 2000 edition. The complete firealarm shall automatically transmit to the firedepartment, dispatching agency, or centralmonitoring company. The complete firealarm system shall include visual signals andaudible alarms that can be heard throughoutthe building and a main panel that intercon-nects all alarm-activating devices and audiblesignals. At a minimum, the complete firealarm system shall consist of a manual pullstation at or near each attendant’s station andeach required exit in accordance with NFPA72, 1999 edition and the following I/II:

1. For facilities with a sprinkler systemin accordance with NFPA 13, 1999 edition,smoke detectors interconnected to the com-plete fire alarm system shall be installed in allcorridors and spaces open to the corridor.Smoke detectors shall be no more than thirtyfeet (30') apart with no point on the ceilingmore than twenty-one feet (21') from asmoke detector. I/II

2. For facilities with a sprinkler systemin accordance with NFPA 13R, 1999 edition,smoke detectors interconnected to the com-plete fire alarm system shall be installed incorridors, spaces open to the corridor, and inaccessible spaces, as required by NFPA 72,1999 edition, not protected by the sprinklersystem. Smoke detectors shall be no morethan thirty feet (30') apart with no point onthe ceiling more than twenty-one feet (21')from a smoke detector. Smoke detectors shallnot be installed in areas where environmentalinfluences may cause nuisance alarms. Suchareas include, but are not limited to kitchens,laundries, bathrooms, mechanical air han-dling rooms, and attic spaces. In these areas,heat detectors interconnected to the completefire alarm system shall be installed. Bath-rooms not exceeding fifty-five (55) squarefeet and clothes closets, linen closets, and

pantries not exceeding twenty-four (24)square feet are exempt from having anydetection device if the wall and ceilings aresurfaced with limited-combustible or non-combustible material as defined in NFPA101, 2000 edition. Concealed spaces of non-combustible or limited combustible construc-tion are not required to have detectiondevices. These spaces may have limitedaccess but cannot be occupied or used forstorage. I/II

3. For facilities without an approvedsprinkler system, smoke detectors intercon-nected to the complete fire alarm system shallbe installed in all accessible spaces, asrequired by NFPA 72, 1999 edition, withinthe facility. Smoke detectors shall be no morethan thirty feet (30') apart with no point onthe ceiling more than twenty-one feet (21')from a smoke detector. Smoke detectors shallnot be installed in areas where environmentalinfluences may cause nuisance alarms. Suchareas include, but are not limited to kitchens,laundries, bathrooms, mechanical air han-dling rooms, and attic spaces. In these areas,heat detectors interconnected to the fire alarmsystem shall be installed. Bathrooms notexceeding fifty-five (55) square feet andclothes closets, linen closets, and pantries notexceeding twenty-four (24) square feet areexempt from having any detection device ifthe wall and ceilings are surfaced with limit-ed-combustible or noncombustible materialas defined in NFPA 101, 2000 edition. Con-cealed spaces of noncombustible or limitedcombustible construction are not required tohave detection devices. These spaces mayhave limited access but cannot be occupied orused for storage. I/II

(B) Facilities that had a complete firealarm system prior to August 28, 2007, shallhave a complete fire alarm system, in accor-dance with the applicable edition of NFPA72, that at a minimum contains the followingcomponents: interconnected smoke detectorsthroughout the facility, automatic transmis-sion to the fire department, dispatching agen-cy, or central monitoring company, manualpull stations at each required exit and atten-dant’s station, heat detectors, and audible andvisual alarm indicators. I/II

1. Smoke detectors interconnected to thecomplete fire alarm system shall be locatedno more than thirty feet (30') apart in thecorridors or passageways with no point in thecorridor or passageway more than fifteen feet(15') from a detector and no point in thebuilding more than thirty feet (30’) from adetector. In facilities licensed prior toNovember 13, 1980, smoke detectors locatedevery fifty feet (50') will be acceptable. I/II



A. Facilities without an approvedsprinkler system shall have one (1) or moreindividual home-type smoke detectors perresident-use room. The individual home-typesmoke detectors shall be UL-approved bat-tery-powered detectors which sense smokeand automatically sound an alarm which canbe heard throughout the facility. I/II

B. Individual home-type detectorsshall be tested monthly and batteries shall bechanged as needed. Any fault with any detec-tor shall be corrected immediately upon dis-covery. A record shall be kept of the dates oftesting and the changing of batteries. II/III

2. Heat detectors, interconnected to thefire alarm system, shall be installed in areaswhere environmental influences may causenuisance alarms, unless the area is protectedby an approved sprinkler system. Such areasinclude, but are not limited to kitchens, laun-dries, bathrooms, mechanical air handlingrooms, and attic spaces. Bathrooms notexceeding fifty-five (55) square feet areexempt from having a heat detector if the walland ceilings are surfaced with limited-com-bustible or noncombustible material asdefined in NFPA 101, 2000 edition. I/II

(C) All facilities shall test and maintain thecomplete fire alarm system in accordancewith NFPA 72, 1999 edition. I/II

(D) All facilities shall have inspections andwritten certifications of the complete firealarm system completed by an approved qual-ified service representative in accordancewith NFPA 72, 1999 edition, at least annual-ly. I/II

(E) Facilities shall test by activating thecomplete fire alarm system at least once amonth. I/II

(F) Facilities shall maintain a record of thecomplete fire alarm tests, inspections, andcertifications required by subsections (9)(C)and (D) of this rule. III

(G) Upon discovery of a fault with thecomplete fire alarm system, the facility shallpromptly correct the fault. I/II

(H) When a complete fire alarm system isto be out of service for more than four (4)hours in a twenty-four (24)-hour period, thefacility shall immediately notify the depart-ment and the local fire authority and imple-ment an approved fire watch in accordancewith NFPA 101, 2000 edition, until the com-plete fire alarm system has returned to fullservice. I/II

(I) The complete fire alarm system shall beactivated by all of the following: sprinklersystem flow alarm, smoke detectors, heatdetectors, manual pull stations, and activationof the rangehood extinguishment system.II/III

(10) Protection from Hazards.(A) In assisted living facilities and residen-

tial care facilities licensed on or after Novem-ber 13, 1980, for more than twelve (12) res-idents, hazardous areas shall be separated byconstruction of at least a one (1)-hour fire-resistant rating. In facilities equipped with acomplete fire alarm system, the one (1)-hourfire separation is required only for furnace orboiler rooms. Hazardous areas equipped witha complete sprinkler system are not requiredto have this one (1)-hour fire separation.Doors to hazardous areas shall be self-closingand shall be kept closed unless an electro-magnetic hold-open device is used which isinterconnected with the fire alarm system.When the sprinkler option is chosen, theareas shall be separated from other spaces bysmoke-resistant partitions and doors. Thedoors shall be self-closing or automatic-clos-ing. Facilities formerly licensed as residentialcare facility I or II, and existing prior toNovember 13, 1980, shall be exempt fromthis requirement. II

(B) The storage of unnecessary com-bustible materials in any part of a building inwhich a licensed facility is located is prohib-ited. I/II

(C) Electric or gas clothes dryers shall bevented to the outside. Lint traps shall becleaned regularly to protect against fire haz-ard. II/III

(D) In facilities that are required to complywith the requirements of 19 CSR 30-86.043and were formerly licensed as residential carefacilities II on or after November 13, 1980,each floor shall be separated by constructionof at least a one (1)-hour fire resistant rating.Buildings equipped with a complete sprinklersystem may have a nonrated smoke separationbarrier between floors. Doors between floorsshall be a minimum of one and three-fourthsinches (1 3/4") thick and be solid core wooddoors or metal doors with an equivalent firerating. II

(E) In facilities licensed prior to November13, 1980, and multi-storied residential carefacilities formerly licensed as residential carefacilities I licensed on or after November 13,1980, there shall be a smoke separation bar-rier between the floors of resident-use areasand any floor below the resident-use area.This shall consist of a solid core wood dooror metal door with an equivalent fire rating atthe top or the bottom of the stairs. There shallnot be a transom above the door that wouldpermit the passage of smoke. II

(F) Atriums open between floors will bepermitted if resident room corridors are sep-arated from the atrium by one (1)-hour ratedsmoke walls. These corridors must haveaccess to at least one (1) of the required exits

without traversing any space opened to theatrium. II

(G) All doors providing separation betweenfloors shall have a self-closing deviceattached. If the doors are to be held open,electromagnetic hold-open devices shall beused that are interconnected with either anindividual smoke detector or a complete firealarm system. II

(H) All facilities shall be divided into atleast two (2) smoke sections with each sec-tion not exceeding one hundred fifty feet(150') in length or width. If the floor’sdimensions do not exceed seventy-five feet(75') in length or width, a division of thefloor into two (2) smoke sections will not berequired. II

(I) In facilities whose plans were approvedor which were initially licensed after Decem-ber 31, 1987, for more than twenty (20) res-idents and all facilities licensed after August28, 2007, each smoke section shall be sepa-rated by one (1)-hour fire rated smoke parti-tions. The smoke partitions shall be continu-ous from outside wall-to-outside wall andfrom floor-to-floor or floor-to-roof deck. Alldoors in this wall shall be at least twenty(20)-minute fire-rated or its equivalent, self-closing, and may be held open only if thedoor closes automatically upon activation ofthe complete fire alarm system. II

(J) In all facilities that were initiallylicensed on or prior to December 31, 1987and all facilities licensed for twenty (20) orfewer beds prior to August 28, 2007, eachsmoke section shall be separated by a one (1)-hour fire-rated smoke partition that extendsfrom the inside portion of an exterior wall tothe inside portion of an exterior wall andfrom the floor to the underside of the floor orroof deck above, through any concealedspaces, such as those above suspended ceil-ings, and through interstitial structural andmechanical spaces. Smoke partitions shall bepermitted to terminate at the underside of amonolithic or suspending ceiling systemwhere the following conditions are met: Theceiling system forms a continuous membrane,a smoketight joint is provided between the topof the smoke partition and the bottom of thesuspended ceiling and the space above theceiling is not used as a plenum. Smoke parti-tion doors shall be at least twenty (20)-minutefire-rated or its equivalent, self-closing, andmay be held open only if the door closesautomatically upon activation of the completefire alarm system. II

(K) Facilities whose plans were approvedor which were initially licensed after Decem-ber 31, 1987, for more than twenty (20) res-idents and which are unsprinklered shall haveone (1)-hour rated corridor walls with one


Secretary of State


and three-quarters inch (1 3/4") solid corewood doors or metal doors with an equivalentfire rating. II

(L) If two (2) or more levels of long-termcare or two (2) different businesses are locat-ed in the same building, the entire buildingshall meet either the most strict constructionand fire safety standards for the combinedfacility or the facilities shall be separatedfrom the other(s) by two (2)-hour fire-resis-tant construction. In buildings equipped witha complete sprinkler system in accordancewith NFPA 13 or NFPA 13R, 1999 edition,this separation may be rated at one (1) hour.II

(11) Sprinkler Systems.(A) Facilities licensed on or after August

28, 2007, or any facility performing majorrenovations to the facility shall have a com-plete sprinkler system installed in accordancewith NFPA 13, 1999 edition. I/II

(B) Facilities that have sprinkler systemsinstalled prior to August 28, 2007, shalloperate, maintain, and test these systems inaccordance with NFPA 13, 1999 edition, orNFPA 13R, 1999 edition, and NFPA 25,1998 edition. I/II

(C) All residential care facilities, andassisted living facilities that do not admit orretain a resident with a physical, cognitive, orother impairment that prevents the individualfrom safely evacuating the facility with mini-mal assistance, that were licensed prior toAugust 28, 2007, with more than twenty (20)residents, and do not have an approved sprin-kler system in accordance with NFPA 13,1999 edition, or NFPA 13R, 1999 edition,shall have until December 31, 2012, to installan approved sprinkler system in accordancewith NFPA 13 or 13R, 1999 edition. I/II Thedepartment shall grant exceptions to thisrequirement if the facility meets Chapter 33of NFPA 101, 2000 edition, and the evacua-tion capability of the facility meets the stan-dards required in NFPA 101A, Guide toAlternative Approaches to Life Safety, 2001edition. I/II

(D) Single-story assisted living facilitiesthat provide care to one (1) or more residentswith a physical, cognitive, or other impair-ment that prevents the individual from safelyevacuating the facility with minimal assis-tance shall install and maintain an approvedsprinkler system in accordance with NFPA13R, 1999 edition. I/II

(E) Multi-level assisted living facilities thatprovide care to one (1) or more residents witha physical, cognitive, or other impairmentthat prevents the individual from safely evac-uating the facility with minimal assistanceshall install and maintain an approved sprin-

kler system in accordance with NFPA 13,1999 edition. I/II

(F) All facilities shall have inspections andwritten certifications of the approved sprin-kler system completed by an approved quali-fied service representative in accordance withNFPA 25, 1998 edition. The inspections shallbe in accordance with the provisions of NFPA25, 1998 edition, with certification at leastannually by a qualified service representative.I/II

(G) When a sprinkler system is to be out-of-service for more than four (4) hours in atwenty-four (24)-hour period, the facilityshall immediately notify the department andimplement an approved fire watch in accor-dance with NFPA 101, 2000 edition, until thesprinkler system has been returned to full ser-vice. I/II

(12) All facilities shall submit, by July 1,2008, a plan for compliance to the state firemarshal showing how the facility meets therequirements of sections (9) and (11) andsubsections (10)(H) and (10)(I) of this rule.If the facility’s plan for compliance does notmeet the requirements of sections (9) and(11) and subsections (10)(H) and (10)(I) ofthis rule, the facility shall provide the statefire marshal with a written plan to include ata minimum an explanation of how therequirements of sections (9) and (11) andsubsections (10)(H) and (10)(I) will be met,when they will be met, and contact informa-tion in the event the plan does not evidencecompliance with these requirements. II

(A) To qualify for a sprinkler systemexception, the facility shall present evidenceto the state fire marshal in writing that thefacility meets the safety requirements ofChapter 33 of existing residential board andcare occupancies of NFPA 101 Life SafetyCode. II

(13) Emergency Lighting.(A) Emergency lighting of sufficient inten-

sity shall be provided for exits, stairs, resi-dent corridors, and attendants’ station. II

(B) The lighting shall be supplied by anemergency service, an automatic emergencygenerator, or battery operated lighting sys-tem. This emergency lighting system shall beequipped with an automatic transfer switch.II

(C) If battery powered lights are used, theyshall be capable of operating the light for atleast one and one-half (1 1/2) hours. II

(14) Interior Finish and Furnishings.(A) In a facility licensed on or after

November 13, 1980, for more than twelve(12) residents, wall and ceiling surfaces of all

occupied rooms and all exitways shall be clas-sified either Class A or B interior finish asdefined in NFPA 101, 2000 edition. II

(B) In facilities licensed prior to November13, 1980, all wall and ceiling surfaces shallbe smooth and free of highly combustiblematerials. II

(C) In a facility licensed on or afterNovember 13, 1980, for more than twelve(12) residents, the new or replacement floorcovering and carpeting shall be Class I interi-or floor finish in nonsprinklered buildingsand Class II interior floor finish in sprin-klered buildings as defined in NFPA 101,2000 edition. II/III

(D) All new or replacement curtains anddrapes in a licensed facility shall be certifiedor treated to be flame-resistant as defined inNFPA 101, 2000 edition. II

(15) Smoking.(A) Smoking shall be permitted in desig-

nated areas only. Areas where smoking ispermitted shall be designated as such andshall be supervised either directly or by a res-ident informing an employee of the facilitythat the area is being used for smoking. II/III

(B) Ashtrays shall be made of noncom-bustible material and safe design and shall beprovided in all areas where smoking is per-mitted. II/III

(C) The contents of ashtrays shall be dis-posed of properly in receptacles made of non-combustible material. II/III

(16) Trash and Rubbish Disposal.(A) Only metal or UL- or FM-fire-resis-

tant rated wastebaskets shall be used fortrash. II

(B) Trash shall be removed from thepremises as often as necessary to prevent firehazards and public health nuisance. II

(C) No trash shall be burned within fiftyfeet (50') of any facility except in an approvedincinerator. I/II

(D) Trash may be burned only in a mason-ry or metal container. II

(E) The container shall be equipped with ametal cover with openings no larger than one-half inch (1/2") in size. III

(17) Standards for Designated SeparatedAreas.

(A) When a resident resides among theentire general population of the facility, thefacility shall take necessary measures to pro-vide such residents with the opportunity toexplore the facility and, if appropriate, itsgrounds. When a resident resides within adesignated, separated area that is secured bylimited access, the facility shall take neces-sary measures to provide such residents with



the opportunity to explore the separated areaand, if appropriate, its grounds. If enclosedor fenced courtyards are provided, residentsshall have reasonable access to such court-yards. Enclosed or fenced courtyards that areaccessible through a required exit door shallbe large enough to provide an area of refugefor fire safety at least thirty feet (30') fromthe building. Enclosed or fenced courtyardsthat are accessible through a door other thana required exit shall have no size require-ments. II

(B) The facility shall provide freedom ofmovement for the residents to common areasand to their personal spaces. The facility shallnot lock residents out of or inside theirrooms. I/II

(C) The facility may allow resident roomdoors to be locked providing the residentsrequest to lock their doors. Any lock on aresident room door shall not require the useof a key, tool, special knowledge, or effort tolock or unlock the door from inside the resi-dent’s room. Only one (1) lock shall be per-mitted on each door. The facility shall ensurethat facility staff has the means or mecha-nisms necessary to open resident room doorsin case of an emergency. I/II

(D) The facility may provide a designated,separated area where residents, who are men-tally incapable of negotiating a pathway tosafety, reside and receive services and whichis secured by limited access if the followingconditions are met:

1. Dining rooms, living rooms, activityrooms, and other such common areas shall beprovided within the designated, separatedarea. The total area for common areas withinthe designated, separated area shall be equalto at least forty (40) square feet per resident;II/III

2. Doors separating the designated, sep-arated area from the remainder of the facilityor building shall not be equipped with locksthat require a key to open; I/II

3. If locking devices are used on exitdoors egressing the facility or on doorsaccessing the designated, separated area,delayed egress magnetic locks shall be used.These delayed egress devices shall complywith the following:

A. The lock must unlock when thefire alarm is activated;

B. The lock must unlock when thepower fails;

C. The lock must unlock within thir-ty (30) seconds after the release device hasbeen pushed for at least three (3) seconds,and an alarm must sound adjacent to thedoor;

D. The lock must be manually resetand cannot automatically reset; and

E. A sign shall be posted on the doorthat reads: PUSH UNTIL ALARMSOUNDS, DOOR CAN BE OPENED IN 30SECONDS. I/II

4. The delayed egress magnetic locksmay also be released by a key pad locatedadjacent to the door for routine use by staff.I/II

AUTHORITY: sections 198.073, 198.074,and 198.076, RSMo Supp. 2008.* This ruleoriginally filed as 13 CSR 15-15.022. Origi-nal 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 May13, 1987, effective Aug. 13, 1987. Amended:Filed Aug. 1, 1988, effective Nov. 10, 1988.Amended: Filed Feb. 28, 2000, effective Sept.30, 2000. Moved to 19 CSR 30-86.022, effec-tive Aug. 28, 2001. Amended: Filed Aug. 16,2004, effective Feb. 28, 2005. Amended:Filed Aug. 1, 2005, effective Jan. 30, 2006.Amended: Filed Aug. 23, 2006, effectiveApril 30, 2007. Emergency amendment filedNov. 24, 2008, effective Dec. 4, 2008,expired June 1, 2009. Amended: Filed Nov.24, 2008, effective May 30, 2009.

*Original authority: 198.073, RSMo 1979, amended1984, 1992, 1999, 2006; 198.074, RSMo 2007; and198.076, RSMo 1979, amended 1984, 2007.

19 CSR 30-86.032 Physical Plant Require-ments for Residential Care Facilities andAssisted Living Facilities

PURPOSE: This rule establishes standardsfor the physical plant of new or existing resi-dential care facilities I and II.


Editor’s Note: All rules relating to long-termcare facilities licensed by the department arefollowed by a Roman Numeral notation whichrefers to the class (either class I, II or III) ofstandard as designated in section 198.085.1,RSMo 2000.


(A) Adult day health care program shallmean a program operated by a provider certi-fied to provide Medicaid-reimbursed adultday health care services to Medicaid-eligibleparticipants in accordance with 19 CSR 70-92.010;

(B) Associated adult day health care pro-gram shall mean an adult day health care pro-gram, which is connected physically with alicensed long-term care facility but has sepa-rate designated space for an adult day healthcare program which is above the licensedspace requirement for the long-term care res-idents. An associated adult day health careprogram may share, in part, staff, equipment,utilities, dietary and security with the con-nected long-term care facility. Recipients ofadult day health care program may participatewith the residents of the long-term care facil-ity for some activities and programs;

(C) Home-like—means a self-containedlong-term care setting that integrates the psy-chosocial, organizational and environmentalqualities that are associated with being athome. Home-like may include, but is not lim-ited to the following:

1. A living room and common use areasfor social interactions and activities;

2. Kitchen and family style eating areafor use by the residents;

3. Laundry area for use by residents;4. A toilet room that contains a toilet,


5. Resident room preferences for resi-dents who wish to share a room, and for res-idents who wish to have private bedrooms;

6. Outdoor area for outdoor activitiesand recreation; and

7. A place where residents can give andreceive affection, explore their interests,exercise control over their environment,engage in interactions with others and haveprivacy, security, familiarity and a sense ofbelonging; and

(D) Non-licensed adult day care programshall mean a group program designated toprovide care and supervision to meet theneeds of four (4) or fewer impaired adults forperiods of less than twenty-four (24) hoursbut more than two (2) hours per day in along-term care facility.

(2) The building shall be substantially con-structed and shall be maintained in goodrepair and in accordance with the construc-tion and fire safety rules in effect at the timeof initial licensing. II/III


Secretary of State




(3) Only activities necessary to the adminis-tration of the facility shall be contained in anybuilding used as a long-term care facilityexcept as follows:

(A) Related activities may be conducted inbuildings subject to prior written approval ofthese activities by the Department of Healthand Senior Services (hereinafter—the depart-ment). Examples of these activities are HomeHealth Agencies, physician’s office, pharma-cy, ambulance service, child day care andfood service for the elderly in the communi-ty;

(B) Adult day care may be provided forfour (4) or fewer participants without priorwritten approval of the department if thelong-term care facility meets the followingstipulations:

1. The operation of the adult day carebusiness shall not interfere with the care anddelivery of services to the long-term care res-idents;

2. The facility shall only accept partici-pants in the adult day care program appropri-ate to the level of care of the facility andwhose needs can be met;

3. The facility shall not change the phys-ical layout of the facility without prior writtenapproval of the department;

4. The facility shall provide a privatearea for adult day care residents to nap orrest;

5. Adult day care participants shall notbe included in the census, and the number ofadult day care participants shall not be morethan four (4) above the licensed capacity ofthe facility; and

6. The adult day care participants, whileon-site, are to be included in the determina-tion of staffing patterns for the long-term carefacility;

(C) An associated adult day health careprogram may be operated without prior writ-ten approval if the provider of the adult dayhealth care services is certified in accordancewith 19 CSR 70-92.010. II/III

(4) All stairways shall be equipped with per-manently secured handrails on at least one (1)side. III

(5) There shall be a telephone in the facilityand additional telephones or extensions asnecessary so that help may be summonedpromptly in case of fire, accident, acute ill-ness or other emergency. II/III

(6) Bath and toilet facilities shall be providedfor the convenience, privacy, comfort andsafety of residents. Fixed partitions or cur-tains shall be provided in toilet and bath-rooms to assure privacy. II/III

(7) Newly licensed facilities shall havehandrails and grab bars affixed in all toiletand bathing areas. Existing licensed facilitiesshall have handrails and grab bars available inat least one (1) bath and toilet area. The fore-going requirements are applicable to residen-tial care facilities. All assisted living facilitiesshall have handrails and grab bars affixed inall toilet and bathing areas. II

(8) There shall be adequate storage areas forfood, supplies, linen, equipment and resi-dent’s personal possessions. III

(9) Each room or ward in which residents arehoused or to which residents have reasonableaccess shall be capable of being heated to notless than eighty degrees Fahrenheit (80°F)under all weather conditions. Temperatureshall not be lower than sixty-eight degreesFahrenheit (68°F) and the reasonable comfortneeds of individual residents shall be met.I/II

(10) In newly licensed facilities or if a newheating system is installed in an existinglicensed facility, the heating of the buildingshall be restricted to steam, hot water, per-manently installed electric heating devices ora warm air system employing central heatingplants with installation such as to safeguardthe inherent fire hazard, or approved installa-tion of outside wall heaters which bear theapproved label of the American Gas Associa-tion or National Board of Fire Underwriters.The foregoing requirements are applicable toresidential care facilities. In assisted livingfacilities, the heating of the building shall berestricted to steam, hot water, permanentlyinstalled electric heating devices or a warmair system employing central heating plantswith installation such as to safeguard theinherent fire hazard, or approved installationof outside wall heaters which bear theapproved label of the American Gas Associa-tion or National Board of Fire Underwriters.For all facilities, oil or gas heating appliancesshall be properly vented to the outside andthe use of portable heaters of any kind is pro-hibited. If approved wall heaters are used,adequate guards shall be provided to safe-guard residents. I/II

(11) Wood-burning stoves shall not beinstalled in newly licensed facilities or inexisting licensed facilities that did not previ-ously have a wood-burning stove. If wood-burning stoves are used in an existinglicensed facility, or wood-burning furnaces orfireplaces are used, flues or chimneys shallbe maintained in good condition and kept freeof accumulation of combustible materials.The foregoing requirements are applicable toresidential care facilities. Wood-burning

stoves shall not be installed in assisted livingfacilities. II

(12) Fireplaces may be used only if there is aprotective screen in place; if there is directstaff supervision of residents while in use;and the fire shall not be left burningovernight. II

(13) In facilities that are constructed or haveplans approved after July 1, 2005, electricalwiring shall be installed and maintained inaccordance with the requirements of theNational Electrical Code, 1999 edition,National Fire Protection Association, Inc.,incorporated by reference, in this rule andavailable by mail at One Batterymarch Park,Quincy, MA 02269, and local codes. Thisrule does not incorporate any subsequentamendments or additions to the materialsincorporated by reference. Facilities builtbetween September 28, 1979 and July 1,2005 shall be maintained in accordance withthe requirements of the National ElectricalCode, which was in effect at the time of theoriginal plan approval and local codes. Thisrule does not incorporate any subsequentamendments or additions. In facilities builtprior to September 28, 1979, electricalwiring shall be maintained in good repair andshall not present a safety hazard. All facili-ties shall have wiring inspected every two (2)years by a qualified electrician. II/III

(14) Lighting is restricted to electricity. II

(15) Lighting in hallways, bathrooms, recre-ational and dining areas and all resident-useareas shall be provided with a minimumintensity of ten (10) footcandles. All lights inresident-use areas shall be provided with ashade to prevent direct glare to the residents’eyes. II/III

(16) Night lights shall be provided for corri-dors, stairways and toilet areas. II

(17) A reading light shall be provided foreach resident desiring to read. Additionallighting shall be provided to meet the indi-vidual needs of each resident. III

(18) If extension cords are used, they must beUnderwriters’ Laboratory (UL)-approved orshall comply with other recognized electricalappliance approval standards and sized tocarry the current required for the applianceused. Only one (1) appliance shall be con-nected to one (1) extension cord and only two(2) appliances may be served by one (1)duplex receptacle. If extension cords areused, they shall not be placed under rugs,through doorways or located where they aresubject to physical damage. II/III

(19) If elevators are used, installation andmaintenance shall comply with local andstate codes and the National Electric Code.II/III

(20) Air conditioning, fans or a ventilatingsystem shall be available and used when theroom temperature exceeds eighty-fivedegrees Fahrenheit (85°F) and the reasonablecomfort needs of individual residents shall bemet. I/II

(21) Gas-fired water heaters shall be proper-ly installed and vented and all water heatersshall be equipped with a temperature andpressure relief valve. II

(22) Furniture and equipment shall be main-tained in good condition and shall be replacedif broken, torn, heavily soiled or damaged.Rooms shall be so designed and furnishedthat the comfort and safety of the residentsare provided for at all times. II/III

(23) Rooms shall be neat, orderly andcleaned daily. II/III

(24) An individual bed, in good repair and ofa rigid type, shall be provided to each resi-dent. Beds shall be at least thirty-six inches(36") wide. Double beds of satisfactory con-struction may be provided for married cou-ples. Rollaway, metal cots or folding bedsshall not be used. II/III

(25) A minimum of three feet (3') shall beavailable between beds when parallel. III

(26) Mattresses shall be clean, in good repairand a minimum of four inches (4") in thick-ness to provide comfort. II/III

(27) Each bed shall be provided with at leastone (1) clean, comfortable pillow. Extra pil-lows shall be available to meet the needs ofthe residents. III

(28) Screens or curtains, either portable orpermanently affixed, shall be available andused in multi-resident bedrooms to provideprivacy as needed or if requested. III

(29) Each resident shall be provided with anindividual locker or other suitable space forstorage of clothing and personal belongings.III

(30) Each resident shall be provided with anindividual rack for a towel(s) and wash-cloth(s) unless provided with a clean wash-cloth(s) or towel(s) for use each time needed.III

(31) A comfortable chair shall be availablefor each resident’s use. III

(32) Each window shall be provided with ashade, drape or curtain to restrict the amountof sunlight when necessary. III

(33) All assisted living facilities and all resi-dential care facilities whose plans areapproved or which are initially licensed formore than twelve (12) residents after Decem-ber 31, 1987 shall be equipped with a callsystem consisting of an electrical intercom-munication system, a wireless pager system,buzzer system or hand bells. An acceptablemechanism for calling attendants shall belocated in each toilet room and resident bed-room. Call systems for facilities whose plansare approved or which are initially licensedafter December 31, 1987 shall be audible inthe attendant’s work area. II/III

(34) Plumbing fixtures which are accessibleto residents and which supply hot water shallbe thermostatically controlled so that thewater temperature at the fixture does notexceed one hundred twenty degrees Fahren-heit (120°F) (49°C) and the water shall be ata temperature range between one hundredfive degrees Fahrenheit (105°F) (41°C) andone hundred twenty degrees Fahrenheit(120°F) (49°C). I/II

(35) Home-Like Requirements with Respectto Construction and Physical Plant Standards.

(A) Any assisted living facility formerlylicensed as a residential care facility shall bemore home-like than institutional withrespect to construction and physical plantstandards. II

(B) Any assisted living facility licensed asa residential care facility II prior to August28, 2006, shall qualify as being more home-like than institutional with respect to con-struction and physical plant standards. II

(C) Any assisted living facility that is builtor has plans approved on or after August 28,2006, shall be more home-like than institu-tional with respect to construction and physi-cal plant standards. II

AUTHORITY: sections 198.076, RSMo 2000and 198.005 and 198.073, RSMo Supp.2006.* This rule originally filed as 13 CSR15-15.032. Original rule filed July 13, 1983,effective Oct. 13, 1983. Emergency amend-ment filed Nov. 9, 1983, effective Nov. 19,1983, expired March 18, 1984. Amended:Filed Nov. 9, 1983, effective Feb. 11, 1984.Emergency amendment filed Aug. 1, 1984,effective Aug. 13, 1984, expired Dec. 10,1984. Amended: Filed Sept. 12, 1984, effec-tive Dec. 13, 1984. Amended: Filed May 13,

1987, effective Aug. 13, 1987. Amended:Filed Aug. 1, 1988, effective Nov. 10, 1988.Moved to 19 CSR 30-86.032, effective Aug.28, 2001. Amended: Filed Nov. 15, 2004,effective May 30, 2005. Amended: Filed Aug.23, 2006, effective April 30, 2007.


19 CSR 30-86.042 Administrative, Person-nel and Resident Care Requirements forNew and Existing Residential Care Facili-ties

PURPOSE: This rule establishes standardsfor administration, personnel and residentcare in residential care facilities I and II.



(A) Department—Department of Healthand Senior Services;

(B) Outbreak—an occurrence in a commu-nity or region of an illness(es) similar innature, clearly in excess of normal expectan-cy and derived from a common or a propa-gated source; and

(C) Evacuate the facility—moving to anarea of refuge or from one (1) smoke sectionto another or exiting the facility.

(2) For a residential care facility, a personshall be designated as administrator/managerwho is either currently licensed as a nursinghome administrator or is at least twenty-one(21) years of age, has never been convicted ofan offense involving the operation of a long-term care or similar facility and who attendsat least one (1) continuing education work-shop within each calendar year given by orapproved by the department. When used inthis chapter of rules, the term manager shallmean that person who is designated by theoperator to be in general administrativecharge of a residential care facility. It shall beconsidered synonymous to “administrator” asdefined in section 198.006, RSMo and theterms administrator and manager may beused interchangeably. II/III

(3) The administrator/manager of a residen-tial care facility shall have successfully com-pleted the state approved Level I Medication


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Aide course unless he or she is a physician,pharmacist, licensed nurse or a certifiedmedication technician, or if the facility isoperating in conjunction with a skilled nurs-ing facility or intermediate care facility on thesame premises, or, for an assisted living facil-ity, if the facility employs on a full-time basis,a licensed nurse who is available seven (7)days per week. II/III

(4) The operator shall be responsible toassure compliance with all applicable lawsand regulations. The administrator/managershall be fully authorized and empowered tomake decisions regarding the operation of thefacility and shall be held responsible for theactions of all employees. The administra-tor/manager’s responsibilities shall includeoversight of residents to assure that theyreceive care appropriate to their needs. II/III

(5) The administrator/manager shall devotesufficient time and attention to the manage-ment of the facility as is necessary for thehealth, safety and welfare of the residents. II

(6) The administrator/manager shall desig-nate, in writing, a staff member in charge inthe administrator/manager’s absence. II/III

(7) The facility shall not care for more resi-dents than the number for which the facilityis licensed. If the facility operates a non-licensed adult day care program within thelicensed facility, the day care participantsshall be counted in the staffing determinationduring the hours the day care participants arein the facility. II/III

(8) The facility’s current license shall beposted in a conspicuous place and noticesprovided to the facility by the departmentgranting exception(s) to regulatory require-ments shall be posted alongside of the facili-ty’s license. III

(9) All personnel responsible for residentcare shall have access to the legal name ofeach resident, name and telephone number ofresident’s physician, resident’s designee orlegally authorized representative in the eventof emergency. II/III

(10) All persons who have any contact withthe residents in the facility shall not know-ingly act or omit any duty in a manner whichwould materially and adversely affect thehealth, safety, welfare or property of resi-dents. No person who is listed on theEmployee Disqualification List (EDL) main-tained by the department as required by sec-tion 198.070, RSMo shall work or volunteer

in the facility in any capacity whether or notemployed by the operator. For the purpose ofthis rule, a volunteer is an unpaid individualformally recognized by the facility as provid-ing a direct care service to residents. Thefacility is required to check the EDL for indi-viduals who volunteer to perform a servicefor which the facility might otherwise have tohire an employee. The facility is not requiredto check the EDL for individuals or groupssuch as scout groups, bingo or sing-alongleaders. The facility is not required to checkthe EDL for an individual such as a priest,minister or rabbi visiting a resident who is amember of the individual’s congregation.However, if the minister, priest or rabbiserves as a volunteer facility chaplain, thefacility is required to check the EDL sincethe individual would have potential contactwith all residents. I/II

(11) Prior to allowing any person who hasbeen hired in a full-time, part-time or tempo-rary position to have contact with any resi-dents the facility shall, or in the case of tem-porary employees hired through or contractedfor an employment agency, the employmentagency shall prior to sending a temporaryemployee to a provider:

(A) Request a criminal background checkfor the person, as provided in section 43.540,RSMo. Each facility must maintain in itsrecord documents verification that the back-ground checks were requested and the natureof the response received for each suchrequest. II

1. The facility must ensure that anyapplicant or person hired or retained who dis-closes prior to the receipt of the criminalbackground check that he or she has beenconvicted of, pled guilty or pled nolo con-tendere to in this state or any other state orhas been found guilty of a crime, which ifcommitted in Missouri would be a class A orB felony violation of Chapter 565, 566, or569, RSMo or any violation of subsection198.070.3, RSMo or of section 568.020,RSMo, will not have contact with residents.I/II

2. Upon receipt of the criminal back-ground check, the facility must ensure that ifthe criminal background check indicates thatthe person hired or retained by the facility hasbeen convicted of, pled guilty or pled nolocontendere to in this state or any other stateor has been found guilty of a crime, which ifcommitted in Missouri would be a class A orB felony violation of Chapter 565, 566, or569, RSMo or any violation of subsection198.070.3, RSMo or of section 568.020,RSMo, the person will not have contact withresidents unless the facility obtains verifica-

tion from the department that a good causewaiver has been granted and maintains a copyof the verification in the individual’s person-nel file; I/II

(B) Make an inquiry to the department,whether the person is listed on the employeedisqualification list as provided in section660.315, RSMo. The inquiry may be madevia Internet at www.dhss.mo.gov/EDL/;II/III

(C) If the person has registered with thedepartment’s Family Care Safety Registry(FCSR), the facility may utilize the Registryin order to meet the requirements of subsec-tions (1)(A) and (11)(B) of this rule. TheFCSR is available via Internet atwww.dhss.mo.gov/EDL/; and II/III

(D) For persons for whom the facility hascontracted for professional services (e.g.,plumbing or air conditioning repair) that willhave contact with any resident, the facilitymust either require a criminal backgroundcheck or ensure that the individual is suffi-ciently monitored by facility staff while in thefacility to reasonably ensure the safety of allresidents. I/II

(12) A facility shall not employ as an agent oremployee who has access to controlled sub-stances any person who has been found guiltyor entered a plea of guilty or nolo contenderein a criminal prosecution under the laws ofany state or of the United States for anyoffense related to controlled substances. II

(A) A facility may apply in writing to thedepartment for a waiver of this section for aspecific employee.

(B) The department may issue a writtenwaiver to a facility upon determination that awaiver would be consistent with the publichealth and safety. In making this determina-tion, the department shall consider the dutiesof the employee, the circumstances surround-ing the conviction, the length of time sincethe conviction was entered, whether a waiverhas been granted by the department’s Bureauof Narcotics and Dangerous Drugs pursuantto 19 CSR 30-1.034 when the facility is reg-istered with that agency, whether a waiver hasbeen granted by the federal Drug Enforce-ment Administration (DEA) pursuant to 21CFR 1301.76 when the facility is also regis-tered with that agency, the security measurestaken by the facility to prevent the theft anddiversion of controlled substances, and anyother factors consistent with public healthand safety. II/III

(13) The facility must develop and implementwritten policies and procedures which requirethat persons hired for any position which is tohave contact with any patient or resident have



been informed of their responsibility to dis-close their prior criminal history to the facil-ity as required by section 660.317.5, RSMo.The facility must also develop and implementpolicies and procedures which ensure that thefacility does not knowingly hire, after August28, 1997, any person who has or may havecontact with a patient or resident, who hasbeen convicted of, plead guilty or nolo con-tendere to, in this state or any other state, orhas been found guilty of any class A or Bfelony violation of Chapter 565, 566 or 569,RSMo, or any violation of subsection 3 ofsection 198.070, RSMo, or of section568.020, RSMo. II/III

(14) All persons who have or may have con-tact with residents shall at all time when onduty or delivering services wear an identifi-cation badge. The badge shall give theirname, title and, if applicable, the status oftheir license or certification as any kind ofhealth care professional. This rule shall applyto all personnel who provide services to anyresident directly or indirectly. III

(15) All personnel shall be able physicallyand emotionally to work in a long-term carefacility. I/II

(16) Personnel who have been diagnosed witha communicable disease may begin work orreturn to duty only with written approval by aphysician or physician’s designee which indi-cates any limitations. II

(17) The administrator/manager shall beresponsible for preventing an employeeknown to be diagnosed with communicabledisease from exposing residents to such dis-ease. The facility’s policies and proceduresmust comply with the department’s regula-tions pertaining to communicable diseases,specifically 19 CSR 20-20.010 through 19CSR 20-20.100. II/III

(18) The facility shall screen residents andstaff 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 newemployee works in the facility he or she shallreceive orientation of at least one (1) hourappropriate to his or her job function. Thisshall include at least the following:

(A) Job responsibilities;(B) Emergency response procedures;(C) Infection control and handwashing pro-

cedures and requirements;(D) Confidentiality of resident informa-

tion;(E) Preservation of resident dignity;

(F) Information regarding what constitutesabuse/neglect and how to report abuse/neglect to the department (1-800-392-0210);

(G) Information regarding the EmployeeDisqualification List;

(H) Instruction regarding the rights of res-idents and protection of property; and

(I) Instruction regarding working with res-idents with mental illness. II/III

(20) In addition to the orientation trainingrequired in section (19) of this rule any facil-ity that provides care to any resident havingAlzheimer’s disease or related dementia shallprovide orientation training regarding mental-ly confused residents such as those withAlzheimer’s disease and related dementias asfollows:

(A) For employees providing direct care tosuch persons, the orientation training shallinclude at least three (3) hours of trainingincluding at a minimum an overview of men-tally confused residents such as those havingAlzheimer’s disease and related dementias,communicating with persons with dementia,behavior management, promoting indepen-dence in activities of daily living, and under-standing and dealing with family issues; II/III

(B) For other employees who do not pro-vide direct care for, but may have daily con-tact with, such persons, the orientation train-ing shall include at least one (1) hour oftraining including at a minimum an overviewof mentally confused residents such as thosehaving dementias as well as communicatingwith persons with dementia; and II/III

(C) For all employees involved in the careof persons with dementia, dementia-specifictraining shall be incorporated into ongoingin-service curricula. II/III

(21) The administrator/manager shall main-tain on the premises an individual personnelrecord on each facility employee, which shallinclude 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 edu-

cation including for positions requiring licen-sure or certification, documentation evidenc-ing competency for the position held, whichincludes copies of current licenses, tran-scripts when applicable, or for those individ-uals requiring certification, such as level Imedication aides (LIMA), certified nurseaides, certified medication technicians(CMT) and insulin administration aides;printing the Web Registry search results pageavailable at www.dhss.mo.gov/cnaregistry

shall meet the requirements of the employer’scheck regarding valid certification:

(F) References, if available;(G) The results of background checks

required by section 660.317, RSMo; and acopy of any good cause waiver granted by thedepartment, if applicable;

(H) Position in the facility;(I) Written statement signed by a licensed

physician or physician’s designee indicatingthe person can work in a long-term care facil-ity and indicating any limitations;

(J) Documentation of the employee’s tuber-cilin screening status;

(K) Documentation of what the employeewas instructed on during orientation training;and

(L) Reason for termination if the employeewas terminated due to abuse or neglect of aresident, residents’ rights issues or residentinjury. III

(22) Personnel records shall be maintainedfor at least two (2) years following termina-tion of employment. III

(23) There shall be written documentationmaintained in the facility showing actualhours worked by each employee. III

(24) No one individual shall be on duty withresponsibility for oversight of residents longerthan eighteen (18) hours per day except in aresidential care facility licensed for twelve(12) or fewer residents. I/II

(25) Employees who are counted in meetingthe minimum staffing ratio and employeeswho provide direct care to the residents shallbe 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 alltimes for the proper care of residents andupkeep of the facility. At a minimum, one (1)employee shall be on duty for every forty (40)residents to provide protective oversight toresidents and for fire safety. I/II

Staff Residents1 1–402 41–803 81–1204 121–160

(B) The required staff person shall be inthe facility awake, dressed and prepared toassist residents in case of emergency, exceptthat in a facility licensed for twelve (12) orfewer residents, this person may be asleepduring the night hours. In a facility licensed


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for twenty (20) or fewer residents, therequired staff person may be asleep if there isa sprinkler system or if there is a completeautomatic fire detection system. I/II

(C) In a facility of more than one hundred(100) residents, the administrator/managershall not be counted when determining thepersonnel required. II

(D) If the facility is opened in conjunctionwith and is immediately adjacent to and con-tiguous to another licensed long-term carefacility and if—

1. The resident bedrooms of the resi-dential care facility are on the same floor oron the ground floor immediately below thatof the other licensed facility;

2. There is an approved call system ineach resident’s bedroom and bathroom or apatient-controlled system connected to a nurs-ing station of the other licensed facility;

3. There is a complete fire alarm systemin the residential care facility connected tothe complete fire alarm system in the otherlicensed facility;

4. The staffing of the other licensedfacility is greater than their minimumrequirements; and

5. Periodic visits to the residential carefacility are made by a staff person to deter-mine the welfare of the resident in the resi-dential care facility; then, for a facility serv-ing twenty (20) or fewer residents, there neednot be an attendant on duty during the dayand evening shifts and the attendant may beasleep during the night shift; or if the facilityis on the same floor as the other licensedfacility, there need not be an attendant atnight. If there are more than twenty (20) res-idents, there shall be at least one (1) staff per-son awake and dressed at all times for everyforty (40) residents or fraction of forty (40).I/II

(E) Those facilities which have only anasleep attendant during the night-time periodand those facilities which have only the min-imum staff required by subsection (27)(D)during the night-time period shall not acceptresidents who are blind, use assistive devices,such as walkers or wheelchairs, or who needcare greater than can be provided with thestaffing pattern in those facilities. Those res-idents who were living in a residential carefacility prior to July 11, 1980, may remain inthat facility with an asleep attendant eventhough they may be blind, deaf or use assis-tive devices provided they can demonstratethe ability to reach safety unassisted or withassistive devices. II

(28) All residents shall be physically andmentally capable of negotiating a normal pathto safety unassisted or with the use of assis-tive devices within five (5) minutes of being

alerted of the need to evacuate the facility asdefined in subsection (1)(C) of this rule. I/II

(29) Residents suffering from short periods ofincapacity due to illness, injury or recupera-tion from surgery may be allowed to remainor be readmitted from a hospital if the periodof incapacity does not exceed forty-five (45)days and written approval of a physician isobtained for the resident to remain in or bereadmitted to the facility. II/III

(30) The facility shall not admit or continueto care for residents whose needs cannot bemet. If necessary services cannot be obtainedin or by the facility, the resident shall bepromptly referred to appropriate outsideresources or discharged from the facility. I/II

(31) In the event a resident is transferredfrom the facility, staff shall forward a reportof the resident’s current medical status,physician’s orders/prescriptions, and if appli-cable, a copy of the resident’s advanceddirectives/living will to the facility to whichthe resident is being transferred. If the resi-dent is transferring to a private residence,facility staff shall provide the reports to theresident or his or her designee or legallyauthorized representative. II/III

(32) Residents admitted to a facility on refer-ral by the Department of Mental Health shallhave an individual treatment plan or individ-ual habilitation plan on file prepared by theDepartment of Mental Health, updated annu-ally. II

(33) Placement of residents in the buildingshall be determined by their abilities. Thoseresidents who require the use of a walker orwho are blind shall be housed on a floorwhich has direct exits at grade, a ramp or nomore than two (2) steps to grade with ahandrail unless an area of refuge as defined in19 CSR 30-86.022 is provided. Those resi-dents who use a wheelchair shall be able todemonstrate the ability to transfer to andfrom the wheelchair unassisted. They shall behoused near an exit and there shall be a directexit at grade or a ramp or an area of refugeas defined in 19 CSR 30-86.022. II

(34) Requirements for facilities which admitor retain residents with mental illness ormental retardation diagnosis and residentswith assaultive or disruptive behaviors:

(A) Each resident who exhibits mental andpsychosocial adjustment difficulty(ies) shallreceive treatment and services to address theresident’s needs and behaviors as stated in theindividual service plan; I/II

(B) If specialized rehabilitative services formental illness or mental retardation arerequired to enable a resident to reach and tocomply with the individualized service plan,the facility must ensure the required servicesare provided; and II

(C) The facility shall maintain in the resi-dent’s record the most recent progress notesand personal plan developed and provided bythe Department of Mental Health or desig-nated administrative agent for each residentwhose care is funded by the Department ofMental Health or designated administrativeagent. III

(35) The use of interventions to manage dis-ruptive or assaultive resident behaviors shallbe employed with sufficient safeguards toensure the safety, welfare and rights of theresident and shall be in accordance with thetherapeutic goals for the resident. I/II

(36) Residents under sixteen (16) years of ageshall not be admitted. III

(37) Residents admitted or readmitted to thefacility shall have an admission physical ex-amination by a licensed physician. Docu-mentation should be obtained prior to admis-sion but shall be on file not later than ten (10)days after admission and shall contain infor-mation regarding the resident’s current medi-cal status and any special orders or proce-dures which should be followed. If theresident is admitted directly from a hospitalor another long-term care facility and isaccompanied on admission by a report whichreflects his/her current medical status, anadmission physical will not be required. II/III

(38) The facility shall follow appropriateinfection control procedures. The administra-tor or his or her designee shall make a reportto the local health authority or the departmentof the presence or suspected presence of anydiseases or findings listed in 19 CSR 20-20.020, sections (1)–(3) according to thespecified time frames as follows:

(A) Category I diseases or findings shall bereported to the local health authority or to thedepartment within twenty-four (24) hours offirst knowledge or suspicion by telephone,facsimile, or other rapid communication;I/II

(B) Category II diseases or findings shallbe reported to the local health authority orthe department within three (3) days of firstknowledge or suspicion; I/II

(C) Category III. The occurrence of anoutbreak or epidemic of any illness, diseaseor condition which may be of public healthconcern, including any illness in a food han-dler that is potentially transmissible through



food. This also includes public health threatssuch as clusters of unusual diseases or mani-festations of illness and clusters of unex-plained deaths. Such incidents shall bereported to the local authority or to thedepartment by telephone, facsimile, or otherrapid communication within twenty-four (24)hours of first knowledge or suspicion. I/II

(39) Protective oversight shall be providedtwenty-four (24) hours a day. For residentsdeparting the premises on voluntary leave,the facility shall have, at a minimum, a pro-cedure to inquire of the resident or resident’sguardian of the resident’s departure, of theresident’s estimated length of absence fromthe facility, and of the resident’s whereaboutswhile on voluntary leave. I/II

(40) Residents shall receive proper care tomeet their needs. Physician orders shall befollowed. I/II

(41) In case of behaviors that present a rea-sonable likelihood of serious harm to himselfor herself or others, serious illness, signifi-cant change in condition, injury or death,staff shall take appropriate action and shallpromptly attempt to contact the individuallisted in the resident’s record as the legallyauthorized representative, designee or place-ment authority. The facility shall contact theattending physician or designee and notify thelocal coroner or medical examiner immedi-ately upon the death of any resident of thefacility prior to transferring the deceased res-ident to a funeral home. II/III

(42) The facility shall encourage and assisteach resident based on his or her individualpreferences and needs, to be clean and free ofbody and mouth odor. II

(43) Except in the case of emergency, the res-ident shall not be inhibited by chemicaland/or physical restraints that would limitself-care or ability to negotiate a path to safe-ty unassisted or with assistive devices. I/II

(44) If the resident brings unsealed medica-tions to the facility, the medications shall notbe used unless a pharmacist, physician ornurse examines, identifies and determines thecontents to be suitable for use. The individ-ual performing the identification shall docu-ment his or her review. II/III

(45) Self-control of prescription medicationby a resident may be allowed only if approvedin writing by the resident’s physician andallowed by facility policy. A resident may bepermitted to control the storage and use ofnonprescription medication unless there is a

physician’s written order or facility policy tothe contrary. Written approval for self-controlof prescription medication shall be rewrittenas needed but at least annually and after anyperiod of hospitalization. II/III

(46) All medication shall be safely stored atproper temperature and shall be kept in asecured location behind at least one (1)locked door or cabinet. Medication shall beaccessible only to persons authorized toadminister medications. II/III

(A) If access is controlled by the resident,a secured location shall mean in a lockedcontainer, a locked drawer in a bedside tableor dresser or in a resident’s private room iflocked in his or her absence, although thisdoes not preclude access by a responsibleemployee of the facility. II/III

(B) Schedule II controlled substances shallbe stored in locked compartments separatefrom non-controlled medications, except thatsingle doses of Schedule II controlled sub-stances may be controlled by a resident incompliance with the requirements for self-control of medication of this rule. II/III

(C) Medication that is not in current useand is not destroyed shall be stored separate-ly from medication that is in current use.II/III

(47) All prescription medications shall besupplied as individual prescriptions exceptwhere an emergency medication supply isallowed. All medications, including over-the-counter medications shall be packaged andlabeled in accordance with applicable profes-sional pharmacy standards and state and fed-eral drug laws. Labeling shall include acces-sory and cautionary instructions as well asthe expiration date, when applicable, and thename of the medication as specified in thephysician’s order. Medication labels shall notbe altered by facility staff and medicationsshall not be repackaged by facility staff exceptas allowed by section (48) of this rule. Over-the-counter medications for individual resi-dents shall be labeled with at least the resi-dent’s name. II/III

(48) Controlled substances and other pre-scription and non-prescription medicationsfor administration when a resident temporar-ily leaves a facility shall be provided as fol-lows:

(A) Separate containers of medications forthe leave period may be prepared by the phar-macy. The facility shall have a policy andprocedure for families to provide adequateadvance notice so that medications can beobtained from the pharmacy; II/III

(B) Prescription medication cards or othermultiple-dose prescription containers current-ly in use in the facility may be provided byany authorized facility medication staff mem-ber if the containers are labeled by the phar-macy with complete pharmacy prescriptionlabeling for use. Original manufacturer con-tainers of non-prescription medications,along with instructions for administration,may be provided by any authorized facilitymedication staff member; II/III

(C) When medications are supplied by thepharmacy in customized patient medicationpackages that allow separation of individualdose containers, the required number of con-tainers may be provided by any authorizedfacility medication staff member. The indi-vidual dose containers shall be placed in anouter container that is labeled with the nameand address of the facility and the date; II/III

(D) When multiple doses of a medicationare required and it is not reasonably possibleto obtain prescription medication labeled bythe pharmacy, and it is not appropriate tosend a container of medication currently inuse in the facility, up to a twenty-four (24)-hour supply of each prescription or non-pre-scription medication may be provided by alicensed nurse in United States Pharmacopeia(USP) approved containers labeled with thefacility name and address, resident’s name,medication name and strength, quantity,instructions for use, date, initials of individu-al providing, and other appropriate informa-tion; II/III

(E) When no more than a single dose of amedication is required, any authorized facili-ty medication staff member may prepare thedose as for in-facility administration in a USPapproved container labeled with the facilityname and address, resident’s name, medica-tion name and strength, quantity, instructionsfor use, date, initials of person providing, andother appropriate information;

(F) The facility may have a policy that lim-its the quantity of medication sent with a res-ident without prior approval of the prescriber;II/III

(G) Returned containers shall be identifiedas having been sent with the resident, andshall not later be returned to the pharmacy forreuse; and II/III

(H) The facility shall maintain accuraterecords of medications provided to andreturned by the resident. II/III

(49) Upon discharge or transfer of a resident,the facility shall release prescription medica-tions, including controlled substances, heldby the facility for the resident when the physi-cian writes an order for each medication to bereleased. Medications shall be labeled by the


Secretary of State




pharmacy with current instructions for use.Prescription medication cards or other con-tainers may be released if the containers arelabeled by the pharmacy with complete phar-macy prescription labeling. II/III

(50) Injections shall be administered only bya physician or licensed nurse, except thatinsulin injections may be administered by aCMT or LIMA who has successfully com-pleted the state-approved course for insulinadministration, taught by a department-approved instructor. A resident who requiresinsulin, may administer his or her owninsulin if approved in writing by the resi-dent’s physician and trained to do so by alicensed nurse or physician. The facility isresponsible to monitor the resident’s condi-tion and continued ability for self-administra-tion. I/II

(51) The administrator/manager shall developand implement a safe and effective system ofmedication control and use, which assuresthat all residents’ medications are adminis-tered by personnel at least eighteen (18) yearsof age, in accordance with physicians’instructions using acceptable nursing tech-niques. The facility shall employ a licensednurse eight (8) hours per week for every thir-ty (30) residents to monitor each resident’scondition and medication. Administration ofmedication shall mean delivering to a resi-dent his or her prescription medication eitherin the original pharmacy container, or forinternal medication, removing an individualdose from the pharmacy container and plac-ing it in a small container or liquid mediumfor the resident to remove from the containerand self-administer. External prescriptionmedication may be applied by facility person-nel if the resident is unable to do so and theresident’s physician so authorizes. All indi-viduals who administer medication shall betrained in medication administration and, ifnot a physician or a licensed nurse, shall be acertified medication technician or level Imedication aide. I/II

(52) Medication Orders.(A) Physician’s instructions, as evidenced

by the prescription label or by signed order ofa physician, shall be accurately followed. Ifthe physician changes the order which is des-ignated on a prescription label, there shall beon file in the resident’s record a signed physi-cian’s order to that effect with the amendedinstructions for use or until the prescriptionlabel is changed by the pharmacy to reflectthe new order. II/III

(B) Physician’s written and signed ordersare not required, but if it is the facility’s or

physician’s policy to use the orders, they shallinclude: name of the medication, dosage,frequency and route of administration and theorders shall be renewed at least every three(3) months. Computer generated signaturesmay be used if safeguards are in place to pre-vent their misuse. Computer identificationcodes shall be accessible to and used only bythe individuals whose signatures they repre-sent. Orders that include optional doses orinclude pro re nata (PRN) administration fre-quencies shall specify a maximum frequencyand the reason for administration. II/III

(C) Telephone and other verbal ordersshall be received only by a licensed nurse,medication technician, level I medicationaide or pharmacist and shall be immediatelyreduced to writing and signed by that indi-vidual. If a telephone or other verbal order isgiven to a medication technician or level Imedication aide, an initial dosage shall not beadministered until the order has beenreviewed by telephone, facsimile or in personby a licensed nurse or pharmacist. II

(D) The review shall be documented by thelicensed nurse’s or pharmacist’s signaturewithin seven (7) days. III

(E) The physician shall sign all telephoneand other verbal orders within seven (7) days.III

(F) Medication staff shall record adminis-tration of medication on a medication sheet ordirectly in the resident’s record. If adminis-tration of medication is recorded on a medi-cation sheet, the medication sheet shall bemade part of the resident’s medical record.The same individual who prepares andadministers the medication shall record theadministration. II/III

(53) Influenza and pneumococcal polysaccha-ride immunizations may be administered perphysician-approved facility policy afterassessment for contraindications.

(A) The facility shall develop a policy thatprovides recommendations and assessmentparameters for the administration of suchimmunizations. The policy shall be approvedby the facility medical director for facilitieshaving a medical director, or by each resi-dent’s attending physician for facilities thatdo not have a medical director, and shallinclude the requirements to:

1. Provide education regarding thepotential benefits and side effects of theimmunization to each resident or the resi-dent’s designee or legally authorized repre-sentative; II/III

2. Offer the immunization to the resi-dent or obtain permission from the resident’sdesignee or legally authorized representativewhen it is medically indicated, unless the res-

ident has already been immunized as recom-mended by the policy; II/III

3. Provide the opportunity to refuse theimmunization; and II/III

4. Perform an assessment for contraindi-cations. II/III

(B) The assessment for contraindicationsand documentation of the education andopportunity to refuse the immunization shallbe dated and signed by the nurse performingthe assessment and placed in the medicalrecord. II/III

(C) The facility shall with the approval ofeach resident’s physician, access screeningand immunization through outside sources,such as county or city health departments,and the facility shall document in the medicalrecord that the requirements in subsection(53)(B) were performed by outside sources.II/III

(54) Stock supplies of nonprescription medi-cation may be kept when specific medicationsare approved in writing by a consulting physi-cian, a registered nurse or a pharmacist. Nostock supply of prescription medication maybe kept in the facility. II/III

(55) Records shall be maintained uponreceipt and disposition of all controlled sub-stances and shall be maintained separatelyfrom other records, for two (2) years.

(A) Inventories of controlled substancesshall be reconciled as follows: II/III

1. Controlled Substance Schedule IImedications shall be reconciled each shift;and II

2. Controlled Substance Schedule III–Vmedications shall be reconciled at least week-ly and as needed to ensure accountability.II/III

(B) Inventories of controlled substancesshall be reconciled by the following:

1. Two (2) medication personnel, one ofwhom is a licensed nurse; or

2. Two (2) medication personnel, one ofwhom is the administrator/manager when nonurse is available on staff; or

3. Two (2) medication personnel eithermedication technicians or level I medicationaides when neither a licensed nurse nor theadministrator/manager is available. II/III

(C) Receipt records shall include the date,source of supply, resident name and prescrip-tion number when applicable, medicationname and strength, quantity and signature ofthe supplier and receiver. Administrationrecords shall include the date, time, residentname, medication name, dose administeredand the initials of the individual administer-ing. The signature and initials of each medi-cation staff documenting on the medication

administration record must be signed in thesignature area of the medication record.II/III

(D) When self-control of medication isapproved a record shall be made of all con-trolled substances transferred to and adminis-tered from the resident’s room. Inventoryreconciliation shall include controlled sub-stances transferred to the resident’s room.I/II

(56) Documentation of the wasting of con-trolled substances at the time of administra-tion shall include the reason for the waste andthe signature of another medication staffmember or the administrator who witnessesthe waste. If no medication staff member orthe administrator is available at the time ofadministration, the controlled substance shallbe properly labeled, clearly identified asunusable, stored in a locked area, anddestroyed as soon as a medication staff mem-ber or the administrator is available to wit-ness the waste. When no medication staffmember or the administrator is available andthe controlled substance is contaminated bypatient body fluids, the controlled substanceshall be destroyed immediately and the cir-cumstances documented. II/III

(57) At least every three (3) months in a res-idential care facility, a pharmacist or regis-tered nurse shall review the controlled sub-stance record keeping including reconcilingthe inventories of controlled substances. Thisshall be done at the time of the drug regimenreview of each resident. All discrepancies incontrolled substance records shall be report-ed to the administrator or manager for reviewand investigation. The theft or loss of con-trolled substances shall be reported as fol-lows: II/III

(A) The facility shall notify the depart-ment’s Section for Long Term Care (SLTC)and other appropriate authorities of any theftor significant loss of any controlled substancemedication written as an individual prescrip-tion for a specific resident upon the discoveryof the theft or loss. The facility shall consid-er at least the following factors in determin-ing if a loss is significant:

1. The actual quantity lost in relation tothe total quantity;

2. The specific controlled substancelost;

3. Whether the loss can be associatedwith 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 isa likely candidate for diversion; and

6. Local trends and other indicators ofdiversion potential; II/III

(B) If an insignificant amount of such con-trolled substance is lost during lawful activi-ties, which includes but are not limited toreceiving, record keeping, access auditing,administration, destruction and returning tothe pharmacy, a description of the occurrenceshall be documented in writing and main-tained with the facility’s controlled substancerecords. The documentation shall include thereason for determining that the loss wasinsignificant. II/III

(58) A pharmacist or registered nurse shallreview the medication regimen of each resi-dent. This shall be done at least every three(3) months in a residential care facility. Thereview shall be performed in the facility andshall include, but shall not be limited to, indi-cation for use, dose, possible medicationinteractions and medication/food interactions,contraindications, adverse reactions and areview of the medication system utilized bythe facility. Irregularities and concerns shallbe reported in writing to the resident’s physi-cian and to the administrator/manager. Ifafter thirty (30) days, there is no action takenby a resident’s physician and significant con-cerns continue regarding a resident’s or resi-dents’ medication order(s), the administra-tor/manager shall contact or recontact thephysician to determine if he or she receivedthe information and if there are any newinstructions. II/III

(59) All medication errors and adverse reac-tions shall be promptly documented andreported to the administrator/manager andthe resident’s physician. If the pharmacymade a dispensing error, it shall also bereported to the issuing pharmacy. II/III

(60) Medications that are not in current useshall be disposed of as follows:

(A) Single doses of contaminated, refused,or otherwise unusable non-controlled sub-stance medications may be destroyed by anyauthorized medication staff member at thetime of administration. Single doses of unus-able controlled substance medications shallbe destroyed according to section (56) of thisrule;

(B) Discontinued medications may beretained up to one hundred twenty (120) daysprior to other disposition if there is reason tobelieve, based on clinical assessment of theresident, that the medication might bereordered;

(C) Medications may be released to theresident or family upon discharge accordingto section (49) of this rule;

(D) After a resident has expired, medica-tions, except for controlled substances, maybe released to the resident’s legal representa-tive upon written request of the legal repre-sentative that includes the name of the medi-cation and the reason for the request;

(E) Medications may be returned to thepharmacy that dispensed the medications pur-suant to 4 CSR 220-3.040 or returned pur-suant to the Prescription Drug RepositoryProgram, 19 CSR 20-50.020;

(F) All other medications, including allcontrolled substances and all expired or oth-erwise unusable medications, shall bedestroyed within thirty (30) days as follows:II/III

1. Medications shall be destroyed withinthe facility by a pharmacist and a licensednurse or by two (2) licensed nurses or whentwo (2) licensed nurses are not available onstaff by two (2) individuals who have author-ity to administer medications, one (1) ofwhom shall be a licensed nurse or a pharma-cist; and II/III

2. A record of medication destroyedshall be maintained and shall include the res-ident’s name, date, medication name andstrength, quantity, prescription number, andsignatures of the individuals destroying themedications; and II/III

(G) A record of medication released orreturned to the pharmacy shall be maintainedand shall include the resident’s name, date,medication name and strength, quantity, pre-scription number, and signatures of the indi-viduals releasing and receiving the medica-tions. III

(61) Residents shall be encouraged to beactive and to participate in activities. In a res-idential care facility licensed for more thantwelve (12) residents, a method for informingthe residents in advance of what activities areavailable, where they will be held and at whattimes they will be held shall be developed,maintained and used. II/III

(62) The facility shall maintain a record inthe facility for each resident which shallinclude the following:

(A) Admission information including theresident’s name; admission date; confiden-tiality number; previous address; birth date;sex; marital status; Social Security number;Medicare and Medicaid numbers (if applica-ble); name, address and telephone number ofthe resident’s physician and alternate; diagno-sis; name, address and telephone number ofthe resident’s legally authorized representa-tive or designee to be notified in case of


Secretary of State


emergency; and preferred dentist, pharmacistand funeral director; III

(B) A review monthly or more frequently,if indicated, of the resident’s general condi-tion and needs; a monthly review of medica-tion consumption of any resident controllinghis or her own medication, noting if pre-scription medications are being used inappropriate quantities; a daily record ofadministration of medication; a logging of themedication regimen review process; a month-ly weight; a record of each referral of a resi-dent for services from an outside service; anda record of any resident incidents includingbehaviors that present a reasonable likelihoodof serious harm to himself or herself or oth-ers and accidents that potentially could resultin injury or did result in injuries involving theresident; and III

(C) Any Physician’s Orders. Except asallowed by section (52) of this rule, the facil-ity shall submit to the physician written ver-sions of any oral or telephone orders withinfour (4) days of the giving of the oral or tele-phone order. III

(63) A record of the daily resident censusshall be retained in the facility. III

(64) Resident records shall be maintained bythe operator for at least five (5) years after aresident leaves the facility or after the resi-dent reaches the age of twenty-one (21),whichever is longer and must include reasonfor discharge or transfer from the facility andcause of death, if applicable. III

AUTHORITY: sections 198.005 and 198.006,RSMo Supp. 2006 and 198.076, RSMo2000.* This rule originally filed as 13 CSR15-15.042. Original rule filed July 13, 1983,effective Oct. 13, 1983. Emergency amend-ment 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 May13, 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 30-86.042, effec-tive Aug. 28, 2001. Emergency amendmentfiled Sept. 12, 2003, effective Sept. 22, 2003,expired March 19, 2004. Amended: FiledSept. 12, 2003, effective Feb. 29, 2004.Amended: Filed Aug. 23, 2006, effectiveApril 30, 2007.

*Original authority: 198.005, RSMo 2006; 198.006,

RSMo 1979, amended 1984, 1987, 2003, 2006; and

198.076, RSMo 1979, amended 1984.

19 CSR 30-86.043 Administrative, Person-nel and Resident Care Requirements forFacilities Licensed as a Residential CareFacility II on August 27, 2006 that WillComply with Residential Care Facility IIStandards

PURPOSE: This rule establishes require-ments for administration, personnel and resi-dent care requirements for facilities licensedpursuant to section 198.005, RSMo that con-tinue to comply with residential care facilities(RCF) II standards in effect on August 27,2006.

Editor’s Note: All rules relating to long-termcare facilities licensed by the department arefollowed by a Roman Numeral notation whichrefers to the class (either Class I, II or III) ofstandard as designated in section 198.085.1,RSMo.

(1) This rule contains the administrative, per-sonnel and resident care standards in effecton August 27, 2006 for residential care facil-ity IIs (formerly published at 19 CSR 30-86.042 (effective 12/31/05)). These stan-dards apply to facilities that were licensed asresidential care facility IIs on August 27,2006 and that choose to be inspected underthese standards rather than the standards pub-lished at 19 CSR 30-86.047.

(2) A person shall be designated to be admin-istrator who is currently licensed as a nursinghome administrator under Chapter 344,RSMo. II

(3) By January 1, 1991, the administrator ofa facility shall have successfully completedthe state approved Level I Medication Aidecourse unless s/he is a physician, pharmacist,licensed nurse or a certified medication tech-nician, or if the facility is operating in con-junction with a skilled nursing facility orintermediate care facility on the same premis-es, or if the facility employs on a full-timebasis, a licensed nurse who is available seven(7) days per week. II/III

(4) The operator shall be responsible toassure compliance with all applicable lawsand regulations. The administrator shall befully authorized and empowered to makedecisions regarding the operation of the facil-ity and shall be held responsible for theactions of all employees. The administrator’sresponsibilities shall include oversight of res-idents to assure that they receive appropriatecare. II/III

(5) The administrator shall devote sufficienttime and attention to the management of thefacility as is necessary for the health, safetyand welfare of the residents. II

(6) The administrator cannot be listed orfunction in more than one (1) facility at thesame time unless s/he serves no more thanfour (4) facilities which are within a thirty(30)-mile radius and licensed to serve in totalno more than one hundred (100) residents.However, one (1) administrator may serve asthe administrator of more than one (1)licensed facility if all facilities are on thesame premises. II/III

(7) The administrator shall designate, in writ-ing, a staff person in charge in his/herabsence. If the administrator is absent formore than thirty (30) consecutive days, dur-ing which time s/he is not readily accessiblefor consultation by telephone with the personin charge or if the administrator is absentfrom the facility for more than sixty (60)working days during the course of a calendaryear the person designated to be in chargeshall be a licensed nursing home administra-tor. II/III

(8) The facility shall not care for more resi-dents than the number for which the facilityis licensed. II/III

(9) The facility’s current license shall beposted in a conspicuous place and noticesprovided to the facility by the Department ofHealth and Senior Services (the department)granting exception(s) to regulatory require-ments shall be posted alongside of the facili-ty’s license. III

(10) All personnel responsible for residentcare shall have access to the legal name ofeach resident, name and telephone number ofphysician and next of kin or responsible partyin the event of emergency. II/III

(11) All persons who have any contact withthe residents in the facility shall not know-ingly act or omit any duty in a manner whichwould materially and adversely affect thehealth, safety, welfare or property of resi-dents. No person who is listed on theEmployee Disqualification List maintained bythe department as required by section198.070, RSMo shall work or volunteer inthe facility in any capacity whether or notemployed by the operator. I/II

(12) Effective August 28, 1997, each facilityshall, not later than two (2) working days ofthe date an applicant for a position to have



contact with residents is hired, request acriminal background check, as provided insections 43.530, 43.540 and 610.120,RSMo. Each facility must maintain in itsrecord documents verifying that the back-ground checks were requested and the natureof the response received for each suchrequest. The facility must ensure that anyapplicant who discloses prior to the check ofhis/her criminal records that he/she has beenconvicted of, plead guilty or nolo contendereto, or has been found guilty of any Class Aor B felony violation of Chapter 565, 566, or569, RSMo, or any violation of subsection 3of section 198.070, RSMo, or of section568.020, RSMo, will not be allowed to workin contact with patients or residents until andunless a check of the applicant’s criminalrecord shows that no such convictionoccurred. II/III

(13) The facility must develop and implementwritten policies and procedures which requirethat persons hired for any position which is tohave contact with any patient or resident havebeen informed of their responsibility to dis-close their prior criminal history to the facil-ity as required by section 660.317.5, RSMo.The facility must also develop and implementpolicies and procedures which ensure that thefacility does not knowingly hire, after August28, 1997, any person who has or may havecontact with a patient or resident, who hasbeen convicted of, plead guilty or nolo con-tendere to, in this state or any other state, orhas been found guilty of any Class A or Bfelony violation of Chapter 565, 566 or 569,RSMo, or any violation of subsection 3 ofsection 198.070, RSMo, or of section568.020, RSMo. II/III

(14) All persons who have or may have con-tact with residents shall at all times when onduty or delivering services wear an identifi-cation badge. The badge shall give theirname, title and, if applicable, the status oftheir license or certification as any kind ofhealth care professional. This rule shall applyto all personnel who provide services to anyresident directly or indirectly. III

(15) All personnel shall be able physicallyand emotionally to work in a long-term carefacility. I/II

(16) Personnel who have been diagnosed witha communicable disease may begin work orreturn to duty only with written approval by aphysician or physician’s designee which indi-cates any limitations. II

(17) The administrator shall be responsiblefor monitoring the health of the employees.II/III

(18) Prior to or on the first day that a newemployee works in the facility s/he shallreceive orientation of at least one (1) hourappropriate to his/her job function. This shallinclude, at a minimum, job responsibilities,how to handle emergency situations, theimportance of infection control and hand-washing, confidentiality of resident informa-tion, preservation of resident dignity, how toreport abuse/neglect to the department (1-800-392-0210), information regarding theEmployee Disqualification List and instruc-tion regarding the rights of residents and pro-tection of property. II/III

(19) The administrator shall maintain on thepremises an individual personnel record oneach employee of the facility which shallinclude: the employee’s name and address;Social Security number; date of birth; date ofemployment; experience and educationincluding documentation of specialized train-ing on medication and/or insulin administra-tion, or both; references, if available; theresults of background checks required by sec-tion 660.317, RSMo; position in the facility;written statement signed by a licensed physi-cian or physician’s designee indicating theperson can work in a long-term care facilityand indicating any limitations; record that theemployee was instructed on residents’ rights,facility’s policies, job duties and any otherorientation and reason for termination. Per-sonnel records shall be maintained for at leastone (1) year following termination of employ-ment. III


(21) No one individual shall be on duty withresponsibility for oversight of residents longerthan eighteen (18) hours per day. I/II

(22) Employees who are counted in meetingthe minimum staffing ratio and employeeswho provide direct care to the residents shallbe at least sixteen (16) years of age. III

(23) One (1) employee at least eighteen (18)years of age shall be on duty at all times. I/II

(24) Staffing. (A) The facility shall have an adequate

number and type of personnel for the propercare of residents and upkeep of the facility. Ata minimum, the staffing pattern for fire safe-

ty and care of residents shall be one (1) staffperson for every fifteen (15) residents ormajor fraction of fifteen (15) during the dayshift, one (1) person for every twenty (20)residents or major fraction of twenty (20)during the evening shift and one (1) personfor every twenty-five (25) residents or majorfraction of twenty-five (25) during the nightshift. I/II

Time Personnel Residents7 a.m. to 3 p.m.

(Day)* 1 3–153 p.m. to 9 p.m.

(Evening)* 1 3–209 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 workschedules of the facility and shall not be lessthan six (6) hours. III

(B) The required staff shall be in the facil-ity awake, dressed and prepared to assist res-idents in case of emergency. I/II

(C) In a facility of more than one hundred(100) residents, the administrator shall not becounted when determining the personnelrequired. II

(D) If the facility is operated in conjunc-tion with and is immediately adjacent to andcontiguous to another licensed long-term carefacility and if the resident bedrooms of thefacility are on the same floor as at least a por-tion of a licensed intermediate care or skillednursing facility; there is an approved call sys-tem in each resident’s bedroom and bathroomor a patient-controlled call system; and thereis a complete fire alarm system in the facilitytied into the complete fire alarm system in theother licensed facility, then the followingminimum staffing for oversight and care ofresidents, for upkeep of the facility and forfire safety shall be one (1) staff person forevery eighteen (18) residents or major frac-tion of residents during the day shift, one (1)person for every twenty-five (25) residents ormajor fraction of residents during the eveningshift and one (1) person for every thirty (30)residents or major fraction of residents dur-ing the night shift. I/II


(Day)* 1 3–183 p.m. to 9 p.m.

(Evening)* 1 3–259 p.m. to 7 a.m.

(Night)* 1 3–30

*If the shift hours vary from those indicated,the hours of the shifts shall show on the workschedules of the facility and shall not be less


Secretary of State


than six (6) hours. III(E) There shall be a licensed nurse

employed by the facility to work at least eight(8) hours per week at the facility for everythirty (30) residents or additional major frac-tion of thirty (30). The nurse’s duties shallinclude, but shall not be limited to, review ofresidents’ charts, medications and specialdiets or other orders, review of each resi-dent’s adjustment to the facility and observa-tion of each individual resident’s generalphysical and mental condition. The nurseshall inform the administrator of any prob-lems noted and these shall be brought to theattention of the resident’s physician. II/III

(25) All residents shall be physically andmentally capable of negotiating a normal pathto safety unassisted or with the use of assis-tive devices. I/II

(26) Residents suffering from short periods ofincapacity due to illness, injury or recupera-tion from surgery may be allowed to remainor be readmitted from a hospital if the periodof incapacity does not exceed forty-five (45)days and written approval of a physician isobtained for the resident to remain in or bereadmitted to the facility. II/III

(27) The facility shall not admit or continueto care for residents whose needs cannot bemet. If necessary services cannot be obtainedin or by the facility, the resident shall bepromptly referred to appropriate outsideresources or transferred to a facility providingthe appropriate level of care. I/II

(28) In the event a resident is transferredfrom the facility, a report of the resident’scurrent medical status shall accompanyhim/her. III

(29) Residents admitted to a facility on refer-ral by the Department of Mental Health shallhave an individual treatment plan or individ-ual habilitation plan on file prepared by theDepartment of Mental Health, updated annu-ally. III


(31) Placement of residents in the buildingshall be determined by their abilities. Thoseresidents who require the use of a walker orwho are blind shall be housed on a floorwhich has direct exits at grade, a ramp or nomore than two (2) steps to grade with ahandrail. Those residents who use awheelchair shall be able to demonstrate theability to transfer to and from the wheelchair

unassisted. They shall be housed near an exitand there shall be a direct exit at grade or aramp. II

(32) Residents admitted or readmitted to thefacility shall have an admission physicalexamination by a licensed physician. Docu-mentation should be obtained prior to admis-sion but shall be on file not later than ten (10)days after admission and shall contain infor-mation regarding the resident’s current medi-cal status and any special orders or proce-dures which should be followed. If theresident is admitted directly from a hospitalor another long-term care facility and isaccompanied on admission by a report whichreflects his/her current medical status, anadmission physical will not be required. II/III

(33) If at any time a resident or prospectiveresident is diagnosed with a communicabledisease, the department shall be notifiedwithin seven (7) days and if the facility canmeet the resident’s needs, the resident may beadmitted or does not need to be transferred.Appropriate infection control proceduresshall be followed if the resident remains in oris accepted by the facility. I/II


(35) Residents shall receive proper care tomeet their needs. Physician orders shall befollowed. I/II

(36) In case of serious illness, accident ordeath, appropriate action shall be taken andthe person designated in the resident’s recordas the responsible party and, if applicable,the guardian shall be immediately notified.II/III

(37) Every resident shall be clean, dry andfree of offensive body and mouth odor. I/II

(38) Except in the case of emergency, the res-ident shall not be inhibited by chemicaland/or physical restraints that would limitself-care or ability to negotiate a path to safe-ty unassisted or with assistive devices. I/II

(39) A supply of clean linen shall be availablein the facility and provided to residents tomeet their daily needs. II/III

(40) Beds shall be made daily and linenchanged at least weekly or more often ifneeded to maintain a clean, dry bed. II/III

(41) The resident’s unit shall be thoroughlycleaned and disinfected following a resident’sdeath, discharge or transfer. II/III

(42) Commodes and urinals, if used, shall bekept at the bedside of the residents. Theyshall not be left open and the container shallbe emptied promptly and thoroughly cleanedafter each use. III

(43) Cuspidors shall be emptied and cleaneddaily or disposable cartons shall be provideddaily. III

(44) Self-control of prescription medicationby a resident may be allowed only if approvedin writing by the resident’s physician andallowed by facility policy. If a resident is nottaking any prescription medication, the resi-dent may be permitted to control the storageand use of nonprescription medication unlessthere is a physician’s written order or facilitypolicy to the contrary. If not permitted, allmedications for that resident, including over-the-counter medications, shall be controlledby the administrator unless the physicianspecifies otherwise. II/III

(45) Written approval for self-control of pre-scription medication shall be rewritten asneeded but at least annually and after anyperiod of hospitalization. III

(46) All medication shall be safely stored atproper temperature and shall be kept in asecured location behind at least one (1)locked door or cabinet. If access is controlledby the resident, a secured location shall meanin a locked container, a locked drawer in abedside table or dresser or in a resident’s pri-vate room if locked in his/her absence,although this does not preclude access by aresponsible employee of the facility. II/III

(47) All prescription medications shall besupplied as individual prescriptions. All med-ications, including over-the-counter medica-tions shall be packaged and labeled in accor-dance with applicable professional pharmacystandards, state and federal drug laws andregulations and the United States Pharma-copeia (USP). Labeling shall include acces-sory and cautionary instructions as well asthe expiration date, when applicable, and thename of the medication as specified in thephysician’s order. Over-the-counter medica-tions for individual residents shall be labeledwith at least the resident’s name. II/III



(48) Injections shall be administered only bya physician or licensed nurse, except that res-idents who require insulin, upon writtenorder of their physician, may administer theirown insulin or the insulin may be adminis-tered by a person trained to do so by alicensed nurse or physician and the resident’scondition shall be monitored by his/her physi-cian. After December 31, 1990, unlessinsulin is self-administered or it is adminis-tered only by a physician or licensed nurse,it shall be administered by a certified medi-cation technician or a level I medication aidewho has successfully completed the state-approved course for insulin administration,taught by an approved instructor and who wasrecommended for training by an administra-tor or nurse with whom he or she works.Anyone trained prior to December 31, 1990,who completed the state-approved insulinadministration course taught by an approvedinstructor shall be considered qualified toadminister insulin in a facility. Anyonetrained prior to December 31, 1990, toadminister insulin by a licensed nurse orphysician not using the state-approved coursemay qualify by challenging the final examina-tion of the insulin administration course. I/II

(49) The administrator shall develop andimplement a safe and effective system ofmedication control and use which assures thatall residents’ medications are administered ordistributed by personnel at least eighteen (18)years of age, in accordance with physicians’instructions using acceptable nursing tech-niques. Until January 1, 1991, those facilitiesadministering medications shall utilize per-sonnel trained in medication administration(a licensed nurse, certified medication techni-cian or level I medication aide) and shallemploy a licensed nurse eight (8) hours perweek for every thirty (30) residents to moni-tor each resident’s condition. Distributionshall mean delivering to a resident his/herprescription medication either in the originalpharmacy container, or for internal medica-tion, removing an individual dose from thepharmacy container and placing it in a smallcontainer or liquid medium for the resident toremove from the container and self-adminis-ter. External prescription medication may beapplied by facility personnel if the resident isunable to do so and the resident’s physicianso authorizes. After December 31, 1990, allpersons who administer or distribute medica-tion shall be trained in medication adminis-tration and, if not a physician or a licensednurse, shall be a certified medication techni-cian or level I medication aide. I/II

(50) Medication Orders.

(A) Physician’s instructions, as evidencedby the prescription label or by signed order ofa physician, shall be accurately followed. Ifthe physician changes the order which is des-ignated on a prescription label, there shall beon file in the resident’s record a signed physi-cian’s order to that effect with the amendedinstructions for use or until the prescriptionlabel is changed by the pharmacy to reflectthe new order. II/III

(B) Physician’s written and signed ordersare not required, but if it is the facility’s orphysician’s policy to use the orders, they shallinclude: name of medication, dosage and fre-quency of administration and the orders shallbe renewed at least every three (3) months.II/III

(C) Verbal and telephone orders shall betaken only by a licensed nurse, medicationtechnician, level I medication aide or phar-macist and shall be immediately reduced towriting and signed by that individual. If atelephone order is given to a medication tech-nician or level I medication aide, an initialdosage of a new prescription shall not be ini-tiated until the order has been reviewed bytelephone or in person by a licensed nurse orpharmacist. II

(D) The review shall be documented by thenurse’s or pharmacist’s signature withinseven (7) days. III

(E) The physician shall sign all verbal andtelephone orders within seven (7) days. III

(F) The administration or distribution ofmedication shall be recorded on a medicationsheet or directly in the resident’s record and,if recorded on a medication sheet, shall bemade part of the resident’s record. Theadministration or distribution shall be record-ed by the same person who prepares the med-ication and who distributes or administers it.II/III

(51) A stock supply of prescription medica-tion may be kept in the facility. An emergen-cy drug supply as recommended by a phar-macist or physician may be kept if approvedby the department. Storage and use of medi-cations in the emergency drug supply shallassure accountability. II/III

(52) Stock supplies of nonprescription medi-cation may be kept for pro re nata (PRN) usein facilities as long as the particular medica-tions are approved in writing by a consultingphysician, a registered nurse or a pharmacist.II/III

(53) All controlled substances shall be han-dled according to state laws and regulationsas given in and required by 19 CSR 30-1 andChapter 195, RSMo. II/III

(54) A pharmacist or registered nurse shallreview the drug regimen of each resident.This shall be done at least every other monthin a facility. The review shall be performed inthe facility and shall include, but shall not belimited to, possible drug and food interac-tions, contraindications, adverse reactionsand a review of the medication system uti-lized by the facility. Irregularities and con-cerns shall be reported in writing to the resi-dent’s physician and to the administrator. Ifafter thirty (30) days, there is no action takenby a resident’s physician and significant con-cerns continue regarding a resident’s or resi-dents’ medication order(s), the administratorshall contact or recontact the physician todetermine if he or she received the informa-tion and if there are any new instructions.II/III

(55) Medications controlled by the facilityshall be disposed of either by destroying,returning to the pharmacy or sending withresidents on discharge. The following shall bedestroyed within the facility within ninety(90) days: discontinued medication notreturnable to the pharmacy, all discontinuedcontrolled substances, outdated or deteriorat-ed medication, medication of expired resi-dents not returnable to the pharmacy andmedications not sent with the resident on dis-charge. II/III

(56) Disposition of medication controlled bythe facility shall be recorded listing the resi-dent’s name, the date and the name, strengthand quantity of the drug and the signature(s)of the person(s) involved. Medicationdestruction shall involve two (2) persons, one(1) of whom shall be a pharmacist, a nurse ora state inspector. III

(57) Residents shall be encouraged to beactive and to participate in activities. In afacility licensed for more than twelve (12)residents, a method for informing the resi-dents in advance of what activities are avail-able, where they will be held and at whattimes they will be held shall be developed,maintained and used. II/III

(58) A record shall be maintained in the facil-ity for each resident which shall include:

(A) Admission information including theresident’s name; admission date; confiden-tiality number; previous address; birth date;sex; marital status; Social Security number;Medicare and Medicaid number; name,address and telephone number of physicianand alternate; name, address and telephonenumber of resident’s next of kin, legalguardian, designee or person to be notified in


Secretary of State


case of emergency; and preferred dentist,pharmacist and funeral director; and III

(B) A resident’s record, including a reviewmonthly or more frequently, if indicated, ofthe resident’s general condition and needs; amonthly review of medication consumptionof any resident controlling his/her own medi-cation, noting if prescription medications arebeing used in appropriate quantities; a dailyrecord of distribution or administration ofmedication; any physician’s orders; a loggingof the drug regimen review process; a month-ly weight; a record of each referral of a resi-dent for services from an outside service; anda record of any patient incidents and acci-dents involving the resident. III

(59) A record of the resident census as wellas records regarding discharge, transfer ordeath of residents shall be kept in the facility.III

(60) Resident records shall be maintained bythe operator for at least five (5) years afterthe resident leaves the facility or after the res-ident reaches the age of twenty-one (21),whichever is longer. III

AUTHORITY: sections 198.005, 198.006 and198.073, RSMo Supp. 2006 and 198.076,RSMo 2000.* Original rule filed Aug. 23,2006, effective April 30, 2007.

*Original authority: 198.005, RSMo 2006; 198.006,RSMo 1979, amended 1984, 1987, 2003, 2006; and198.073, RSMo 1979, amended 1984, 1992, 1999, 2006.

19 CSR 30-86.045 Standards and Require-ments for Assisted Living Facilities WhichProvide Services to Residents with a Phys-ical, Cognitive, or Other Impairment thatPrevents the Individual from Safely Evacu-ating the Facility with Minimal Assistance

PURPOSE: This rule establishes the addi-tional standards for those assisted livingfacilities which provide services to residentswith a physical, cognitive, or other impair-ment that prevents the individual from safelyevacuating the facility with minimal assis-tance.

AGENCY NOTE: All rules relating tolong-term care facilities licensed by thedepartment are followed by a Roman Numer-al notation which refers to the class (eitherClass I, II or III) of standard as designated insection 198.085.1, RSMo.

(1) This rule contains the additional standardsfor those assisted living facilities licensedpursuant to sections 198.005 and 198.073,

RSMo (CCS HCS SCS SB 616, 93rd Gener-al Assembly, Second Regular Session (2006))and complying with sections 198.073.4 and198.073.6, RSMo (CCS HCS SCS SB 616,93rd General Assembly, Second Regular Ses-sion (2006)) and 19 CSR 30-86.047 thatchoose to admit or continue to care for anyindividual having a physical, cognitive orother impairment that prevents the individualfrom safely evacuating the facility with mini-mal assistance.

(2) Definitions. For the purposes of this rule,the following definitions shall apply:

(A) Area of refuge—A space located in orimmediately adjacent to a path of travel lead-ing to an exit that is protected from theeffects of fire, either by means of separationfrom other spaces in the same building or itslocation, permitting a delay in evacuation.An area of refuge may be temporarily used asa staging area that provides some relativesafety to its occupants while potential emer-gencies are assessed, decisions are made, andevacuation has begun;

(B) Evacuating the facility—The act of theresident going from one (1) smoke section toanother within the facility, going to an area ofrefuge within the facility, or going out of thefacility;

(C) Individualized evacuation plan—A planto remove the resident from the facility, to anarea of refuge within the facility or from one(1) smoke section to another within the facil-ity. The plan is specific to the resident’sneeds and abilities based on the current com-munity based assessment;

(D) Minimal assistance—1. Is the criterion which determines

whether or not staff must develop and includean individualized evacuation plan as part ofthe resident’s service plan;

2. Minimal assistance may be the verbalintervention that staff must provide for a res-ident to initiate evacuating the facility;

3. Minimal assistance may be the physi-cal intervention that staff must provide, suchas turning a resident in the correct direction,for a resident to initiate evacuating the facili-ty;

4. A resident needing minimal assis-tance is one who is able to prepare to leaveand then evacuate the facility within five (5)minutes of being alerted of the need to evac-uate and requires no more than one (1) phys-ical intervention and no more than three (3)verbal interventions of staff to complete evac-uation from the facility;

5. The following actions required ofstaff are considered to be more than minimalassistance:

A. Assistance to traverse down stair-

ways;B. Assistance to open a door; andC. Assistance to propel a wheelchair;

(E) Resident, only for the purpose of thisrule, means any individual having a physical,cognitive or other impairment that preventsthe individual from safely evacuating thefacility with minimal assistance who is admit-ted to or continues to be cared for in the facil-ity under the provisions of this rule; and

(F) Smoke section—A fire-rated separationof one (1) section of the building from therest of the building.

(3) General Requirements. I/II(A) If the facility admits or retains any

individual needing more than minimal assis-tance due to having a physical, cognitive orother impairment that prevents the individualfrom safely evacuating the facility, the facili-ty shall:

1. Meet the fire safety requirements of19 CSR 30-86.022(16); I/II

2. Take necessary measures to provideresidents with the opportunity to explore thefacility and, if appropriate, its grounds; II

3. Use a personal electronic monitoringdevice for any resident whose physician rec-ommends the use of such device; II

4. Have sufficient staff present andawake twenty-four (24) hours a day to assistin the evacuation of all residents; I/II

5. Include an individualized evacuationplan in the resident’s individual service plan;II

6. At a minimum the evacuation planshall include the following components:

A. The responsibilities of specificstaff positions in an emergency specific to theindividual; II

B. The fire protection interventionsneeded to ensure the safety of the resident;and II

C. The plan shall evaluate the residentfor his or her location within the facility andthe proximity to exits and areas of refuge.The plan shall evaluate the resident, as appli-cable, for his or her risk of resistance, mobil-ity, the need for additional staff support, con-sciousness, response to instructions, responseto alarms, and fire drills; II

7. The resident’s evacuation plan shallbe amended or revised based on the ongoingassessment of the needs of the resident; II

8. Those employees with specificresponsibilities shall be instructed andinformed regarding their duties and responsi-bilities under the resident’s evacuation plan atleast every six (6) months and upon any sig-nificant change in the plan; II



9. A copy of the resident’s evacuationplan shall be readily available to all staff; andII

10. Comply with all requirements of thisrule. I/II

(4) Staffing Requirements.(A) The facility shall have an adequate

number and type of personnel for the propercare of residents and upkeep of the facility. Ata minimum, the staffing pattern for fire safe-ty and care of residents shall be one (1) staffperson for every fifteen (15) residents ormajor fraction of fifteen (15) during the dayshift, one (1) person for every fifteen (15)residents or major fraction of fifteen (15)during the evening shift, and one (1) personfor every twenty (20) residents or major frac-tion of twenty (20) during the night shift. I/II


(Day)* 1 3–153 p.m. to 9 p.m.

(Evening)* 1 3–159 p.m. to 7 a.m.

(Night)* 1 3–20


(B) The required staff shall be in the facil-ity awake, dressed, and prepared to assist res-idents in case of emergency. I/II

(C) The administrator shall count towardstaffing when physically present at the facili-ty. II

(D) These staffing requirements are appli-cable only when the facility actually has inresidence one (1) or more residents whorequire more than minimal assistance in evac-uating the facility. II

(E) At a minimum there shall be a licensednurse employed by the facility to work at leastthe following hours per week:

3–30 Residents—8 hours31–60 Residents—16 hours61–90 Residents—24 hours91 or more Residents—40 hours. II(F) The licensed nurse shall be available to

assess residents for pain and significant andacute changes in condition. The nurse’sduties shall include, but shall not be limitedto, review of residents’ records, medications,and special diets or other orders, review ofeach resident’s adjustment to the facility, andobservation of each individual resident’s gen-eral physical, psychosocial, and mental sta-tus. The nurse shall inform the administratorof any problems noted and these shall bebrought to the attention of the resident’s

physician and legally authorized representa-tive or designee. II/III

AUTHORITY: sections 198.073 and 198.076,RSMo Supp. 2007.* This rule originally filedas 13 CSR 15-15.045. Emergency rule filedDec. 14, 2000, effective Jan. 2, 2001, expiredJune 30, 2001. Original rule filed Dec. 14,2000, effective June 30, 2001. Moved to 19CSR 30-86.045, effective Aug. 28, 2001.Amended: Filed Aug. 23, 2006, effectiveApril 30, 2007. Amended: Filed March 13,2008, effective Oct. 30, 2008.

*Original authority: 198.073, RSMo 1979, amended1984, 1992, 1999, 2006, 2007 and 198.076, RSMo 1979,amended 1984, 2007.

19 CSR 30-86.047 Administrative, Person-nel and Resident Care Requirements forAssisted Living Facilities

PURPOSE: This rule establishes standardsfor all assisted living facilities licensed pur-suant to sections 198.005 and 198.073,RSMo (CCS HCS SCS SB 616, 93rd GeneralAssembly, Second Regular Session (2006))and required to meet assisted living facilitystandards pursuant to section 198.073.3,RSMo (CCS HCS SCS SB 616, 93rd GeneralAssembly, Second Regular Session (2006))and section 198.076, RSMo 2000.


AGENCY NOTE: All rules relating tolong-term care facilities licensed by thedepartment are followed by a Roman Numer-al notation which refers to the class (eitherClass I, II or III) of standard as designated insection 198.085.1, RSMo.

(1) Facilities licensed as assisted living facil-ities shall be inspected pursuant to the stan-dards outlined herein beginning April 1,2007. An assisted living facility may request,in writing to the department, to comply withthese standards prior to April 1, 2007. Uponreceipt of the request, the department shallconduct an inspection to determine compli-

ance with the standards outlined herein priorto issuing a license indicating such compli-ance.

(2) Consumer Education Requirements. Thefacility shall disclose to a prospective resi-dent, or legal representative of the resident,information regarding the services the facili-ty is able to provide or coordinate, the cost ofsuch services to the resident, and the groundsfor discharge or transfer as permitted orrequired by the Omnibus Nursing Home Act,Chapter 198, RSMo and the department’sregulations, including the provisions set forthin section (29) of this rule. II

(3) Nothing in this rule shall be construed toallow any facility that has not met the require-ments of 198.073(4) and (6), RSMo, (CCSHCS SCS SB 616, 93rd General Assembly,Second Regular Session (2006)) and 19 CSR30-86.045 to care for any individual with aphysical, cognitive or other impairment thatprevents the individual from safely evacuatingthe facility with minimal assistance. I/II


(A) Appropriately trained and qualifiedindividual means an individual who islicensed or registered with the state of Mis-souri in a health care related field or an indi-vidual with a degree in a health care relatedfield or an individual with a degree in ahealth care, social services, or human ser-vices field or an individual licensed underChapter 344, RSMo, and who has receivedfacility orientation training under 19 CSR 30-86.042(18), and dementia training under sec-tion 660.050, RSMo, and twenty-four (24)hours of additional training, approved by thedepartment, consisting of definition andassessment of activities of daily living,assessment of cognitive ability, service plan-ning, and interview skills;

(B) Area of refuge—A space located in orimmediately adjacent to a path of travel lead-ing to an exit that is protected from theeffects of fire, either by means of separationfrom other spaces in the same building or itslocation, permitting a delay in evacuation.An area of refuge may be temporarily used asa staging area that provides relative safety toits occupants while potential emergencies areassessed, decisions are made, and evacuationis begun;

(C) Assisted living facility (ALF)—Is asdefined in 19 CSR 30-83.010;

(D) Chemical restraint—Is as defined in 19CSR 30-83.010;


Secretary of State


(E) Community based assessment—Docu-mented basic information and analysis pro-vided by appropriately trained and qualifiedindividuals describing an individual’s abili-ties and needs in activities of daily living,instrumental activities of daily living,vision/hearing, nutrition, social participationand support, and cognitive functioning usingan assessment tool approved by the depart-ment, that is designed for community basedservices and that is not the nursing homeminimum data set. The assessment tool maybe one developed by the department or oneused by a facility which has been approved bythe department;

(F) Evacuating the facility—For the pur-pose of this rule, evacuating the facility shallmean moving to an area of refuge or from onesmoke section to another or exiting the facil-ity;

(G) Home-like—Means a self-containedlong-term care setting that integrates the psy-chosocial, organizational and environmentalqualities that are associated with being athome. Home-like may include, but is notlimited to the following:

1. A living room and common use areasfor social interactions and activities;

2. Kitchen and family style eating areafor use by the residents;

3. Laundry area for use by residents;4. A toilet room that contains a toilet,


5. Resident room preferences for resi-dents who wish to share a room, and for res-idents who wish to have private bedrooms;

6. Outdoor area for outdoor activitiesand recreation; and

7. A place where residents can give andreceive affection, explore their interests,exercise control over their environment,engage in interactions with others and haveprivacy, security, familiarity and a sense ofbelonging;

(H) Individualized service plan (ISP)—Shall mean the planning document preparedby an assisted living facility, which outlines aresident’s needs and preferences, services tobe provided, and the goals expected by theresident or the resident’s legal representativein partnership with the facility;

(I) Keeping residents in place—Meansmaintaining residents in place during a fire inlieu of evacuation where a building’s occu-pants are not capable of evacuation, whereevacuation has a low likelihood of success, orwhere it is recommended in writing by localfire officials as having a better likelihood ofsuccess and/or a lower risk of injury;

(J) Minimal assistance—

1. Is the criterion which determineswhether or not staff must develop and includean individualized evacuation plan as part ofthe resident’s service plan;

2. Minimal assistance may be the verbalintervention that staff must provide for a res-ident to initiate evacuating the facility;

3. Minimal assistance may be the physi-cal intervention that staff must provide, suchas turning a resident in the correct direction,for a resident to initiate evacuating the facili-ty;

4. A resident needing minimal assis-tance is one who is able to prepare to leaveand then evacuate the facility within five (5)minutes of being alerted of the need to evac-uate and requires no more than one (1) phys-ical intervention and no more than three (3)verbal interventions of staff to complete evac-uation from the facility;

5. The following actions required ofstaff are considered to be more than minimalassistance:

A. Assistance to traverse down stair-ways;

B. Assistance to open a door; andC. Assistance to propel a wheelchair;

(K) Physical restrain—Any manual methodor physical or mechanical device, material orequipment attached to or adjacent to the res-ident’s body that the individual cannotremove easily which restricts freedom ofmovement or normal access to one’s body.Physical restraints include, but are not limit-ed to leg restraints, arm restraints, handmitts, soft ties or vests, lap cushions and laptrays the resident cannot remove easily. Phys-ical restraints also include facility practicesthat meet the definition of a restraint, such asthe following:

1. Using side rails that keep a residentfrom voluntarily getting out of bed;

2. Tucking in or using Velcro to hold asheet, fabric or clothing tightly so that a res-ident’s movement is restricted;

3. Using devices in conjunction with achair, such as trays, tables, bars or belts, thatthe resident cannot remove easily, that pre-vent the resident from rising;

4. Placing the resident in a chair thatprevents a resident from rising; and

5. Placing a chair or bed so close to awall that the wall prevents the resident fromrising out of the chair or voluntarily gettingout of bed;

(L) Significant change—means any changein the resident’s physical, emotional or psy-chosocial condition or behavior that will notnormally resolve itself without further inter-vention by staff or by implementing standarddisease-related clinical interventions, that hasan impact on more than one (1) area of the

resident’s health status, and requires interdis-ciplinary review or revision of the individual-ized service plan, or both;

(M) Skilled nursing facility—Means anypremises, other than a residential care facili-ty, assisted living facility or an intermediatecare facility, which is utilized by its owner,operator or manager to provide for twenty-four (24) hour accommodation, board andskilled nursing care and treatment services toat least three (3) residents who are not relat-ed within the fourth degree of consanguinityor affinity to the owner, operator or managerof the facility. Skilled nursing care and treat-ment services are those services commonlyperformed by or under the supervision of aregistered professional nurse for individualsrequiring twenty-four (24)-hours-a-day careby licensed nursing personnel including actsof observation, care and counsel of the aged,ill, injured or infirm, the administration ofmedications and treatments as prescribed by alicensed physician or dentist, and other nurs-ing functions requiring substantial specializedjudgment and skill;

(N) Skilled nursing placement—Meansplacement in a skilled nursing facility asdefined 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 individu-al delivered in a setting that is more home-like than institutional, that promote the digni-ty, individuality, privacy, independence andautonomy of the individual, that respects res-idents’ differences and promotes residents’choices.

(5) The operator shall designate an individu-al for administrator who is currently licensedas a nursing home administrator under Chap-ter 344, RSMo. II

(6) The operator shall be responsible toassure compliance with all applicable lawsand regulations. The administrator shall befully authorized and empowered to makedecisions regarding the operation of the facil-ity and shall be held responsible for theactions of all employees. The administrator’sresponsibilities shall include oversight of res-idents to assure that they receive care asdefined in the individualized service plan.II/III

(7) The administrator cannot be listed or func-tion in more than one (1) licensed facility atthe same time unless he or she serves no morethan five (5) facilities within a thirty (30)-mileradius and licensed to serve in total no morethan one hundred (100) residents, and theadministrator has an individual designated as



the daily manager of each facility. However,the administrator may serve as the adminis-trator of more than one (1) licensed facility ifall facilities are on the same premises. II

(8) The administrator shall designate, in writ-ing, a staff member in charge in the adminis-trator’s absence. If the administrator is absentfor more than thirty (30) consecutive days,during which time he or she is not readilyaccessible for consultation by telephone withthe delegated individual, the individual desig-nated to be in charge shall be a currentlylicensed nursing home administrator. Suchthirty (30)-consecutive-day absences mayonly occur once within any consecutivetwelve (12)-month period. II/III

(9) The facility shall not care for more resi-dents than the number for which the facilityis licensed. However, if the facility operates anon-licensed adult day care program for four(4) or fewer participants within the licensedfacility, the day care participants shall not beincluded in the total facility census. Adultday care participants shall be counted instaffing determination during the hours theday care participants are in the facility. II/III

(10) The facility shall not admit or continueto care for residents whose needs cannot bemet. If necessary services cannot be obtainedin or by the facility, the resident shall bepromptly referred to appropriate outsideresources or discharged from the facility. I/II

(11) All personnel responsible for residentcare shall have access to the legal name ofeach resident, name and telephone number ofresident’s physician, resident’s designee orlegally authorized representative in the eventof emergency. II/III

(12) All persons who have any contact withthe residents in the facility shall not know-ingly act or omit any duty in a manner thatwould materially and adversely affect thehealth, safety, welfare or property of resi-dents. No person who is listed on the depart-ment’s Employee Disqualification List (EDL)shall work or volunteer in the facility in anycapacity whether or not employed by theoperator. For the purpose of this rule, a vol-unteer is an unpaid individual formally rec-ognized by the facility as providing a directcare service to residents. The facility isrequired to check the EDL for individualswho volunteer to perform a service for whichthe facility might otherwise have to hire anemployee. The facility is not required tocheck the EDL for individuals or groups suchas scout groups, bingo or sing-along leaders.

The facility is not required to check the EDLfor an individual such as a priest, minister orrabbi visiting a resident who is a member ofthe individual’s congregation. However, if aminister, priest or rabbi serves as a volunteerfacility chaplain, the facility is required tocheck to determine if the individual is listedon the EDL since the individual would havecontact with all residents. I/II

(13) Prior to allowing any person who hasbeen hired in a full-time, part-time, or tem-porary employee position to have contact withany residents, the facility shall, or in the caseof temporary employees hired through orcontracted from an employment agency, theemployment agency shall, prior to sending atemporary employee to a provider:

(A) Request a criminal background checkfor the person, as provided in section 43.540,RSMo. Each facility must maintain in itsrecord documents verifying that the back-ground checks were requested and the natureof the response received for each suchrequest.

1. The facility must ensure that anyapplicant or person hired or retained who dis-closes prior to the receipt of the criminalbackground check that he/she has been con-victed of, pled guilty or pled nolo contendereto in this state or any other state or has beenfound guilty of a crime, which if committedin Missouri would be a Class A or B felonyviolation of Chapter 565, 566, or 569, RSMoor any violation of subsection 198.070.3,RSMo or of section 568.020, RSMo, will nothave contact with residents. II/III

2. Upon receipt of the criminal back-ground check, the facility must ensure that ifthe criminal background check indicates thatthe person hired or retained by the facility hasbeen convicted of, pled guilty or pled nolocontendere to in this state or any other stateor has been found guilty of a crime, which ifcommitted in Missouri would be a Class A orB felony violation of Chapter 565, 566, or569, RSMo or any violation of subsection198.070.3, RSMo or of section 568.020,RSMo, the person will not have contact withresidents unless the facility obtains verifica-tion from the department that a good causewaiver has been granted and maintains a copyof the verification in the individual’s person-nel file. II/III

(B) Make an inquiry to the department,whether the person is listed on the employeedisqualification list as provided in section660.315, RSMo. The inquiry may be madevia Internet at www.dhss.mo.gov/EDL/.II/III

(C) If the person has registered with thedepartment’s Family Care Safety Registry

(FCSR), the facility may utilize the Registryin order to meet the requirements of subsec-tions (13)(A) and (13)(B) of this rule. TheFCSR is available via Internet atwww.dhss.mo.gov/FCSR/Background-Check.html. II/III

(D) For persons for whom the facility hascontracted for professional services (e.g.,plumbing or air conditioning repair) that willhave contact with any resident, the facilitymust either require a criminal backgroundcheck or ensure that the individual is suffi-ciently monitored by facility staff while in thefacility to reasonably ensure the safety of allresidents. I/II

(14) A facility shall not employ, as an agentor employee who has access to controlledsubstances, any person who has been foundguilty or entered a plea of guilty or nolo con-tendere in a criminal prosecution under thelaws of any state or of the United States forany offense related to controlled substances.II

(A) A facility may apply in writing to thedepartment for a waiver of this section of thisrule for a specific employee.

(B) The department may issue a writtenwaiver to a facility upon determination that awaiver would be consistent with the publichealth and safety. In making this determina-tion, the department shall consider the dutiesof the employee, the circumstances surround-ing the conviction, the length of time sincethe conviction was entered, whether a waiverhas been granted by the department’s Bureauof Narcotics and Dangerous Drugs pursuantto 19 CSR 30-1.034 when the facility is reg-istered with that agency, whether a waiver hasbeen granted by the federal Drug Enforce-ment Administration (DEA) pursuant to 21CFR 1301.76 when the facility is also regis-tered with that agency, the security measurestaken by the facility to prevent the theft anddiversion of controlled substances, and anyother factors consistent with public healthand safety. II

(15) The facility must develop and implementwritten policies and procedures which requirethat persons hired for any position which is tohave contact with any patient or resident havebeen informed of their responsibility to dis-close their prior criminal history to the facil-ity as required by section 660.317.5, RSMo.The facility must also develop and implementpolicies and procedures which ensure that thefacility does not knowingly hire, after August28, 1997, any person who has or may havecontact with a patient or resident, who hasbeen convicted of, plead guilty or nolo con-tendere to, in this state or any other state, or


Secretary of State


has been found guilty of any Class A or Bfelony violation of Chapter 565, 566 or 569,RSMo, or any violation of subsection 3 ofsection 198.070, RSMo, or of section568.020, RSMo. II/III

(16) All persons who have or may have con-tact with residents shall at all times when onduty or delivering services wear an identifi-cation badge. The badge shall give theirname, title and, if applicable, the status oftheir license or certification as any kind ofhealth care professional. This rule shall applyto all personnel who provide services to anyresident directly or indirectly. III

(17) Personnel who have been diagnosed witha communicable disease may begin work orreturn to duty only with written approval by aphysician or physician’s designee, whichindicates any limitations. II

(18) The administrator shall be responsible toprevent an employee known to be diagnosedwith communicable disease from exposingresidents to such disease. The facility’s poli-cies and procedures must comply with thedepartment’s regulations pertaining to com-municable diseases, specifically 19 CSR 20-20.010 through 19 CSR 20-20.100. II /III

(19) The facility shall screen residents andstaff for tuberculosis as required for long-term care facilities by 19 CSR 20-20.100. II

(20) The administrator shall maintain on thepremises an individual personnel record oneach facility employee, which shall includethe 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 edu-

cation including for positions requiring licen-sure or certification, documentation evidenc-ing competency for the position held, whichincludes copies of current licenses, tran-scripts when applicable, or for those individ-uals requiring certification, such as certifiedmedication technicians, level I medicationaides and insulin administration aides; print-ing the Web Registry search results pageavailable at www.dhss.mo.gov/cnaregistryshall meet the requirements of the employer’scheck regarding valid certification;

(F) References, if available;(G) The results of background checks

required by section 660.317, RSMo; and acopy of any good cause waiver granted by thedepartment, if applicable;

(H) Position in the facility;(I) Written statement signed by a licensed

physician or physician’s designee indicatingthe person can work in a long-term care facil-ity and indicating any limitations;

(J) Documentation of the employee’s tuber-culin screening status;

(K) Documentation of what the employeewas instructed on during orientation training;and

(L) Reason for termination if the employeewas terminated due to abuse or neglect of aresident, residents’ rights issues or residentinjury. III

(21) Personnel records shall be maintainedfor at least two (2) years following termina-tion of employment. III


(23) No one individual shall be on duty withresponsibility for oversight of residents longerthan eighteen (18) hours per day. I/II

(24) Employees who are counted in meetingthe minimum staffing ratio and employeeswho provide direct care to the residents shallbe at least sixteen (16) years of age. Oneemployee at least eighteen (18) years of ageshall be on duty at all times. II

(25) Each facility resident shall be under themedical supervision of a physician licensed topractice in Missouri who has been informedof the facility’s emergency medical proce-dures and is kept informed of treatments ormedications prescribed by any other profes-sional lawfully authorized to prescribe medi-cations. III

(26) The facility shall ensure that each resi-dent being admitted or readmitted to the facil-ity receives an admission physical examina-tion by a licensed physician. The facilityshall request documentation of the physicalexamination prior to admission but must havedocumentation of the physical examination onfile no later than ten (10) days after admis-sion. The physical examination shall containdocumentation regarding the individual’s cur-rent medical status and any special orders orprocedures to be followed. If the resident isadmitted directly from an acute care oranother long-term care facility and is accom-panied on admission by a report that reflectshis or her current medical status, an admis-sion physical shall not be required. III


(28) The facility may admit or retain an indi-vidual for residency in an assisted living facil-ity only if the individual does not require hos-pitalization or skilled nursing placement asdefined in this rule, and only if the facility:

(A) Provides for or coordinates oversightand services to meet the needs, the social andrecreational preferences in accordance withthe individualized service plan of the residentas documented in a written contract signed bythe resident, or legal representative of theresident; II

(B) Has twenty-four (24) hour staff appro-priate in numbers and with appropriate skillsto provide such services; II

(C) Has a written plan for the protection ofall residents in the event of a disaster such astornado, fire, bomb threat or severe weather,including:

1. Keeping residents in place;2. Evacuating residents to areas of

refuge;3. Evacuating residents from the build-

ing if necessary; or4. Other methods of protection based on

the disaster and the individual buildingdesign; I/II

(D) Completes a premove-in screeningconducted as required by section 198.073.4(4), RSMo (CCS HCS SCS SB 616, 93rdGeneral Assembly, Second Regular Session(2006)). II

(E) The premove-in screening shall becompleted prior to admission with the partic-ipation of the prospective resident and bedesigned to determine if the individual is eli-gible for admission to the assisted livingfacility and shall be based on the admissionrestrictions listed at section (29) of this rule;II

(F) Completes a community based assess-ment conducted by an appropriately trainedand qualified individual as defined in section(4) of this rule:

1. Time frame requirements for assess-ment shall be:

A. Within five (5) calendar days ofadmission; II

B. At least semiannually; and IIC. Whenever a significant change has

occurred in the resident’s condition, whichmay require a change in services. II

2. The facility shall use form MO 580-2835, Assessment for Admission To Assist-ed Living Facilities, (9-06), incorporated byreference, provided by the Department ofHealth and Senior Services, PO Box 570, Jef-ferson City, MO 65102-0570 and which isavailable to long-term care facilities atwww.dhss.mo.gov or by telephone at (573)526-8548. This rule does not incorporate anysubsequent amendments or additions; or II



3. The facility may use another assess-ment form if approved in advance by thedepartment; II

(G) Develops an individualized serviceplan (ISP), which means the planning docu-ment prepared by an assisted living facilitywhich outlines a resident’s needs and prefer-ences, services to be provided, and goalsexpected by the resident or the resident’slegal representative in partnership with thefacility; II

(H) Reviews the ISP with the resident, orlegal representative of the resident, at leastannually or when there is a significant changein the resident’s condition which may requirea change in services; II

(I) Includes the signatures of an authorizedrepresentative of the facility and the residentor the resident’s legal representative in theindividualized service plan to acknowledgethat the service plan has been reviewed andunderstood by the resident or legal represen-tative; II

(J) Develops and implements a plan to pro-tect the rights, privacy, and safety of all resi-dents and to protect against the financialexploitation of all residents; and II

(K) Complies with the dementia specifictraining requirements of subsection 8 of sec-tion 660.050, RSMo. II

(29) The facility shall not admit or continueto care for a resident who:

(A) Has exhibited behaviors that present areasonable likelihood of serious harm to him-self or herself or others; I/II

(B) Requires physical restraint as definedin this rule; II

(C) Requires chemical restraint as definedin this rule; II

(D) Requires skilled nursing services asdefined in section 198.073.4, RSMo forwhich the facility is not licensed or able toprovide; II

(E) Requires more than one (1) person tosimultaneously physically assist the residentwith any activity of daily living, with theexception of bathing and transferring; orII/III

(F) Is bed-bound or similarly immobilizeddue to a debilitating or chronic condition. II

(30) The requirements of subsections(29)(D), (E) and (F) shall not apply to a res-ident receiving hospice care, provided theresident, his or her legally authorized repre-sentative or designee, or both, and the facili-ty, physician and licensed hospice provider allagree that such program of care is appropri-ate for the resident. II

(31) Programs and Services Requirements forResidents.

(A) The facility shall designate a staffmember to be responsible for leisure activitycoordination and for promoting the socialmodel, multiple staff role directing all staff toprovide routine care in a manner that empha-sizes the opportunity for the resident and thestaff member to enjoy a visit rather than sim-ply perform a procedure. II/III

(B) The facility shall make available andimplement self-care, productive and leisureactivity programs which maximize andencourage the resident’s optimal functionalability for residents. The facility shall pro-vide person-centered activities appropriate tothe resident’s individual needs, preferences,background and culture. Individual or groupactivity programs may consist of the follow-ing:

1. Gross motor activities, such as exer-cise, dancing, gardening, cooking and otherroutine tasks;

2. Self-care activities, such as dressing,grooming and personal hygiene;

3. Social and leisure activities, such asgames, music and reminiscing;

4. Sensory enhancement activities, suchas auditory, olfactory, visual and tactile stim-ulation;

5. Outdoor activities, such as walkingand field trips;

6. Creative arts; or 7. Other social, leisure or therapeutic

activities that encourage mental and physicalstimulation or enhance the resident’s well-being. II/III

(C) Staff shall inform residents in advanceof any organized group activity including thetime and place of the activity. II/III

(32) Requirements for Facilities ProvidingCare to Residents Having Mental Illness orMental Retardation Diagnosis.

(A) Each resident who exhibits mental andpsychosocial adjustment difficulty(ies) shallreceive treatment and services to address theresident’s needs and behaviors as stated in theindividualized service plan. I/II

(B) If specialized rehabilitative services formental illness or mental retardation arerequired to enable a resident to reach and tocomply with the individualized service plan,the facility shall ensure the required servicesare provided. II

(C) The facility shall maintain in the resi-dent’s record the most recent progress notesand personal plan developed and provided bythe Department of Mental Health or desig-nated administrative agent for each residentwhose care is funded by the Department of

Mental Health or designated administrativeagent. III

(33) No facility shall accept any individualwith a physical, cognitive, or other impair-ment that prevents the individual from safelyevacuating the facility with minimal assis-tance unless the facility meets all require-ments of section 198.073, RSMo (CCS HCSSCS SB 616, 93rd General Assembly, Sec-ond Regular Session (2006)) and those stan-dards set forth in 19 CSR 30-86.045. I/II

(34) The facility shall follow appropriateinfection control procedures. The administra-tor or his or her designee shall make a reportto the local health authority or the departmentof the presence or suspected presence of anydiseases or findings listed in 19 CSR 20-20.020, sections (1)–(3) according to thespecified time frames as follows:

(A) Category I diseases or findings shall bereported to the local health authority or to thedepartment within twenty-four (24) hours offirst knowledge or suspicion by telephone,facsimile, or other rapid communication;

(B) Category II diseases or findings shallbe reported to the local health authority orthe department within three (3) days of firstknowledge or suspicion;

(C) Category III—The occurrence of anoutbreak or epidemic of any illness, diseaseor condition which may be of public healthconcern, including any illness in a food han-dler that is potentially transmissible throughfood. This also includes public health threatssuch as clusters of unusual diseases or mani-festations of illness and clusters of unex-plained deaths. Such incidents shall bereported to the local authority or to thedepartment by telephone, facsimile, or otherrapid communication within twenty-four (24)hours of first knowledge or suspicion. I/II


(36) Residents shall receive proper care asdefined in the individualized service plan.I/II

(37) In case of behaviors that present a rea-sonable likelihood of serious harm to himselfor herself or others, serious illness, signifi-cant change in condition, injury or death,


Secretary of State


staff shall take appropriate action and shallpromptly attempt to contact the person listedin the resident’s record as the legally autho-rized representative, designee or placementauthority. The facility shall contact theattending physician or designee and notify thelocal coroner or medical examiner immedi-ately upon the death of any resident of thefacility prior to transferring the deceased res-ident to a funeral home. I/II

(38) The facility shall encourage and assisteach resident based on his or her individualpreferences and needs to be clean and free ofbody and mouth odor. II

(39) If the resident brings unsealed medica-tions to the facility, the medications shall notbe used unless a pharmacist, physician ornurse examines, identifies and determines thecontents to be suitable for use. The personperforming the identification shall documenthis or her review. II/III

(40) Self-control of prescription medicationby a resident may be allowed only if approvedin writing by the resident’s physician andincluded in the resident’s individualized ser-vice plan. A resident may be permitted tocontrol the storage and use of nonprescriptionmedication unless there is a physician’s writ-ten order or facility policy to the contrary.Written approval for self-control of prescrip-tion medication shall be rewritten as neededbut at least annually and after any period ofhospitalization. II/III

(41) All medication shall be safely stored atproper temperature and shall be kept in asecured location behind at least one (1)locked door or cabinet. Medication shall beaccessible only to persons authorized toadminister medications. II/III

(A) If access is controlled by the resident,a secured location shall mean in a lockedcontainer, a locked drawer in a bedside tableor dresser or in a resident’s private room iflocked in his or her absence, although thisdoes not preclude access by a responsibleemployee of the facility.

(B) Schedule II controlled substances shallbe stored in locked compartments separatefrom non-controlled medications, except thatsingle doses of Schedule II controlled sub-stances may be controlled by a resident incompliance with the requirements for self-control of medication of this rule.

(C) Medication that is not in current useand is not destroyed shall be stored separate-ly from medication that is in current use.II/III

(42) All prescription medications shall besupplied as individual prescriptions exceptwhere an emergency medication supply isallowed. All medications, including over-the-counter medications, shall be packaged andlabeled in accordance with applicable profes-sional pharmacy standards, and state and fed-eral drug laws. Labeling shall include acces-sory and cautionary instructions as well asthe expiration date, when applicable, and thename of the medication as specified in thephysician’s order. Medication labels shall notbe altered by facility staff and medicationsshall not be repackaged by facility staff exceptas allowed by section (43) of this rule. Over-the-counter medications for individual resi-dents shall be labeled with at least the resi-dent’s name. II/III

(43) Controlled substances and other pre-scription and non-prescription medicationsfor administration when a resident temporar-ily leaves a facility shall be provided as fol-lows:

(A) Separate containers of medications forthe leave period may be prepared by the phar-macy. The facility shall have a policy andprocedure for families to provide adequateadvance notice so that medications can beobtained from the pharmacy.

(B) Prescription medication cards or othermultiple-dose prescription containers current-ly in use in the facility may be provided byany authorized facility medication staff mem-ber if the containers are labeled by the phar-macy with complete pharmacy prescriptionlabeling for use. Original manufacturer con-tainers of non-prescription medications,along with instructions for administration,may be provided by any authorized facilitymedication staff member.

(C) When medications are supplied by thepharmacy in customized patient medicationpackages that allow separation of individualdose containers, the required number of con-tainers may be provided by any authorizedfacility medication staff member. The indi-vidual dose containers shall be placed in anouter container that is labeled with the nameand address of the facility and the date.

(D) When multiple doses of a medicationare required and it is not reasonably possibleto obtain prescription medication labeled bythe pharmacy, and it is not appropriate tosend a container of medication currently inuse in the facility, up to a twenty-four (24)-hour supply of each prescription or non-pre-scription medication may be provided by alicensed nurse in United States Pharmacopeia(USP) approved containers labeled with thefacility name and address, resident’s name,medication name and strength, quantity,

instructions for use, date, initials of individu-al providing, and other appropriate informa-tion.

(E) When no more than a single dose of amedication is required, any authorized facili-ty medication staff member may prepare thedose as for in-facility administration in a USPapproved container labeled with the facilityname and address, resident’s name, medica-tion name and strength, quantity, instructionsfor use, date, initials of person providing, andother appropriate information.

(F) The facility may have a policy that lim-its the quantity of medication sent with a res-ident without prior approval of the prescriber.

(G) Returned containers shall be identifiedas having been sent with the resident, andshall not later be returned to the pharmacy forreuse.

(H) The facility shall maintain accuraterecords of medications provided to andreturned by the resident. II/III

(44) Upon discharge or transfer of a resident,the facility shall release prescription medica-tions, including controlled substances, heldby the facility for the resident when the physi-cian writes an order for each medication to bereleased. Medications shall be labeled by thepharmacy with current instructions for use.Prescription medication cards or other con-tainers may be released if the containers arelabeled by the pharmacy with complete phar-macy prescription labeling. II/III

(45) Injections shall be administered only bya physician or licensed nurse, except thatinsulin injections may also be administeredby a certified medication technician or level Imedication aide who has successfully com-pleted the state-approved course for insulinadministration, taught by a department-approved instructor. Anyone trained prior toDecember 31, 1990, who completed thestate-approved insulin administration coursetaught by an approved instructor shall be con-sidered qualified to administer insulin in anassisted living facility. A resident whorequires insulin, may administer his or herown insulin if approved in writing by the res-ident’s physician and trained to do so by alicensed nurse or physician. The facility shallmonitor the resident’s condition and ability tocontinue self-administration. I/II

(46) The administrator shall develop andimplement a safe and effective system of med-ication control and use, which assures that allresidents’ medications are administered bypersonnel at least eighteen (18) years of age,in accordance with physicians’ instructionsusing acceptable nursing techniques. The



facility shall employ a licensed nurse eight (8)hours per week for every thirty (30) residentsto monitor each resident’s condition and med-ication. Administration of medication shallmean delivering to a resident his or her pre-scription medication either in the originalpharmacy container, or for internal medica-tion, removing an individual dose from thepharmacy container and placing it in a smallcup container or liquid medium for the resi-dent to remove from the container and self-administer. External prescription medicationmay be applied by facility personnel if theresident is unable to do so and the resident’sphysician so authorizes. All individuals whoadminister medication shall be trained inmedication administration and, if not a physi-cian or a licensed nurse, shall be a certifiedmedication technician or level I medicationaide. I/II

(47) Medication Orders.(A) No medication, treatment or diet shall

be administered without an order from anindividual lawfully authorized to prescribesuch and the order shall be followed. II/III

(B) Physician’s written and signed ordersshall include: name of medication, dosage,frequency and route of administration and theorders shall be renewed at least every three(3) months. Computer generated signaturesmay be used if safeguards are in place to pre-vent their misuse. Computer identificationcodes shall be accessible to and used by onlythe individuals whose signatures they repre-sent. Orders that include optional doses orinclude pro re nata (PRN) administration fre-quencies shall specify a maximum frequencyand the reason for administration. II/III

(C) Telephone and other verbal ordersshall be received only by a licensed nurse,certified medication technician, level I medi-cation aide or pharmacist, and shall be imme-diately reduced to writing and signed by thatindividual. A certified medication technicianor level I medication aide may receive a tele-phone or other verbal order only for a medi-cation or treatment that the technician or levelI medication aide is authorized to administer.If a telephone or other verbal order is givento a medication technician or level I medica-tion aide, an initial dosage shall not beadministered until the order has beenreviewed by telephone, facsimile or in personby a licensed nurse or pharmacist. Thereview shall be documented by the reviewerco-signing the telephone or other verbalorder. II

(D) The review shall be documented by thelicensed nurse’s or pharmacist’s signaturewithin seven (7) days. III

(E) The facility shall submit to the physi-cian written versions of any oral or telephoneorders within four (4) days of the giving ofthe oral or telephone order. III

(F) Influenza and pneumococcal polysac-charide immunizations may be administeredper physician-approved facility policy afterassessment for contraindications—

1. The facility shall develop a policy thatprovides recommendations and assessmentparameters for the administration of suchimmunizations. The policy shall be approvedby the facility medical director for facilitieshaving a medical director, or by each resi-dent’s attending physician for facilities thatdo not have a medical director, and shallinclude the requirements to:

A. Provide education to each residentor the resident’s designee or legally autho-rized representative regarding the potentialbenefits and side effects of the immunization;II/III

B. Offer the immunization to the res-ident or obtain permission from the resident’sdesignee or legally authorized representativewhen the immunization is medically indicat-ed unless the resident has already beenimmunized as recommended by the policy;II/III

C. Provide the opportunity to refusethe immunization; and II/III

D. Perform an assessment for con-traindications; II/III

2. The assessment for contraindicationsand documentation of the education andopportunity to refuse the immunization shallbe dated and signed by the nurse performingthe assessment and placed in the medicalrecord; or

3. The facility shall with the approval ofeach resident’s physician, access screeningand immunization through outside sourcessuch as county or city health departments.II/III

(G) The administration of medication shallbe recorded on a medication sheet or directlyin the resident’s record and, if recorded on amedication sheet, shall be made part of theresident’s record. The administration shall berecorded by the same individual who pre-pares the medication and administers it.II/III

(48) The facility may keep an emergencymedication supply if approved by a pharma-cist or physician. Storage and use of medica-tions in the emergency medication supplyshall assure accountability. When the emer-gency medication supply contains controlledsubstances, the facility shall be registeredwith the Bureau of Narcotics and DangerousDrugs (BNDD) and shall be in compliance

with 19 CSR 30-1.052 and other applicablestate and federal controlled substance lawsand regulations. II/III

(49) Automated dispensing systems may becontrolled by the facility or may be controlledon-site or remotely by a pharmacy.

(A) Automated dispensing systems may beused for an emergency medication supply.

(B) Automated dispensing systems that arecontrolled by a pharmacy may be used forcontinuing doses of controlled substance andnon-controlled substance medications. Whencontinuing doses are administered from anautomated dispensing system that is con-trolled by a pharmacy, a pharmacist shallreview and approve each new medicationorder prior to releasing the medication fromthe system. The pharmacy and the facilitymay have a policy and procedure to allow therelease of initial doses of approved medica-tions when a pharmacist is not available inlieu of a separate emergency medication sup-ply. When initial doses are used when apharmacist is not available, a pharmacist shallreview and approve the order within twenty-four (24) hours of administration of the firstdose.

(C) Automated dispensing systems shall beused in compliance with state and federallaws and regulations. When an automateddispensing system controlled by the facilitycontains controlled substances for an emer-gency medication supply, the facility shall beregistered with the BNDD. When an auto-mated dispensing system is controlled by apharmacy, the facility shall use it in compli-ance with 20 CSR 2220-2.900. II/III

(50) Stock supplies of nonprescription medi-cation may be kept when specific medicationsare approved in writing by a consulting physi-cian, a registered nurse or a pharmacist. II/III

(51) Records shall be maintained upon receiptand disposition of all controlled substancesand shall be maintained separately from otherrecords, for two (2) years.

(A) Inventories of controlled substancesshall be reconciled as follows:

1. Controlled Substance Schedule IImedications shall be reconciled each shift;and II

2. Controlled Substance Schedule III–Vmedications shall be reconciled at least week-ly and as needed to ensure accountability. II

(B) Inventories of controlled substancesshall be reconciled by the following:

1. Two (2) medication personnel, one ofwhom is a licensed nurse; or

2. Two (2) medication personnel, whoare certified medication technicians or level I


Secretary of State




medication aides, when a licensed nurse isnot available. II

(C) Receipt records shall include the date,source of supply, resident name and prescrip-tion number when applicable, medicationname and strength, quantity and signature ofthe supplier and receiver. Administrationrecords shall include the date, time, residentname, medication name, dose administeredand the initials of the individual administer-ing. The signature and initials of each medi-cation staff documenting on the medicationadministration record must be signed in thesignature area of the medication record. II

(D) When self-control of medication isapproved a record shall be made of all con-trolled substances transferred to and adminis-tered from the resident’s room. Inventoryreconciliation shall include controlled sub-stances transferred to the resident’s room. II

(52) Documentation of waste of controlledsubstances at the time of administration shallinclude the reason for the waste and the sig-nature of another facility medication staffmember who witnesses the waste. If a sec-ond medication staff member is not availableat the time of administration, the controlledsubstance shall be properly labeled, clearlyidentified as unusable, stored in a lockedarea, and destroyed as soon as a medicationstaff member is available to witness thewaste. When a second medication staff mem-ber is not available and the controlled sub-stance is contaminated by patient body fluids,the controlled substance shall be destroyedimmediately and the circumstances docu-mented. II/III

(53) At least every other month, a pharmacistor registered nurse shall review the controlledsubstance record keeping including reconcil-ing the inventories of controlled substances.This shall be done at the time of the drug reg-imen review of each resident. All discrepan-cies in controlled substance records shall bereported to the administrator for review andinvestigation. The theft or loss of controlledsubstances shall be reported as follows:

(A) The facility shall notify the depart-ment’s Section for Long Term Care (SLTC)and other appropriate authorities of any theftor significant loss of any controlled substancemedication written as an individual prescrip-tion for a specific resident upon the discoveryof the theft or loss. The facility shall consid-er at least the following factors in determin-ing if a loss is significant:

1. The actual quantity lost in relation tothe total quantity;

2. The specific controlled substancelost;

3. Whether the loss can be associatedwith 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 alikely candidate for diversion; and

6. Local trends and other indicators ofdiversion potential;

(B) If an insignificant amount of such con-trolled substance is lost during lawful activi-ties, which includes but are not limited toreceiving, record keeping, access auditing,administration, destruction and returning tothe pharmacy, a description of the occurrenceshall be documented in writing and main-tained with the facility’s controlled substancerecords. The documentation shall include thereason for determining that the loss wasinsignificant; and

(C) When the facility is registered with theBNDD, the facility shall report to or docu-ment for the BNDD any loss of any stocksupply controlled substance in compliancewith 19 CSR 30-1.034. II/III

(54) A physician, pharmacist or registerednurse shall review the medication regimen ofeach resident. This shall be done at leastevery other month. The review shall be per-formed in the facility and shall include, butshall not be limited to, indication for use,dose, possible medication interactions andmedication/food interactions, contraindica-tions, adverse reactions and a review of themedication system utilized by the facility.Irregularities and concerns shall be reportedin writing to the resident’s physician and tothe administrator/manager. If after thirty (30)days, there is no action taken by a resident’sphysician and significant concerns continueregarding a resident’s or residents’ medica-tion order(s), the administrator shall contactor recontact the physician to determine if heor she received the information and if thereare any new instructions. II/III

(55) All medication errors and adverse reac-tions shall be promptly documented andreported to the administrator and the resi-dent’s physician. If the pharmacy made a dis-pensing error, it shall also be reported to theissuing pharmacy. II/III

(56) Medications that are not in current useshall be disposed of as follows:

(A) Single doses of contaminated, refused,or otherwise unusable non-controlled sub-stance medications may be destroyed by anyauthorized medication staff member at thetime of administration. Single doses of unus-able controlled substance medications may be

destroyed according to section (52) of thisrule;

(B) Discontinued medications may beretained up to one hundred twenty (120) daysprior to other disposition if there is reason tobelieve, based on clinical assessment of theresident, that the medication might bereordered;

(C) Medications may be released to theresident or family upon discharge accordingto section (44) of this rule;

(D) After a resident has expired, medica-tions, except for controlled substances, maybe released to the resident’s legal representa-tive upon written request of the legal repre-sentative that includes the name of the medi-cation and the reason for the request;

(E) Medications may be returned to thepharmacy that dispensed the medications pur-suant to 20 CSR 2220-3.040 or returned pur-suant to the Prescription Drug RepositoryProgram, 19 CSR 20-50.020. All other med-ications, including all controlled substancesand all expired or otherwise unusable medi-cations, shall be destroyed within thirty (30)days as follows:

1. Medications shall be destroyed withinthe facility by a pharmacist and a licensednurse or by two (2) licensed nurses or whentwo (2) licensed nurses are not available onstaff by two (2) individuals who have author-ity to administer medications, one (1) ofwhom shall be a licensed nurse or a pharma-cist; and

2. A record of medication destroyedshall be maintained and shall include the res-ident’s name, date, medication name andstrength, quantity, prescription number, andsignatures of the individuals destroying themedications; and

(F) A record of medication released orreturned to the pharmacy shall be maintainedand shall include the resident’s name, date,medication name and strength, quantity, pre-scription number, and signatures of the indi-viduals releasing and receiving the medica-tions. II/III

(57) Residents experiencing short periods ofincapacity due to illness or injury or recuper-ation from surgery may be allowed to remainor be readmitted from a hospital if the periodof incapacity does not exceed forty-five (45)days and written approval of a physician isobtained for the resident to remain in or bereadmitted to the facility. II

(58) The facility shall maintain a record inthe facility for each resident, which shallinclude the following:

(A) Admission information including theresident’s name; admission date; confiden-tiality number; previous address; birth date;sex; marital status; Social Security number;Medicare and Medicaid numbers (if applica-ble); name, address and telephone number ofthe resident’s physician and alternate; diagno-sis, name, address and telephone number ofthe resident’s legally authorized representa-tive or designee to be notified in case ofemergency; and preferred dentist, pharmacistand funeral director; III

(B) A review monthly or more frequently,if indicated, of the resident’s general condi-tion and needs; a monthly review of medica-tion consumption of any resident controllinghis or her own medication, noting if pre-scription medications are being used inappropriate quantities; a daily record ofadministration of medication; a logging of themedication regimen review process; a month-ly weight; a record of each referral of a resi-dent for services from an outside service; anda record of any resident incidents includingbehaviors that present a reasonable likelihoodof serious harm to himself or herself or oth-ers and accidents that potentially could resultin injury or did result in injuries involving theresident; and

(C) Any physician’s orders. The facilityshall submit to the physician written versionsof any oral or telephone orders within four(4) days of the giving of the oral or telephoneorder. III

(59) A record of the resident census shall beretained in the facility. III

(60) Resident records shall be maintained bythe operator for at least five (5) years after aresident leaves the facility or after the resi-dent reaches the age of twenty-one (21),whichever is longer and must include reasonfor discharge or transfer from the facility andcause of death, as applicable. III

(61) Staffing Requirements.(A) The facility shall have an adequate

number and type of personnel for the propercare of residents, the residents’ social wellbeing, protective oversight of residents andupkeep of the facility. At a minimum, thestaffing pattern for fire safety and care of res-idents shall be one (1) staff person for everyfifteen (15) residents or major fraction of fif-teen (15) during the day shift, one (1) personfor every twenty (20) residents or major frac-tion of twenty (20) during the evening shiftand one (1) person for every twenty-five (25)residents or major fraction of twenty-five(25) during the night shift. I/II


(Day)* 1 3–153 p.m. to 9 p.m.

(Evening)* 1 3–209 p.m. to 7 a.m.

(Night)* 1 3–25


(B) The administrator shall count towardstaffing when physically present in the facili-ty. II

(C) The required staff shall be in the facil-ity awake, dressed and prepared to assist res-idents in case of emergency. I/II

(D) Meeting these minimal staffingrequirements may not meet the needs of resi-dents as outlined in the residents’ assess-ments and individualized service plans. I/II

(E) There shall be a licensed nurseemployed by the facility to work at least eight(8) hours per week at the facility for everythirty (30) residents or additional major frac-tion of thirty (30). The nurse’s duties shallinclude, but shall not be limited to, review ofresidents’ charts, medications, and specialdiets or other orders, review of each resi-dent’s adjustment to the facility, and observa-tion of each individual resident’s generalphysical and mental condition. The nurseshall inform the administrator of any prob-lems noted, and these shall be brought to theattention of the resident’s physician. II/III

(62) Prior to or on the first day that a newemployee works in the facility he or she shallreceive orientation of at least two (2) hoursappropriate to his or her job function. Thisshall include at least the following:

(A) Job responsibilities;(B) Emergency response procedures;(C) Infection control and handwashing pro-

cedures and requirements;(D) Confidentiality of resident informa-

tion;(E) Preservation of resident dignity;(F) Information regarding what constitutes

abuse/neglect and how to reportabuse/neglect to the department (1-800-392-0210);

(G) Information regarding the EmployeeDisqualification List;

(H) Instruction regarding the rights of res-idents and protection of property;

(I) Instruction regarding working with res-idents with mental illness; and

(J) Instruction regarding person-centeredcare and the concept of a social model ofcare, and techniques that are effective in

enhancing resident choice and control overhis or her own environment. II/III

(63) In addition to the orientation trainingrequired in section (62) of this rule any facil-ity that provides care to any resident havingAlzheimer’s disease or related dementia shallprovide orientation training regarding mental-ly confused residents such as those withAlzheimer’s disease and related dementias asfollows:

(A) For employees providing direct care tosuch persons, the orientation training shallinclude at least three (3) hours of trainingincluding at a minimum an overview of men-tally confused residents such as those havingAlzheimer’s disease and related dementias,communicating with persons with dementia,behavior management, promoting indepen-dence in activities of daily living, techniquesfor creating a safe, secure and socially ori-ented environment, provision of structure,stability and a sense of routine for residentsbased on their needs, and understanding anddealing with family issues; and II/III

(B) For other employees who do not pro-vide direct care for, but may have daily con-tact with, such persons, the orientation train-ing shall include at least one (1) hour oftraining including at a minimum an overviewof mentally confused residents such as thosehaving dementias as well as communicatingwith persons with dementia; and II/III

(C) For all employees involved in the careof persons with dementia, dementia-specifictraining shall be incorporated into ongoing in-service curricula. II/III

(64) All in-service or orientation trainingrelating to the special needs, care and safetyof residents with Alzheimer’s disease andother dementia shall be conducted, presentedor provided by an individual who is qualifiedby education, experience or knowledge in thecare of individuals with Alzheimer’s diseaseor other dementia. II/III

(65) Requirements for training related tosafely transferring residents.

(A) The facility shall ensure that all staffresponsible for transferring residents areappropriately trained to transfer residentssafely. Individuals authorized to provide thistraining include a licensed nurse, a physicaltherapist, a physical therapy assistant, anoccupational therapist or a certified occupa-tional therapy assistant. The individual whoprovides the transfer training shall observethe caregiver’s skills when checking compe-tency in completing safe transfers, shall doc-ument the date(s) of training and competency


Secretary of State




and shall sign and maintain training docu-mentation. Initial training shall include aminimum of two (2) classroom instructionhours in addition to the on-the-job trainingrelated to safely transferring residents whoneed assistance with transfers. II/III

(B) The facility shall ensure that a mini-mum of one (1) hour of transfer training isprovided by a licensed nurse annually regard-ing safe transfer skills. II/III

AUTHORITY: sections 198.073 and 198.076,RSMo Supp. 2007.* Original rule filed Aug.23, 2006, effective April 30, 2007. Amended:Filed March 13, 2008, effective Oct. 30,2008.

*Original authority: 198.073, RSMo 1979, amended1984, 1992, 1999, 2006, 2007 and 198.076, RSMo 1979,amended 1984, 2007.

19 CSR 30-86.052 Dietary Requirementsfor Residential Care Facilities and Assist-ed Living Facilities

PURPOSE: This rule establishes standardsfor meeting dietary needs of residents in res-idential care facilities I and II.


(1) Each resident shall be served food pre-pared and served under safe, sanitary condi-tions that is prepared consistent with the pref-erences of the resident and in accordancewith attending physician’s orders. The nutri-tional needs of the residents shall be met.Balanced nutritious meals using a variety offoods shall be served. Consideration shall begiven to the food habits, preferences, medicalneeds and physical abilities of the residents.II/III

(2) Each resident shall receive and the facili-ty shall provide at least three (3) meals daily,at regular times comparable to normal meal-times in the community. At least two (2)meals daily shall be hot. II/III

(3) There shall be no more than fourteen (14)hours between a substantial evening meal andbreakfast the following day, except when anourishing snack is provided at bedtime. Upto sixteen (16) hours may elapse between asubstantial evening meal and breakfast thefollowing day if a resident group agrees tothis meal span, and a nourishing snack isserved. III

(4) Fresh water shall be available to the resi-dent at all times. II/III

(5) Dining room service for residents shall beattractive and each resident shall receiveappropriate table service. III

(6) Menus shall be planned in advance andshall be readily available for personnelinvolved in food purchase and preparation.Food shall be served as planned althoughsubstitutes of equal nutritional value andcomplementary to the remainder of the mealcan be made if recorded. III

(7) A three (3)-day supply of food shall bemaintained in the facility. III

(8) If a physician prescribes in writing a mod-ified diet for a resident, the resident may beaccepted or remain in the facility if—

(A) The physician monitors the resident’scondition on a regular periodic basis and atleast quarterly; II

(B) The diet, food preparation and servingis reviewed at least quarterly by a consultingnutritionist, dietitian, registered nurse orphysician and there is written documentationof the review; II/III

(C) The modified diet menu is posted inthe kitchen and includes portions to beserved; III and

(D) The facility has entered into a writtenagreement for dietary consultation with anutritionist, dietitian registered nurse orphysician. III

(9) Nothing in this rule shall be construed astaking precedence over the resident’s right tomake decisions regarding his or her eatingand dining preferences.

(A) In assisted living facilities, informationabout the resident’s eating and dining prefer-ences shall be incorporated in his or her indi-vidualized service plan based on an assess-ment that includes the resident’s culture,life-long routines, habits, patterns and prefer-ences. III

(B) In assisted living facilities, if the resi-dent’s eating and dining preferences have apotential health risk, staff shall inform theresident or his or her legally authorized rep-resentative of the potential health risks anddocument this in his or her individualizedservice plan. III

AUTHORITY: sections 198.076, RSMo 2000and 198.005 and 198.073, RSMo Supp.2006.* This rule originally filed as 13 CSR15-15.052. Original rule filed July 13, 1983,effective Oct. 13, 1983. Emergency amend-ment filed Aug. 1, 1984, effective Aug. 13,

1984, expired Dec. 10, 1984. Amended:Filed Sept. 12, 1984, effective Dec. 13, 1984.Amended: Filed Aug. 1, 1988, effective Nov.10, 1988. Moved to 19 CSR 30-86.052, effec-tive Aug. 28, 2001. Amended: Aug. 23, 2006,effective April 30, 2007.



Rules of


Division 30—Division of Regulation and LicensureChapter 87—Sanitation Requirements for

Long-Term Care Facilities

Title Page

19 CSR 30-87.010 Definitions ......................................................................................3

19 CSR 30-87.020 General Sanitation Requirements for New and Existing Long-TermCare Facilities .................................................................................3

19 CSR 30-87.030 Sanitation Requirements for Food Service.................................................6


LicensureChapter 87—Sanitation Requirements

for Long-Term Care Facilities

19 CSR 30-87.010 Definitions

PURPOSE: This rule defines terms used inrelation to sanitation requirements for long-term care facilities.

(1) Adulterated means the condition of a foodif it bears or contains any poisonous or dele-terious substance in a quantity which mayrender it injurious to health; if it bears orcontains any added poisonous or deleterioussubstance for which no safe tolerance hasbeen established by rules, or in excess of tol-erance if one has been established; if it con-sists in whole or in part of any filthy, putridor decomposed substance, or if it is other-wise unfit for human consumption; if it hasbeen processed, prepared, packed or heldunder unsanitary conditions, where it mayhave been rendered injurious to health; if it isin whole or in part the product of a diseasedanimal or an animal which has died otherthan by slaughter; or if its container is com-posed in whole or in part of any poisonous ordeleterious substance which may render thecontents injurious to health.

(2) Commissary means a catering establish-ment, restaurant or any other place in whichfood, containers or supplies are kept, han-dled, prepared, packaged or stored.

(3) Corrosion-resistant materials means thosematerials that maintain their original surfacecharacteristics under prolonged influence ofthe food to be contacted, the normal use ofcleaning compounds and bactericidal solu-tions and other conditions-of-use environ-ment.

(4) Easily cleanable means that surfaces arereadily accessible and made of materials andfinish and so fabricated that residue may beeffectively removed by normal cleaning meth-ods.

(5) Food service employee means individualshaving supervisory or management duties andany other person working in a food-servicearea of a long-term care facility.

(6) Equipment means stoves, ovens, ranges,hoods, slicers, mixers, meat blocks, tables,counters, refrigerators, sinks, dishwashingmachines, steam tables and similar items

(other than utensils) used in the operation ofa food-service establishment.

(7) Food means any raw, cooked or processededible substance, ice, beverage or ingredientused or intended for use or for sale in wholeor in part for human consumption.

(8) Food-contact surface means any surfaceof equipment and utensils with which foodnormally comes in contact and any surfacefrom which food may drain, drip or splashback onto surfaces normally in contact withfood.

(9) Food-service area means any place wherefood is prepared and intended for individual-portion service and includes the site at whichindividual portions are provided. The termincludes any such place regardless of whetherconsumption is on or off the premises andregardless of whether there is a charge for thefood. The term also includes delicatessen-type operations that prepare sandwichesintended for individual-portion services. Theterm does not include private homes wherefood is prepared or served for individual fam-ily consumption, retail food stores, the loca-tion of food vending machines and supplyvehicles.

(10) Hermetically-sealed container means acontainer designed and intended to be secureagainst the entry of microorganisms and tomaintain the commercial sterility of its con-tent after processing.

(11) Kitchenware means all multiuse utensilsother than tableware.

(12) Law includes federal, state and localstatutes, ordinances and regulations.

(13) Packaged means bottled, canned, car-toned or securely wrapped.

(14) Person includes any individual, partner-ship, corporation, association or other legalentity. Person in charge means the individualpresent in a food-service establishment whois the apparent supervisor of the food-serviceestablishment at the time of inspection. If noindividual is the apparent supervisor, thenany employee present is the person in charge.

(15) Potentially hazardous food means anyfood that consists in whole or part of milk ormilk products; eggs, meat, poultry, fish,shellfish, edible crustacea or other ingredi-ents, including synthetic ingredients, in aform capable of supporting rapid and pro-gressive growth of infectious or toxigenic

microorganisms. The term does not includeclean, whole, uncracked, odor-free shell eggsor foods which have a pH level of four andsix-tenths (4.6) or below or a water activity(aw) value of eighty-five hundredths (0.85) orless.

(16) Reconstituted means dehydrated foodproducts recombined with water or liquids.

(17) Safe materials means articles manufac-tured from or composed of materials that maynot reasonably be expected to result, directlyor indirectly, in their becoming a componentor otherwise affecting the characteristics ofany food. All materials are safe only if theyare in compliance with the state Food Drugand Cosmetic Act in sections 196.010–180,RSMo (1986) and the federal Food, Drug andCosmetic Act and are used in conformitywith all applicable regulations.

(18) Sanitization means effective bactericidaltreatment by a process that provides enoughaccumulative heat or concentration of chemi-cals for sufficient time to reduce the bacteri-al count, including pathogens, to a safe levelon utensils and equipment.

(19) Sealed means free of cracks or otheropenings that permit the entry or passage ofmoisture.

(20) Single-service articles means cups, con-tainers, lids, closures, plates, knives, forks,spoons, stirrers, paddles, straws, napkins,wrapping materials, toothpicks and similararticles intended for one (1)-time, one (1)-person use and then discarded.

(21) Tableware means multiuse eating anddrinking utensils.

(22) Utensil means any implement used in thestorage, preparation, transportation or serviceof food.

AUTHORITY: section 198.009, RSMo 1986.*This rule originally filed as 13 CSR 15-17.010. Original rule filed July 13, 1983,effective Oct. 13, 1983. Moved to 19 CSR 30-87.010, effective Aug. 28, 2001.

*Original authority: 198.009, RSMo 1979, amended1993, 1995.

19 CSR 30-87.020 General Sanitation Re-quirements for New and Existing Long-Term Care Facilities

PURPOSE: This rule establishes standardsrelated to general sanitation and housekeep-ing in a long-term care facility to protect thehealth and safety of the residents.


Chapter 87—Sanitation Requirements for Long-Term Care Facilities 19 CSR 30-87

PUBLISHER’S NOTE: The secretary of statehas determined that the publication of theentire text of the material which is incorpo-rated by reference as a portion of this rulewould be unduly cumbersome or expensive.Therefore, the material which is so incorpo-rated is on file with the agency who filed thisrule, and with the Office of the Secretary ofState. Any interested person may view thismaterial at either agency’s headquarters orthe same will be made available at the Officeof the Secretary of State at a cost not toexceed actual cost of copy reproduction. Theentire text of the rule is printed here. Thisnote refers only to the incorporated by refer-ence material.


(1) All parts of property used in connectionwith the operation of the facility shall be keptfree of litter. Only articles necessary for theoperation or maintenance of the facility shallbe stored on the premises. III

(2) The walking and driving surfaces of allexterior areas of the facility shall be surfacedwith concrete or asphalt, or with gravel orsimilar material effectively treated to facili-tate maintenance and minimize dust. Thesesurfaces shall be graded to prevent poolingand shall be kept free of litter. III

(3) There shall be present in the facility onlythose poisonous or toxic materials necessaryfor maintaining the establishment, cleaningand sanitizing equipment and utensils andcontrolling insects and rodents. II

(4) Containers of poisonous or toxic materi-als shall be prominently and distinctly labeledaccording to law for easy identification ofcontents. II

(5) Poisonous or toxic materials consist of thefollowing categories: insecticides and roden-ticides; disinfectants, sanitizer and relatedcleaning or drying agents; and caustics,acids, polishes and other chemicals. Each ofthese three (3) categories set forth shall bestored and physically located separate fromeach other. All poisonous or toxic materialsshall be stored in locked cabinets or in a sim-ilar physically separate place used for noother purpose which is not accessible to res-idents. II

(6) Bactericides, cleaning compounds orother compounds intended for use on food-contact surfaces shall not be used in a waythat leaves a toxic residue on surfaces or thatconstitutes a hazard to residents, employeesor other persons. II

(7) Poisonous or toxic materials shall not beused in a way that contaminates food, equip-ment or utensils, nor in a way that constitutesa hazard to residents, employees or other per-sons, nor in a way other than in full compli-ance with the manufacturer’s labeling. II

(8) All rooms shall have sufficient ventilationto keep them free of excessive heat, steam,condensation, vapors, obnoxious odors,smoke and fumes. Ventilation systems shallbe installed and operated according to lawand, when vented to the outside, shall notcreate an unsightly, harmful or unlawful dis-charge. I/II

(9) Intake and exhaust air ducts shall bemaintained to prevent the entrance of dust,dirt and other contaminating materials. III

(10) In new or extensively remodeled facili-ties, all rooms from which obnoxious odors,vapors or fumes originate shall be mechani-cally vented to the outside. II

(11) Deodorizers or sprays shall not be usedto cover up odors. Odors shall be eliminatedto the source by prompt cleaning of bed pansand commodes, floors, furniture and equip-ment and by proper ventilation. II/III

(12) All floors in the facility shall be cleanand shall be maintained in good repair.Floors and floor coverings of all food-prepa-ration, food-storage and utensil-washingareas, and the floors of all walk-in refrigerat-ing units, dressing rooms, locker rooms, toi-let rooms and vestibules shall be constructedof smooth durable material such as sealedconcrete, terrazzo, ceramic tile, durablegrades of linoleum or plastic, or tight woodimpregnated with plastic. Nothing in this sec-tion shall prohibit the use of antislip floorcovering in areas where necessary for safetyreasons. III

(13) Carpeting, if used as a floor covering,shall be of closely woven construction, prop-erly installed, easily cleanable and main-tained in good repair. Carpeting is prohibitedin food-preparation, equipment-washing andutensil-washing areas where it would beexposed to large amounts of grease and water,in food-storage areas and toilet room areaswhere urinals or toilet fixtures are located. III

(14) Mats and duckboards shall be of nonab-sorbent, grease-resistant materials and of thatsize, design and construction as to facilitatetheir being easily cleaned. Duckboards shallnot be used as storage racks. III

(15) Walls and ceilings, including doors, win-dows and skylights, shall be clean and main-tained in good repair. III

(16) Wall- and ceiling-covering materialsshall be attached and sealed so as to be easi-ly cleanable.

(17) The walls, including nonsupporting par-titions, wall coverings and ceilings of walk-inrefrigerating units, food-preparation areas,equipment-washing and utensil-washingareas, toilet rooms and vestibules shall besmooth, nonabsorbent and easily cleanable.Concrete or pumice blocks used for interiorwall construction in these locations shall befinished and sealed to provide an easily clean-able surface. III

(18) Studs, joists and rafters, shall not beexposed in walk-in refrigerating units, food-preparation areas, equipment-washing areas,toilet rooms and vestibules. III

(19) Light fixtures, vent covers, wall-mount-ed fans, decorative materials and similarequipment attached to walls and ceilings shallbe easily cleanable and shall be maintainedclean and in good repair. III

(20) Cleaning of floors and walls, exceptemergency cleaning of floors, shall be doneduring periods when the least amount of foodis exposed, such as between meals. Mopsused for cleaning bathrooms shall be disin-fected after use and before using in otherareas. III

(21) In new or extensively remodeled facili-ties for more than twelve (12) residents atleast one (1) utility sink or curbed facilitywith a floor drain shall be provided and usedfor the cleaning of mops or similar wet-floorcleaning tools and for the disposal of mopwater or similar liquid wastes. The use oflavatories, utensil washing or equipmentwashing or food-preparation sinks for thispurpose is prohibited. III

(22) Enough potable water for the needs ofthe facility shall be provided from a sourceconstructed and operated according to law.Compliance is required with sections 1401,1411, 1414, 1431 and 1445 of the PublicService Act as amended by the Safe DrinkingWater Act, Public Law 93—523 CFR 11990


Secretary of State


as set forth in 10 CSR 60. Water shall befrom a source approved by the regulatingagency. I/II

(23) All potable water not provided directlyby pipe to the facility from the source shall betransported in a bulk water-transport systemand shall be delivered to a closed-water sys-tem. Both of these systems shall be con-structed and operated according to law. I/II

(24) All sewage, including liquid waste, shallbe disposed of by public sewage system or bya sewage disposal system constructed andoperated according to law. Nonwater-carriedsewage disposal facilities are prohibited. II

(25) Plumbing shall be sized, installed andmaintained according to the NationalPlumbing Code. II/III

(26) There shall be no cross-connectionbetween the potable water supply nor anysource of pollution through which the potablewater supply might become contaminated. II

(27) A nonpotable water system is permittedonly for purposes such as air conditioningand fire protection and only if the system isinstalled according to law and the nonpotablewater does not contact, directly or indirectly,food, potable water, equipment that contactsfood or utensils. The piping of any non-potable water system shall be durably identi-fied so that it is readily distinguishable frompiping that carries potable water. II

(28) The potable water system shall beinstalled to preclude the possibility of back-flow. Devices shall be installed to protectagainst backflow and back siphonage at allfixtures and equipment where an air gap atleast twice the diameter of the water supplyinlet is not provided between the water supplyinlet and the fixture’s flood level rim. A hoseshall not be attached to a faucet unless abackflow prevention device is installed. II

(29) Except for properly trapped open sinks,there shall be no direct connection betweenthe sewage system and any drains originatingfrom equipment in which food, portableequipment or utensils are placed. When adishwashing machine is located within fivefeet (5') of a trapped floor drain, the dish-washer waste outlet may be connected direct-ly on the inlet side of a properly vented floordrain trap if permitted by law. II

(30) Garbage and refuse shall be kept indurable, easily-cleanable, insect-proof androdent-proof containers that do not leak and

do not absorb liquids. Plastic bags and wet-strength paper bags may be used to line thesecontainers, and they may be used for storageinside the facility. III

(31) Waste containers used in food-prepara-tion and utensil-washing areas shall be keptcovered when not in actual use. III

(32) Waste containers stored outside theestablishment and dumpsters, compactorsand compactor systems shall be easily clean-able, shall be provided with tight-fitting lids,doors or covers and shall be kept coveredwhen not in actual use. In containersdesigned with drains, drain plugs shall be inplace at all times, except during cleaning. III

(33) Cardboard or other packaging materialnot containing garbage or food wastes neednot be stored in covered containers. III

(34) Soiled containers shall be cleaned at afrequency to prevent insect and rodent attrac-tion. Liquid waste from compacting or clean-ing operations shall be disposed of as sewage.III

(35) Garbage or refuse storage rooms, ifused, shall be constructed of easily cleanable,nonabsorbent, washable materials, shall bekept clean, shall be insect-proof and rodent-proof and shall be large enough to store thegarbage and refuse containers that accumu-late. III

(36) Outside storage areas or enclosures shallbe large enough to store the garbage andrefuse containers that accumulate and shall bekept clean. III

(37) Garbage and refuse shall be disposed ofoften enough to prevent the development ofodor and the attraction of insects and rodents.III

(38) Where refuse is burned on the premises,it shall be done in accordance with fire safe-ty regulations. III

(39) Effective measures intended to minimizethe presence of rodents, flies, cockroachesand other insects on the premises shall be uti-lized. The premises shall be kept in such con-dition as to prevent the harborage or feedingof insects or rodents. II/III

(40) Openings to the outside shall be effec-tively protected against the entrance ofrodents. Outside openings shall be protectedagainst the entrance of insects by tight-fitting,self-closing doors, closed windows, screen-

ing, control of air currents or other means.Screen doors shall be self-closing and screensfor windows, doors, skylights, transoms,intake and exhaust air ducts, and other open-ings to the outside shall be tight-fitting andfree of breaks. Screening material shall not beless than sixteen (16) mesh to the inch. II/III

(41) Toilet rooms shall be conveniently locat-ed and easily accessible to residents andemployees. Toilet rooms shall be completelyenclosed. Toilet fixtures shall be kept cleanand in good repair. A supply of toilet tissueshall be provided at each toilet at all times.Easily cleanable receptacles shall be providedfor waste materials. Toilet rooms used bywomen employees shall have at least one (1)covered waste receptacle. III

(42) Lavatories shall also be located in orimmediately adjacent to toilet rooms orvestibules and shall be easily accessible toresidents and employees. Lavatories shall belocated to permit convenient use by allemployees in food-preparation areas andutensil-washing areas. In new facilities, sinksused for food-preparation or for washingequipment or utensils shall not be used forhandwashing. III

(43) Each lavatory, bathtub or shower shall beprovided with hot and cold water tempered bymeans of mixing valve or combination faucet.Any self-closing, slow-closing or meteringfaucet used shall be designed to provide aflow of water for at least fifteen (15) secondswithout the need to reactivate the faucet.Steam-mixing valves are prohibited. III

(44) A supply of hand-cleansing soap ordetergent shall be available at each employee-use lavatory. A supply of sanitary towels or ahand-drying device providing heated air shallbe conveniently located near each lavatory,except that hand towels for individual use arepermitted. Common towels are prohibited. Ifdisposable towels are used, easily cleanablewaste receptacles shall be conveniently locat-ed near the hand-washing facilities. III

(45) Lavatories, soap dispensers, hand-dryingdevices and all related fixtures shall be keptclean and in good repair. III

(46) If employees routinely change clotheswithin the facility, rooms or areas shall bedesignated and used for that purpose. Thesedesignated rooms or areas shall not be usedfor food preparation, storage or service, orfor utensil washing or storage. Lockers orother suitable facilities shall be provided andused for the orderly storage of employee



clothing and other belongings. Lockers orother suitable facilities may be located only inthe designated dressing rooms or in food-storage rooms or areas containing only com-pletely packaged food or packaged single-ser-vice articles. III

(47) Laundry facilities shall be so designedand procedures instituted to prevent cross-contamination of clean and dirty linen. II

(48) If laundry for the facility is done com-mercially, either entirely or in part, spaceshall be provided for sorting, processing andstoring soiled linen. II/III

(49) Storage space shall be located to facili-tate convenient pickup and delivery by com-mercial laundry. III

(50) Equipment shall be provided to prewashlinen soiled by incontinent residents before itis sent to the laundry. II/III

(51) For intermediate care and skilled nursingfacilities, existing assisted living facilities andnew residential care facilities and assisted liv-ing facilities licensed for more than twelve(12) residents, if laundry is done in the facil-ity entirely or partially, the laundry roomshall be in a separate room from the kitchen,the residents’ room(s), the sitting or livingroom and the bathrooms or the nursing utili-ty room. Adequate space shall be provided inthe laundry room for storing, sorting and pro-cessing soiled linen. Table linen shall belaundered separately from bed linen, towelsand clothing. Space shall be provided forstoring clean linen in a separate room fromthe laundry. Nothing in this rule shall prohib-it a facility from providing a laundry area foruse by residents. II/III

(52) Provision shall be made for the propercare of soiled linen and clean linen on eachfloor of each building. A laundry hamper,with lid, laundry chute or some other suitablearrangement shall be provided. II/III

(53) Soiled clothes and linens shall be storedin nonabsorbent containers or washable laun-dry bags and shall be transported for laun-dering in tightly enclosed bags or containers.Nothing in this rule shall require residents touse tightly enclosed bags or containers whentransporting their personal laundry items tothe resident laundry area referred to in sec-tion (51). III

(54) Linen soiled by incontinent residentsshall be washed or prewashed immediately.II/III

(55) Clean clothes and linens shall be storedin a clean place and protected from contami-nation until used. III

AUTHORITY: sections 198.009, RSMo 2000and 198.005 and 198.073, RSMo Supp.2006.* This rule originally filed as 13 CSR15-17.020. Original rule filed July 13, 1983,effective Oct. 13, 1983. Emergency rule filedAug. 1, 1984, effective Aug. 13, 1984,expired Dec. 10, 1984. Amended: Filed Sept.12, 1984, effective Dec. 13, 1984. Amended:Filed Aug. 1, 1988, effective Nov. 11, 1988.Moved to 19 CSR 30-87.020, effective Aug.28, 2001. Amended: Filed Aug. 23, 2006,effective April 30, 2007.

*Original authority: 198.005, RSMo 2006; 198.009,RSMo 1979, amended 1993, 1995; and 198.073, RSMo1979, amended 1984, 1992, 1999, 2006.

19 CSR 30-87.030 Sanitation Require-ments for Food Service

PURPOSE: This rule establishes standardsrelated to food supplies, food protection andstorage, food preparation and handling, foodservice, food equipment and utensils, dish-washing methods and other general require-ments related to the food preparation and ser-vice area. These rules have been adaptedfrom the 1976 recommended ordinance gov-erning food service establishments and estab-lished by the United States Food and DrugAdministration.



(1) Employees shall maintain a high degree ofpersonal cleanliness and shall conform togood hygienic practices during all workingperiods. II/III

(2) Employees shall thoroughly wash theirhands and the exposed portions of their armswith soap and warm water before startingwork, during work as often as is necessary tokeep them clean and after smoking, eating,drinking or using the toilet. Employees shallkeep their fingernails clean and trimmed.II/III

(3) The outer clothing of all employees shallbe clean and employees shall use effectivehair restraints to prevent the contamination offood or food-contact surfaces. III

(4) Employees shall consume food only indesignated dining areas. An employee diningarea shall not be so designated if consumingfood there may result in contamination ofother food, equipment, utensils or otheritems needing protection. Nothing in this sec-tion shall prohibit staff from dining with res-idents when the facility utilizes the socialmodel for mealtime. III

(5) Employees shall not use tobacco in anyform while engaged in food preparation orservice, nor while in areas used for equip-ment or utensil washing or for food prepara-tion. Employees shall use tobacco only indesignated areas. An employee tobacco-usearea shall not be designated for that purposeif the use of tobacco there may result in con-tamination of food, equipment, utensils orother items needing protection. III

(6) The traffic of unnecessary personsthrough the food-preparation and utensil-washing areas is prohibited. III

(7) Food preparation and storage shall not beconducted in any room used as living orsleeping quarters. In a facility licensed formore than twelve (12) residents, except in anexisting residential care facility, food serviceoperations shall be separated from living orsleeping quarters by complete partitioningand solid, self-closing doors. Nothing in thissection shall prohibit an assisted living facili-ty from providing kitchen and family styleeating areas for use by residents. III

(8) Maintenance and cleaning tools such asbrooms, mops, vacuum cleaners and similarequipment shall be maintained and stored ina way that does not contaminate food, uten-sils, equipment or linens and shall be storedin an orderly manner. III

(9) Live animals, including birds and turtlesshall be excluded from the food storage ser-vice and preparation areas. This exclusiondoes not apply to edible fish, crustacea,


Secretary of State


shellfish or to fish in aquariums. Patrol dogsaccompanying security or police officers, orservice or guide dogs assisting residents orvisitors shall be permitted in dining areas.Other dogs and cats may be permitted in thedining area if food service sanitation is notcompromised and residents do not object. III

(10) Birds within enclosed aviaries may be inthe dining area with the following stipula-tions:

(A) The facility ensures the aviary iscleaned at least twice a week and more oftenas needed to maintain a clean environment;III

(B) The facility provides proper handwashing instructions to those staff havingaccess to the birds and monitors to ensurecompliance; and III

(C) The facility contacts the local or coun-ty Health Department and informs thatdepartment that an aviary has been installed.III

(11) Food shall be in sound condition, freefrom spoilage, filth or other contaminationand shall be safe for human consumption.Food shall be obtained from sources thatcomply with all laws relating to food and foodlabeling. The use of food in hermeticallysealed containers that was not prepared in afood processing establishment is prohibited.Nothing in this section shall prohibit facilitiesfrom using fresh vegetables or fruits pur-chased from farmers’ markets or obtainedfrom the facility garden or residents’ familygardens. I/II

(12) Fluid milk and fluid milk products usedor served shall be pasteurized and shall meetthe Grade A quality standards as establishedby law. Dry milk and dry milk products shallbe made from pasteurized milk products. I/II

(13) At all times, including while beingstored, prepared, displayed, served or trans-ported to or from the facility, food shall beprotected from potential contamination,including dust, insects, rodents, uncleanequipment and utensils, unnecessary han-dling, coughs and sneezes, flooding, drainageand overhead leakage or overhead drippagefrom condensation. The temperature ofpotentially hazardous food shall be forty-fivedegrees Fahrenheit (45°F) or below or onehundred forty degrees Fahrenheit (140°F) orabove at all times, except as otherwise pro-vided in this section. In the event of a fire,flood, power outage or similar event thatmight result in the contamination of food, orthat might prevent potentially hazardous foodfrom being held at required temperatures, the

person in charge shall immediately contactthe Department of Health and SeniorServices (the department). Upon receivingnotice of this occurrence, the departmentshall take whatever action that it deems nec-essary to protect the residents. II/III

(14) Food, whether raw or prepared, ifremoved from the container or package inwhich it was obtained, shall be stored in aclean covered container except during neces-sary periods of preparation or service.Container covers shall be impervious andnonabsorbent except that linens or napkinsmay be used for lining or covering bread orroll containers. III

(15) Containers of food shall be stored abovethe floor in a manner that protects the foodfrom splash and other contamination and thatpermits easy cleaning of the storage area,except that metal pressurized beverage con-tainers, and cased food packaged in cans,glass or other waterproof containers need notbe elevated when the food container is notexposed to floor moisture; and containersmay be stored on dollies, racks or pallets,provided the equipment is easily movable. III

(16) Food and containers of food shall bestored in a manner which protect it from con-tamination. The storage of food in toiletrooms or vestibules is prohibited. II/III

(17) Unless its identity is unmistakable, bulkfood, such as cooking oil, syrup, salt, sugaror flour not stored in the product container orpackage in which it was obtained, shall bestored in a container identifying the food bycommon name. III

(18) Enough conveniently located refrigera-tion facilities or effectively insulated facilitiesshall be provided to assure the maintenanceof potentially hazardous food at required tem-peratures during storage. Each mechanicallyrefrigerated facility storing potentially haz-ardous food shall be provided with a numeri-cally scaled indicating thermometer, accurateto plus or minus three degrees Fahrenheit(±3°F), located to measure the air tempera-ture in the warmest part of the refrigeratedfacility and located to be easily readable.Recording thermometers, accurate to plus orminus three degrees Fahrenheit (±3°F), maybe used in lieu of indicating thermometers. III

(19) Potentially hazardous food requiringrefrigeration after preparation shall be rapid-ly cooled to an internal temperature of forty-five degrees Fahrenheit (45°F) or below, uti-lizing such methods as shallow pans, agita-

tion, quick chilling or water circulation exter-nal to the food container so that the coolingperiod shall not exceed four (4) hours.Potentially hazardous food to be transportedshall be prechilled and held at a temperatureof forty-five degrees Fahrenheit (45°F) orbelow. I/II

(20) Frozen food shall be kept frozen andshould be stored at a temperature of zerodegrees Fahrenheit (0°F) or below. III

(21) Ice intended for human consumptionshall not be used as a medium for coolingstored food, food containers or food utensils,except that such ice may be used for coolingtubes conveying beverages or beverage ingre-dients to a dispenser head. Ice used for cool-ing stored food and food containers shall notbe used for human consumption. III

(22) Tubing conveying beverages or beverageingredients to dispensing heads may be incontact with stored ice provided that, the tub-ing is fabricated from safe materials, is grom-meted at entry and exit points to precludemoisture (condensation) from entering the icemachine or the ice storage bin and is keptclean. Drainage or drainage tubes from dis-pensing units shall not pass through the icemachine or the ice storage bin. III

(23) Enough conveniently located hot foodstorage facilities shall be provided to assurethe maintenance of food at the required tem-perature during storage. Each hot food facili-ty storing potentially hazardous food shall beprovided with a numerically scaled indicatingthermometer, accurate to plus or minus threedegrees Fahrenheit (±3°F), located to mea-sure the air temperature in the coolest part ofthe hot food storage facility and located to beeasily readable. Recording thermometers,accurate to plus or minus three degreesFahrenheit (±3°F), may be used in lieu ofindicating thermometers. Where it is imprac-tical to install thermometers on equipmentsuch as bains-maries, steam tables, steamkettles, heat lamps, calrod units or insulatedfood transport carriers, a product thermome-ter must be available and used to check inter-nal food temperature. III

(24) The internal temperature of potentiallyhazardous foods requiring hot storage shall beone hundred forty degrees Fahrenheit(140°F) or above, except during periods ofpreparation. Potentially hazardous food to betransported shall be held at a temperature ofone hundred forty degrees Fahrenheit(140°F) or above. I/II



(25) Raw fruits and vegetables shall be thor-oughly washed with potable water beforebeing cooked or served. II/III

(26) Potentially hazardous foods requiringcooking shall be cooked to heat all parts ofthe food to a temperature of at least one hun-dred forty degrees Fahrenheit (140°F),except that poultry, poultry stuffings, stuffedmeats and stuffings containing meat shall becooked to heat all parts of the food to at leastone hundred sixty-five degrees Fahrenheit(165°F) with no interruption of the cookingprocess. Pork and food containing pork shallbe cooked to heat all parts of the food to atleast one hundred fifty degrees Fahrenheit(150°F); rare roast beef shall be cooked to aninternal temperature of at least one hundredthirty degrees Fahrenheit (130°F); and rarebeef steak shall be cooked to a temperature ofone hundred thirty degrees Fahrenheit(130°F) unless otherwise ordered by the res-ident. II/III

(27) Liquid, frozen, dry eggs and egg prod-ucts shall be used only for cooking and bak-ing purposes. II/III

(28) Only clean whole eggs, with shell intactand without cracks or checks, or pasteurizedliquid or frozen, or dry eggs or pasteurizeddry egg products shall be used, except thathard-boiled, peeled eggs, commercially pre-pared and packaged, may be used. II

(29) Potentially hazardous foods that havebeen cooked and then refrigerated shall bereheated rapidly to one hundred sixty-fivedegrees Fahrenheit (165°F) or higherthroughout before being served or beforebeing placed in a hot food-storage facility. II

(30) Steam tables, bains-maries, warmers andsimilar hot food-holding facilities are prohib-ited for the rapid reheating of potentially haz-ardous foods. II/III

(31) Nondairy creaming, whitening or whip-ping agents may be reconstituted on thepremises only when they will be stored insanitized, covered containers not exceedingone (1) gallon in capacity and cooled to forty-five degrees Fahrenheit (45°F) or belowwithin four (4) hours after preparation. II/III

(32) Metal stem-type numerically scaled indi-cating thermometers, accurate to plus orminus two degrees Fahrenheit (±2°F), shallbe provided and used to assure the attainmentand maintenance of proper internal cooking,holding or refrigeration temperatures of allpotentially hazardous foods. II/III

(33) Potentially hazardous foods shall bethawed in refrigerated units at a temperaturenot to exceed forty-five degrees Fahrenheit(45°F); or under potable running water at atemperature of seventy degrees Fahrenheit(70°F) or below, with sufficient water veloc-ity to agitate and float off loose food particlesinto the overflow; or in a microwave ovenonly when the food will be immediatelytransferred to conventional cooking facilitiesas part of a continuous cooking process orwhen the entire, uninterrupted cooking pro-cess takes place in the microwave oven; or aspart of the conventional cooking process.II/III

(34) At time of service to the resident, foodshall be at least one hundred twenty degreesFahrenheit (120°F) or forty-five degreesFahrenheit (45°F) or below. II/III

(35) Milk and milk products for drinking pur-poses shall be provided to the resident in anunopened, commercially filled package notexceeding one (1) pint in capacity, or shall bedrawn from a commercially filled containerstored in a mechanically refrigerated bulkmilk dispenser, or shall be poured directlyinto glass(es) to be used by the resident(s)from a commercially filled gallon or half-gal-lon container provided the container is com-pletely emptied in the process and then dis-carded, or if a portion of milk remains, thatno milk may be returned to that container andis immediately refrigerated. Where a bulkdispenser for milk and milk products is notavailable and portions of less than one-half(1/2) pint are required for mixed drinks, cere-al or dessert service, milk and milk productsmay be poured from a commercially filledcontainer of not more than one (1) galloncapacity and no milk may be returned to thatcontainer. II/III

(36) Reconstituted dry milk and dry milkproducts shall not be used for drinking pur-poses but may be used in instant desserts andwhipped products, or for cooking and bakingpurposes. III

(37) Cream or half-and-half or nondairycreaming agents or whitening agents shall beprovided in an individual service container,protected pour-type pitcher or drawn from arefrigerated dispenser designed for such ser-vice. III

(38) Condiments, seasoning and dressings forself-service use shall be provided in individ-ual packages, from dispensers or from pro-tected containers. III

(39) Condiments provided for table orcounter service shall be individually por-tioned, except that catsup and other saucesmay be served in the original container orpour-type dispenser. Sugar for consumershall be provided in individual packages or inpour-type dispensers. III

(40) Ice shall be dispensed only with scoops,tongs or other ice-dispensing utensils orthrough automatic self-service, ice-dispens-ing equipment. Ice-dispensing utensils shallbe stored on a clean surface or in the ice withthe dispensing utensil’s handle extended outof the ice. Between uses, ice transfer recepta-cles shall be stored in a way that protectsthem from contamination. Ice storage binsshall be drained through an air gap. III

(41) To avoid unnecessary manual contactwith food, suitable preparation and dispens-ing utensils shall be used by employees orprovided to consumers who serve themselves.Between uses, during service, dispensingutensils shall be stored in a manner whichwould prevent contamination. III

(42) Once served to a resident, portions ofleftover food shall not be served again exceptthat packaged food, other than potentiallyhazardous food, that is still packaged and isstill in sound condition may be re-served. III

(43) Food on display shall be protected fromresident contamination by the use of packag-ing or by the use of easily cleanable counter,serving line or salad bar protector devices,display cases or by other effective means.Enough hot or cold food facilities shall beavailable to maintain the required temperatureof potentially hazardous foods on display. III

(44) Equipment and utensils shall be con-structed and repaired with safe materialsincluding finishing materials; shall be corro-sion-resistant and nonabsorbent; and shall besmooth, easily cleanable and durable underconditions of normal use. Single-service arti-cles shall be made from clean, sanitary, safematerials. Equipment utensils and single-ser-vice articles shall not impart odors, color ortaste nor contribute to the contamination offood. III

(45) Hard maple or equivalently nonab-sorbent material may be used for cuttingblocks, cutting boards, salad bowls andbaker’s tables. The use of wood as a food-contact surface under other circumstances isprohibited. III


Secretary of State


(46) Safe plastic or safe rubber or safe rub-ber-like materials that are resistant under nor-mal conditions of use to scratching, scoring,decomposition, crazing, chipping and distor-tion, that are of sufficient weight and thick-ness to permit cleaning and sanitizing by nor-mal dishwashing methods, and which meetthe general requirements of this rule, are per-mitted for repeated use. III

(47) Re-use of single service articles is pro-hibited. III

(48) Food-contact surfaces shall be easilycleanable, smooth and free of breaks, openseams, cracks, chips, pits and similar imper-fections and free of difficult-to-clean internalcorners and crevices. Cast iron may be usedas a food-contact surface only if the surface isheated, such as in grills, griddle tops andskillets. Threads shall be designed to facili-tate cleaning; ordinary “V” type threads areprohibited in food-contact surfaces, exceptthat in equipment such as ice makers or hotoil-cooking equipment and hot oil-filteringsystems, these threads shall be minimized. III

(49) Equipment containing bearings andgears requiring unsafe lubricants shall bedesigned and constructed so that the lubricantcannot leak, drip or be forced into food oronto food-contact surfaces. Only safe lubri-cants shall be used on equipment designed toreceive lubrication of bearings and gears onor within food-contact surfaces. III

(50) All sinks and drain boards shall be self-draining. III

(51) Unless designed for in-place cleaning,food-contact surfaces shall be accessible forcleaning and inspection without being disas-sembled; or by disassembling without the useof tools; or by easy disassembling with theuse of only simple tools such as a mallet, ascrewdriver or an open-end wrench keptavailable near the equipment. III

(52) Equipment intended for in-place clean-ing shall be so designed and fabricated thatcleaning and sanitizing solutions can be cir-culated throughout a fixed system using aneffective cleaning and sanitizing regimen;cleaning and sanitizing solutions will contactall interior food-contact surfaces; and the sys-tem is self-draining or capable of being com-pletely evacuated. III

(53) Fixed equipment designed and fabricat-ed to be cleaned and sanitized by pressurespray methods shall have sealed electricalwiring, switches and connections. III

(54) Surfaces of equipment not intended forcontact with food, but which are exposed tosplash or food debris or which otherwiserequire frequent cleaning, shall be designedand fabricated to be smooth, washable, freeof unnecessary ledges, projections orcrevices, and readily accessible for cleaning,and shall be of such material and in a repairas to be easily maintained in a clean and san-itary condition. III

(55) Ventilation hoods and devices shall bedesigned to prevent grease or condensationfrom collecting on walls and ceilings andfrom dripping into food or onto food-contactsurfaces. Filters or other grease-extractingequipment shall be readily removable forcleaning and replacement if not designed tobe cleaned in place. III

(56) Equipment that was installed in an exist-ing licensed facility and that does not fullymeet all of the design and fabrication require-ments shall be deemed acceptable in thatestablishment if it is in good repair, capableof being maintained in a sanitary conditionand the food-contact surfaces are nontoxic.Replacement equipment and new equipmentshall meet the requirements for design andfabrication. III

(57) Equipment that is placed on tables orcounters, unless portable, shall be sealed tothe table or counter or elevated on legs toprovide clearance between the table orcounter and equipment and shall be installedto facilitate the cleaning of the equipmentadjacent areas. Equipment is portable if it issmall and light enough to be moved easily byone (1) person; and it has no utility connec-tion, or has a utility connection that discon-nects quickly, or has a flexible utility connec-tion line of sufficient length to permit theequipment to be moved for easy cleaning. III

(58) Floor-mounted equipment, unless readi-ly movable, shall be sealed to the floor; orinstalled on a raised platform of concrete orother smooth masonry in a way that meets allof the requirements for sealing or floor clear-ance; or elevated on legs to provide clearancebetween the floor and equipment, except thatvertically-mounted floor mixers may be ele-vated to provide at least a four inch (4")-clearance between the floor and equipment ifno part of the floor under the mixer is morethan six inches (6") from the cleaning access.Equipment is easily movable if it is mountedon wheels or casters; and it has no utilityconnection or has a utility connection thatdisconnects quickly, or has a flexible utility

line of sufficient length to permit the equip-ment to be moved for easy cleaning. III

(59) Unless sufficient space is provided foreasy cleaning between, behind and aboveeach unit of fixed equipment, the spacebetween it and adjoining equipment units andadjacent walls or ceilings shall not be morethan one-thirty-second inch (1/32"); or ifexposed to seepage, the equipment shall besealed to the adjoining equipment or adjacentwalls or ceilings. III

(60) Aisles and working spaces between unitsof equipment and walls shall be unobstructedand of sufficient width to permit employeesto perform their duties readily without con-tamination of food or food-contact surfacesby clothing or personal contact. All easilymovable storage equipment such as pallets,racks and dollies shall be positioned to pro-vide accessibility to working areas. III

(61) Tableware shall be washed, rinsed andsanitized after each use. II

(62) Kitchenware and food-contact surfacesof equipment shall be washed, rinsed andsanitized after each use and following anyinterruption of operations during which timecontamination may have occurred. Waterpitchers which are for individual resident useshall be sanitized daily. II/III

(63) Where equipment and utensils are usedfor the preparation of potentially hazardousfoods on a continuous or production-linebasis, utensils and the food-contact surfacesof equipment shall be washed, rinsed andsanitized at intervals throughout the day on aschedule based on food temperature, type offood and amount of food particle accumula-tion. III

(64) The food-contact surfaces of grills, grid-dles and similar cooking devices and the cav-ities and door seals of microwave ovens shallbe cleaned at least once a day, except that thisshall not apply to hot oil-cooking equipmentand hot oil-filtering systems. The food-con-tact surfaces of all cooking equipment shallbe kept free of encrusted grease deposits andother accumulated soil. III

(65) Nonfood-contact surfaces of equipmentshall be cleaned as often as is necessary tokeep the equipment free of accumulation ofdust, dirt, food particles and other debris. III

(66) Cloths used for wiping food spills ontableware, such as plates or bowls being



served to the consumer, shall be clean, dryand used for no other purpose. III

(67) Moist cloths or sponges used for wipingfood spills on kitchenware and food-contactsurfaces of equipment shall be clean andrinsed frequently in one (1) of the permittedsanitizing solutions and used for no otherpurpose. These cloths and sponges shall bestored in the sanitizing solution between uses.Moist cloths or sponges used for cleaningnonfood-contact surfaces of equipment suchas counters, dining table tops and shelvesshall be clean and rinsed and used for noother purpose. These cloths and sponges shallbe stored in the sanitizing solution betweenuses. III

(68) For manual washing, rinsing and sanitiz-ing of utensils and equipment, a sink with notfewer than three (3) compartments shall beprovided and used. Sink compartments shallbe large enough to permit the accommodationof the equipment and utensils and each com-partment of the sink shall be supplied withhot and cold potable running water, exceptthat in an existing licensed facility, the use ofa two (2)-vat sink and a supplementaryportable container to be used for sanitizationis acceptable. Fixed equipment and utensilsand equipment too large to be cleaned in sinkcompartment shall be washed manually orcleaned through pressure spray methods. III

(69) Drain boards or easily movable dishtables of adequate size shall be provided forproper handling of soiled utensils prior towashing and for cleaned utensils followingsanitizing and shall be located so as not tointerfere with the proper use of the dishwash-ing facilities. III

(70) Equipment and utensils shall be pre-flushed or prescraped and, when necessary,presoaked to remove gross food particles andsoil. III

(71) Except for fixed equipment and utensilstoo large to be cleaned in sink compartments,manual washing, rinsing and sanitizing shallbe conducted in the following sequence: sinksshall be cleaned prior to use; equipment andutensils shall be thoroughly washed in thefirst compartment with hot detergent solutionthat is kept clean; equipment and utensilsshall be rinsed free of detergent and abrasiveswith clean water in the second compartment;and equipment and utensils shall be sanitizedin the third compartment. III

(72) The food-contact surfaces of all equip-ment and utensils shall be sanitized by

immersion for at least one-half (1/2) minutein clean, hot water at a temperature of at leastone hundred seventy degrees Fahrenheit(170°F); or immersion for at least one (1)minute in a clean solution containing at leastfifty (50) parts per million of available chlo-rine as a hypochlorite and at a temperature ofat least seventy-five degrees Fahrenheit(75°F); or immersion for at least one (1)minute in a clean solution containing at leasttwelve and one-half (12.5) parts per millionof available iodine and having a pH not high-er than five (5.0) and at a temperature of atleast seventy-five degrees Fahrenheit (75°F);or immersion in a clean solution containingany other chemical sanitizing agent allowedunder 21 CFR 178.1010 of the (Revised2005), Food and Drug Code of the UnitedStates Food and Drug Administration,Department of Health and Human Services,200 Independence Avenue SW, Washington,DC 20201, Telephone: 202-619-0257, TollFree: 1-877-696-6775, that will provide theequivalent bactericidal effect of a solutioncontaining at least fifty (50) parts per millionof available chlorine as a hypochlorite at atemperature of at least seventy-five degreesFahrenheit (75°F); or treatment with steam,free from materials or additives other thanthose specified in 21 CFR 173.310 of the(Revised 2005), Food and Drug Code of theof the United States Food and DrugAdministration, Department of Health andHuman Services, in the case of equipmenttoo large to sanitize by immersion, but inwhich steam can be confined; or rinsing,spraying or swabbing with a chemical sanitiz-ing solution of at least twice the strengthrequired for that particular sanitizing solutionin the case of equipment too large to sanitizeby immersion. (21 CFR 178.1010 (Revised2005) and 21 CFR 173.310 (Revised 2005)are incorporated by reference in this rule andavailable by Internet at: www.access.gpo.gov.This rule does not incorporate any subse-quent amendments or additions.) II/III

(73) When hot water is used for sanitizing, asallowed by section (72) of this rule, the fol-lowing facilities shall be provided and used:an integral heating device or fixture installedin, on or under the sanitizing compartment ofthe sink capable of maintaining the water at atemperature of at least one hundred seventydegrees Fahrenheit (170°F); and a numeri-cally scaled indicating thermometer, accurateto plus or minus three degrees Fahrenheit(±3°F), convenient to the sink for frequentchecks of water temperature; and dish basketsof such size and design to permit completeimmersion of the tableware, kitchenware andequipment in the hot water. II/III

(74) When chemicals are used for sanitiza-tion, they shall not have concentrations high-er than the maximum permitted under 21CFR 178.1010 of the (Revised 2005), Foodand Drug Code of the United States Food andDrug Administration, Department of Healthand Human Services, and a test kit or otherdevice that accurately measures the parts permillion concentration of the solution shall beprovided and used. III

(75) Cleaning and sanitizing may be done byspray-type or immersion dishwashingmachines or by any other type of machine ordevice if it is demonstrated that it thoroughlycleans and sanitizes equipment and utensils.In a facility with a licensed capacity of twelve(12) or fewer beds, a home-type dishwashingmachine shall be acceptable. If a newmachine is purchased, it shall be one withsanitizing capabilities. In a facility licensedfor a larger capacity, if a dishwasher is used,it shall meet the requirements in sections(72)–(74) of this rule. Machines and devicesshall be properly installed and maintained ingood repair; shall be operated in accordancewith manufacturers’ instructions; and utensilsand equipment placed in the machine shall beexposed to all dishwashing cycles. Automaticdetergent dispensers, wetting agent dispensersand liquid sanitizer injectors, if any, shall beproperly installed and maintained. II/III

(76) The pressure of final rinse water sup-plied to spray-type dishwashing machinesshall not be less than fifteen (15) nor morethan twenty-five (25) pounds per square inchmeasured in the water line immediately adja-cent to the final rinse control valve. A one-fourth inch (1/4") IPS valve shall be provid-ed immediately upstream from the final rinsecontrol valve to permit checking the flowpressure of the final rinse water. III

(77) Machine- or water line-mounted numer-ically scaled indicating thermometers, accu-rate to plus or minus three degrees Fahrenheit(±3°F), shall be provided to indicate thetemperature of the water in each tank of themachine and the temperature of the finalrinse water as it enters the manifold. III

(78) Rinse water tanks shall be protected bybaffles, curtains or other effective means ofminimizing the entry of wash water into therinse water. Conveyors in dishwashingmachines shall be accurately timed to assureproper exposure times in wash and rinsecycles in accordance with manufacturers’specifications attached to the machines. III


Secretary of State


(79) Drain boards shall be provided and be ofadequate size for the proper handling ofsoiled utensils prior to washing and ofcleaned utensils following sanitization andshall be so located and constructed as not tointerfere with the proper use of the dishwash-ing facilities. This does not preclude the useof easily movable dish tables for the storageof soiled utensils or the use of each movabledish table for the storage of clean utensils fol-lowing sanitization. III

(80) Equipment and utensils shall be flushedor scraped and, when necessary, soaked toremove gross food particles and soil prior tobeing washed in a dishwashing machineunless a prewash cycle is a part of the dish-washing machine operation. Equipment andutensils shall be placed in racks, trays or bas-kets, or on conveyors, in a way that food-con-tact surfaces are exposed to the unobstructedapplication of detergent wash and clean rinsewaters and that permits free draining. III

(81) Machines (single-tank, stationary-rack,door-type machines and spray-type glasswashes) using chemicals for sanitization maybe used provided that—the temperature of thewash water is not less than one hundred twen-ty degrees Fahrenheit (120°F), the washwater is kept clean, chemicals added for san-itization purposes are automatically dis-pensed; utensils and equipment are exposedto the final chemical sanitizing rinse in accor-dance with manufacturers’ specifications fortime and concentration, the chemical sanitiz-ing rinse water temperature is not less thanseventy-five degrees Fahrenheit (75°F) norless than the temperature specified by themachine’s manufacturer; chemical sanitizersused shall meet the requirements of 21 CFR178.1010 (Revised 2005), Food and DrugCode of the United States Food and DrugAdministration, Department of Health andHuman Services and a test kit or otherdevice that accurately measures the parts permillion concentration of the solution is avail-able and is used. II/III

(82) Machines using hot water for sanitizingmay be used provided that they are operatedin accordance with the manufacturer’sinstructions and are maintained in goodrepair. II/III

(83) All dishwashing machines shall be thor-oughly cleaned at least once a day or moreoften when necessary to maintain them in asatisfactory operating condition. III

(84) After mechanical or manual sanitization,all equipment and utensils shall be air dried.

All utensils shall be stored in a self-drainingposition. III

(85) Cleaned and sanitized equipment andutensils shall be handled in a way that pro-tects them from contamination. Spoons,knives and forks shall be touched only bytheir handles. Cups, glasses, bowls, platesand similar items shall be handled withoutcontact with inside surfaces or surfaces thatcontact the user’s mouth. III

(86) Cleaned and sanitized utensils andequipment shall be stored above the floor in aclean, dry location in a way that protectsthem from contamination by splash, dust andother means. The food-contact surfaces offixed equipment shall also be protected fromcontamination. III

(87) Glasses and cups shall be stored invert-ed. Other stored utensils shall be covered orinverted, wherever practical. Facilities for thestorage of knives, forks and spoons shall bedesigned and used to present the handle to theemployee or consumer. Unless tableware isprewrapped, holders for knives, forks andspoons at self-service locations shall protectthese articles from contamination and presentthe handle of the utensil to the consumer. III

(88) Single-service articles shall be storedabove the floor in closed cartons or contain-ers which protect them from contamination.III

(89) Single-service articles shall be handledand dispensed in a manner that prevents con-tamination of surfaces which may come incontact with food or with the mouth of theuser. III

(90) Single-service knives, forks and spoonspackaged in bulk shall be inserted into hold-ers or be wrapped by a person who haswashed his/her hands immediately prior tosorting or wrapping utensils. Unless single-service knives, forks and spoons areprewrapped or prepackaged, holders shall beprovided to protect these items from contam-ination. III

(91) Prohibited Storage Area. The storage offood equipment, utensils or single-servicearticles in toilet rooms or vestibules is pro-hibited. III

(92) All storage and installation of equipmentunder exposed sewage or water line, exceptfor automatic fire protection sprinkler heads,is prohibited. II

(93) Permanently fixed artificial light sourcesshall be installed to provide at least twenty(20) footcandles of light on all food prepara-tion surfaces and at equipment or utensil-washing work levels. III

(94) Permanently fixed artificial light sourcesshall be installed to provide, at a distance ofthirty inches (30") from the floor, at leasttwenty (20) footcandles of light in utensil andequipment storage areas and in lavatory andtoilet areas, and at least ten (10) footcandlesof light in walk-in refrigerating units, dryfood-storage areas and in all other areas. Thisshall also include dining areas during clean-ing operations. III

(95) Shielding to protect against broken glassfalling onto food shall be provided for all arti-ficial lighting fixtures located over, by orwithin food storage, preparation, service anddisplay facilities, and facilities where utensilsand equipment are cleaned and stored. III

(96) Infrared or other heat lamps shall beprotected against breakage by a shield sur-rounding and extending beyond the bulb,leaving only the face of the bulb exposed. III

(97) Nothing in this rule shall prohibit a facil-ity from hosting a resident/family picnic,carry-in dinner, fish fry or barbecue or allow-ing a local community or church group tosponsor such activities for residents.Reasonable practices shall be used for main-taining sanitation and appropriate tempera-tures of food brought to the facility. III

AUTHORITY: sections 198.009, 198.076 and198.079, RSMo 2000 and 198.005 and198.073, RSMo Supp. 2006.* This rule orig-inally filed as 13 CSR 15-17.030. Originalrule 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 Aug.1, 1988, effective Nov. 11, 1988. Moved to 19CSR 30-87.030, effective Aug. 28, 2001.Amended: Filed Aug. 23, 2006, effectiveApril 30, 2007.

*Original authority: 198.005, RSMo 2006; 198.009,RSMo 1979, amended 1993, 1995; 198.073, RSMo 1979,amended 1984, 1992, 1999, 2006; 198.076, RSMo 1979,amended 1984; and 198.079, RSMo 1979.




Rules of


Division 30—Division of Regulation and LicensureChapter 88—Resident’s Rights and HandlingResident Funds and Property in Long-Term

Care Facilities

Title Page

19 CSR 30-88.010 Resident Rights..................................................................................3

19 CSR 30-88.020 Resident’s Funds and Property ...............................................................6


Division 30—Division of Regulation and Licensure

Chapter 88—Resident’s Rights andHandling Resident Funds andProperty in Long-Term Care

Facilities

19 CSR 30-88.010 Resident Rights

PURPOSE: This rule establishes require-ments for protection of resident rights in alltypes of licensed long-term care facilities.


AGENCY NOTE: All rules relating to long-term care facilities licensed by the depart-ment are followed by a Roman Numeral nota-tion which refers to the class (either Class I,II or III) of standard as designated in section198.085.1, RSMo.

(1) The facility shall retain and make avail-able for public inspection at the facility tofacility personnel, residents, their next of kin,legal representatives or designees and thegeneral public, a list of names, addresses andoccupations of all individuals who have aproperty interest in the facility as well as acomplete copy of each official notificationfrom the Department of Health and SeniorServices (the department) of violations, defi-ciencies, licensure approval, disapprovals, ora combination of these, and responses. Thisincludes, as a minimum, statements of defi-ciencies, copies of plan(s) of correction,acceptance or rejection notice regarding theplan(s) of corrections and revisit inspectionreport. II/III

(2) Any notice of noncompliance shall beposted in a conspicuous location along with acopy of the most recent inspection reports, asrequired by section 198.026(6), RSMo. II/III

(3) A copy of the most current departmentrules governing the facility shall be kept avail-able and easily accessible in the facility for

review by residents, their next of kin, legallyauthorized representatives or designees, andthe public. II/III

(4) Each resident admitted to the facility, orhis or her next of kin, legally authorized rep-resentative or designee, shall be fullyinformed of the individual’s rights andresponsibilities as a resident. These rightsshall be reviewed annually with each resi-dent, and/or his or her next of kin, legallyauthorized representative or designee, eitherin a group session or individually. II/III

(5) All incoming and present residents, ortheir next of kin, legally authorized represen-tatives or designees in a facility shall be pro-vided statements of resident rights and a copyof any facility policies which relate to resi-dent conduct and responsibilities. Such infor-mation shall be provided in a manner whicheffectively communicates, in terms the resi-dent can reasonably be expected to under-stand, those rights and responsibilities. II/III

(6) The facility shall document the disclosureof resident’s rights information as required insections (4) and (5). III

(7) Information regarding resident rights andfacility rules shall be posted in a conspicuouslocation in the facility and copies shall beprovided to anyone requesting this informa-tion. Informational documents which con-tain, but are not limited to, updated informa-tion on selecting an Alzheimer’s special careunit or program shall be given by a facilityoffering to provide or providing these ser-vices to any person seeking information aboutor placement in an Alzheimer’s special careunit or program. III

(8) Prior to or at the time of admission andduring his or her stay in the facility, each res-ident and/or his or her next of kin, legallyauthorized representative or designee shall befully informed, in writing, of services avail-able in the facility and of related charges,including any charges for services not cov-ered by the facility’s basic per diem rate orfederal or state programs. Information shallinclude procedures to be followed by thefacility in cases of medical emergency,including transfer agreements and costs. Allresidents who receive treatment in anAlzheimer’s special care program or unit andtheir next of kin, legally authorized represen-tatives or designees shall be given a copy ofthe Alzheimer’s Special Care Services Dis-closure Form at the time of admission. Res-idents also shall be informed of services out-side the facility which may reasonably be

made available to the resident and of any rea-sonable estimate of any foreseeable costs con-nected with those services. II/III

(9) Prior to or upon admission, each prospec-tive resident or each resident, or his or hernext of kin, legally authorized representativeor designee shall be informed of the homeand community based services available inthis state by providing such resident a copy ofMissouri’s Guide to Home and CommunityBased Services (Revised 4/4/05), incorporat-ed by reference, provided by the MissouriDepartment of Health and Senior Services,PO Box 570, Jefferson City, MO 65102-0570and which is available to long-term care facil-ities at www.ged.oa.mo.gov/PICServices/Pamphlet/index.shtml or by telephone at 1-800-235-5503. This rule does not incorporateany subsequent amendments or additions. III

(10) Prior to or upon admission and at leastannually after that, each resident or his or hernext of kin, legally authorized representativesor designees shall be informed of facilitypolicies regarding provision of emergencyand life-sustaining care, of an individual’sright to make treatment decisions for himselfor herself and of state laws related to advancedirectives for health-care decision making.The annual discussion may be handled eitheron a group or on an individual basis. Resi-dents’ next of kin, legally authorized repre-sentatives or designees shall be informed,upon request, regarding state laws related toadvance directives for health-care decisionmaking as well as the facility’s policiesregarding the provision of emergency or life-sustaining medical care or treatment. If a res-ident has a written advance health-care direc-tive, a copy shall be placed in the resident’smedical record and reviewed annually withthe resident unless, in the interval, he or shehas been determined incapacitated, in accor-dance with section 475.075 or 404.825,RSMo. Residents’ next of kin, legally autho-rized representatives or designees shall becontacted annually to assure their accessibili-ty and understanding of the facility policiesregarding emergency and life-sustaining care.II/III

(11) A physician shall fully inform each res-ident of his or her health and medical condi-tion unless medically contraindicated. If thephysician determines the resident’s medicalcondition contraindicates the resident beingfully informed of his or her diagnosis, treat-ment or any known prognosis, the medicalrecord shall contain documentation and justi-fication of this signed by the physician. Ifthere is a legally authorized representative to


Chapter 88—Resident’s Rights and Handling Resident Funds andProperty in Long-Term Care Facilities 19 CSR 30-88

make health-care decisions, or the residenthas designated any individual to have access,that person shall be fully informed of the res-ident’s medical condition and shall have freeaccess to the resident’s medical records forthat purpose, subject to the limitations pro-vided by a power of attorney, duly-executedauthorization or any federal law. I/II

(12) If the facility has a policy which requiresthat residents’ medications be bubble packedor otherwise individual dose packaged, thefacility shall, prior to each resident’s admis-sion, make such information available to theresident and/or his or her next of kin, legallyauthorized representatives, designees orplacement authority. II/III

(13) Each resident shall be afforded theopportunity to participate in the planning ofhis or her total care and medical treatment, torefuse treatment and to participate in experi-mental research only upon his or herinformed written consent. If a resident refus-es treatment, this refusal shall be document-ed in the resident’s record and the resident,his or her legally authorized representativesor designees, or both, shall be informed ofpossible consequences of not receiving treat-ment. II

(14) Each resident shall have the privilege ofselecting his or her own physician who willbe responsible for the resident’s total care. II

(15) No resident shall be transferred or dis-charged except in the case of an emergencydischarge unless the resident, and the next ofkin, or a legally authorized representative ordesignee, and the resident’s attending physi-cian and the responsible agency, if any, arenotified at least thirty (30) days in advance ofthe transfer or discharge, and casework ser-vices or other means are utilized to assurethat adequate arrangements exist for meetingthe resident’s needs. In the event that there isno next of kin, legally authorized representa-tive or designee known to the facility, thefacility shall notify the appropriate regionalcoordinator of the Missouri State Ombuds-man’s office. II

(16) A resident may be transferred or dis-charged only for medical reasons or for his orher welfare or that of other residents, or fornonpayment for his or her stay. II

(17) No resident may be discharged withoutfull and adequate notice of his or her right toa hearing before the department’s Adminis-trative Hearings Unit and an opportunity tobe heard on the issue of whether his or her

discharge is necessary. Such notice shall begiven in writing no less than thirty (30) daysin advance of the discharge except in the caseof an emergency discharge and must complywith the requirements set forth in 19 CSR 30-82.050. II/III

(18) In emergency discharge situations thefacility shall submit to the resident and his orher next of kin, legally authorized represen-tative or designee a written notice of dis-charge. The written notice of discharge shallbe given as soon as practicable and advise theresident of the right to request an expeditedhearing. In the event that there is no next ofkin, legally authorized representative ordesignee known to the facility, the facilityshall send a copy of the notice to the appro-priate regional coordinator of the MissouriState Ombudsman’s office. II/III

(19) A room transfer of a resident within afacility, except in an emergency situation,requires consultation with the resident as farahead of time as possible and shall not bepermitted where this transfer would result inany avoidable detriment to the resident’sphysical, mental or emotional condition.II/III

(20) Each resident shall be encouraged andassisted, throughout his or her period of stay,to exercise his or her rights as a resident andas a citizen and to this end a resident mayvoice grievances and recommend changes inpolicies and services to facility personnel orto outside representatives of his or herchoice. A staff person shall be designated toreceive grievances and the residents shall befree to voice their complaints and recommen-dations to the staff designee, an ombudsmanor to any person outside the facility. Resi-dents shall be informed of and provided aviable format for recommending changes inpolicy and services. The facility shall assistresidents in exercising their rights to vote.II/III

(21) The exercise of resident rights shall befree from restraint, interference, coercion,discrimination or reprisal. II/III

(22) Each resident shall be free from abuse.Abuse is the infliction of physical, sexual, oremotional injury or harm and includes verbalabuse, corporal punishment, and involuntaryseclusion. I

(23) The facility shall develop and implementwritten policies and procedures that prohibitmistreatment, neglect, and abuse of any resi-dent and misappropriation of resident proper-

ty and funds, and develop and implementpolicies that require a report to be made tothe department for any resident or to both thedepartment and the Department of MentalHealth for any vulnerable person whom theadministrator or employee has reasonablecause to believe has been abused or neglect-ed. II/III

(24) The facility shall ensure all staff aretrained on the applicable laws and rulesregarding reporting of suspected abuse andneglect of any resident. II

(25) If the administrator or other employee ofa long-term care facility has reasonable causeto believe that a resident of the facility hasbeen abused or neglected, the administratoror employee shall immediately report orcause a report to be made to the department.Any administrator or other employee of along-term care facility having reasonablecause to suspect that a vulnerable person hasbeen subjected to abuse or neglect orobserves such a person being subjected toconditions or circumstances that would rea-sonably result in abuse or neglect shall imme-diately report or cause a report to be made tothe department and to the Department ofMental Health. I/II

(26) The resident has the right to be free fromany physical or chemical restraint except asfollows:

(A) When used to treat a specified medicalsymptom as a part of a total program of careto assist the resident to attain or maintain thehighest practicable level of physical, mental,or psychosocial well-being. The use ofrestraints must be authorized in writing by aphysician for a specified period of time; or

(B) When necessary in an emergency toprotect the resident from injury to himself orherself or to others, in which case restraintsmay be authorized by professional personnelso designated by the facility. The action takenshall be reported immediately to the resi-dent’s physician and an order obtained whichshall include the reason for the restraint,when the restraint may be removed, the typeof restraint, and any other actions required.When restraints are indicated, only devicesthat are the least restrictive for the residentand consistent with the resident’s total treat-ment program shall be used. I/II

(27) In a residential care facility or an assist-ed living facility, if it is ever necessary to usea restraint in case of emergency, the residentshall be reevaluated immediately for appro-priateness of placement and transferred ifnecessary. II/III


Secretary of State


(28) All information contained in a resident’smedical, personal or financial record andinformation concerning source of paymentshall be held confidential. Facility personnelshall not discuss aspects of the resident’srecord or care in front of persons notinvolved in the resident’s care or in front ofother residents. Written consent of the resi-dent or his or her legally authorized repre-sentative shall be required for the release ofinformation to persons not otherwise autho-rized by law to receive it. II/III

(29) Each resident shall be treated with con-sideration, respect, and full recognition of hisor her dignity and individuality, includingprivacy in treatment and care of his or herpersonal needs. All persons, other than theattending physician, the facility personnelnecessary for any treatment or personal care,or the department or Department of MentalHealth staff, as appropriate, shall be exclud-ed from observing the resident during anytime of examination, treatment, or careunless consent has been given by the resident.II/III

(30) No resident shall be required to performservices for the facility. If the resident desiresand it is not contraindicated by his or herphysician, the resident may perform tasks orservices for himself or herself or others. II/III

(31) Each resident shall be permitted to com-municate, associate, and meet privately withpersons of his or her choice whether on theresident’s initiative or the other person’s ini-tiative, unless to do so would infringe uponthe rights of other residents. The person(s)may visit, talk with, and make personal,social, or legal services available, inform res-idents of their rights and entitlements bymeans of distributing educational materials ordiscussions, assisting residents in assertingtheir legal rights regarding claims for publicassistance, medical assistance and SocialSecurity benefits, and engaging in any othermethods of assisting, advising, and represent-ing residents so as to extend to them the fullenjoyment of their rights. The facility, how-ever, may place reasonable limitations onsolicitations. II/III

(32) The facility shall permit a resident tomeet alone with a person or persons of his orher choice and provide an area which assuresprivacy. II/III

(33) Telephones appropriate to the residents’needs shall be accessible at all times. Tele-phones available for residents’ use shall

enable all residents to make and receive callsprivately. II/III

(34) If the resident cannot open mail, writtenconsent by the resident or his or her legallyauthorized representative shall be obtained tohave all mail opened and read to the resident.II/III

(35) Each resident shall be permitted to par-ticipate, as well as not participate, in activi-ties of social, religious, or community groupsat his/her discretion, both within the facility,as well as outside the facility, unless con-traindicated for reasons documented by physi-cian in the resident’s medical record. II/III

(36) Each resident shall be permitted to retainand use personal clothing and possessions asspace permits. Personal possessions mayinclude furniture and decorations in accor-dance with the facility’s policies and shall notcreate a fire hazard. The facility shall main-tain a record of any personal items accompa-nying the resident upon admission to thefacility, or which are brought to the residentduring his or her stay in the facility, whichare to be returned to the resident or responsi-ble party upon discharge, transfer, or death.II/III

(37) Each married resident shall be assuredprivacy for visits by his or her spouse. II/III

(38) If both husband and wife are residents,they shall be allowed the choice of sharing ornot sharing a room. III

(39) If siblings and/or a parent and his or herchild are both residents, the facility shallallow the family members the choice of shar-ing or not sharing a room upon availability ofroom(s) appropriate to accommodate the res-idents. III

(40) Each resident shall be allowed the optionof purchasing or renting goods or services notincluded in the per diem or monthly ratefrom a supplier of his or her own choice, pro-vided the quality of goods or services meetsthe reasonable standards of the facility. Eachresident shall be allowed the option of pur-chasing his or her medications from a phar-macy of his or her choice, provided the qual-ity of the medications and packaging meetsreasonable standards of the facility.

(41) Residents shall not have their personallives regulated or controlled beyond reason-able adherence to meal schedules and otherwritten policies which may be necessary for

the orderly management of the facility andthe personal safety of the residents. II

(42) All written accounts of the resident’sfunds shall be brought current monthly and awritten statement showing the current balanceand all transactions shall be given to the res-ident, or his or her next of kin, legally autho-rized representative, or designee on a quar-terly basis and upon request. The facilityshall keep written receipts of all personal pos-sessions and all funds received by or deposit-ed with the facility and all disbursementsmade to or on behalf of the resident and shalldisclose such receipts to the resident, and/orhis or her next of kin, legally authorized rep-resentative, or designee upon request. II/III

(43) The resident, or his or her next of kin,legally authorized representative, or designeeshall receive an itemized bill for all goodsand services actually rendered. No later thanthirty (30) days after the discharge or death ofa resident, the operator of the facility shallsubmit a final itemized bill for all goods andservices rendered, showing any credit bal-ances accruing on the date of discharge ordeath of the resident, and a complete accountof the resident’s remaining funds with thefacility, in any account, with whatever titlethe account(s) may be known, to the resi-dent’s guardian, conservator, fiduciary of theresident’s estate, or the individual who wasdesignated to receive the quarterly accountingof all financial transactions made. II/III

AUTHORITY: sections 198.009 and 198.088,RSMo 2000, and sections 198.073, 198.076,198.079, and 660.050, RSMo Supp. 2007.*This rule originally filed as 13 CSR 15-18.010. Original rule filed July 13, 1983,effective Oct. 13, 1983. Amended: Filed Sept.12, 1984, effective Dec. 13, 1984. Amended:Filed Jan. 3, 1992, effective Aug. 6, 1992.Amended: Feb. 13, 1998, effective Sept. 30,1998. Moved to 19 CSR 30-88.010, effectiveAug. 28, 2001. Amended: Filed March 1,2004, effective Oct. 30, 2004. Amended:Filed Dec. 15, 2005, effective July 30, 2006.Amended: Filed Aug. 23, 2006, effectiveApril 30, 2007. Amended: Filed March 13,2008, effective Oct. 30, 2008.

*Original authority: 198.009, RSMo 1979, amended1993, 1995; 198.073, RSMo 1979, amended 1984, 1992,1999, 2006, 2007; 198.076, RSMo 1979, amended 1984,2007; 198.079, RSMo 1979, amended 2007; 198.088,RSMo 1979, amended 1988, 1989, 1994; and 660.050,RSMo 1984, amended 1988, 1992, 1993, 1994, 1995,2001.




Secretary of State


19 CSR 30-88.020 Resident’s Funds andProperty

PURPOSE: This rule establishes standardsfor protecting resident’s personal funds andproperty in all types of licensed long-termcare facilities.


(1) No operator shall be required to hold anypersonal funds or money in trust unless someother governmental agency placing residentsin the facility makes this a requirement. Therecord keeping and other requirements of thissection apply only to those personal posses-sions and funds which the facility accepts tohold in trust for the resident as provided inthe facility’s policy and does not apply toother possessions residents have in theirrooms or bring into the facility.

(2) The administrator, other designated per-son, or both, shall use the personal funds ofthe resident exclusively for the use of the res-ident and, only when authorized in writing bythe resident, his/her designee or legalguardian. A designee shall not be the admin-istrator or an employee of the facility. II/III

(3) When a resident is admitted, s/he andhis/her designee or guardian shall be provid-ed with a statement explaining the facility’spolicies and resident’s rights regarding per-sonal funds. If the facility handles resident’sfunds, this statement shall include an expla-nation of the procedure for deposit or with-drawals of funds from any source to the resi-dent or to the resident’s account. The facilityshall allow the residents access to their per-sonal possessions and funds during regularbusiness hours, Monday through Friday. III

(4) The separate account(s) required to bemaintained by section 198.090.1(3), RSMoshall be maintained in a bank or savings andloan association and interest accrued shall becredited to each resident’s account at leastannually. With written authorization from theresident, the operator may purchase a burialpolicy for the purpose of burying the resi-dent. III

(5) A petty cash fund of up to fifty dollars($50) for each resident for whom the facilityis holding funds may be kept in the facility

and shall be maintained separately from thefacility's funds. II/III

(6) A written account for each resident,showing receipts to and disbursements fromthe personal funds of each resident, shall bemaintained. These may be kept in one (1)ledger or record or they may be kept individ-ually. If the facility policy provides, and ifappropriate or required by another govern-mental agency, two (2) personal fundsaccounts may be kept for residents—one (1)for clothing allowance and one (1) for spend-ing money. III

(7) Receipt of a resident’s funds or personalpossessions held in trust shall be acknowl-edged by a written receipt or cancelledchecks. III

(8) Receipts for any purchases made by theoperator and paid for from the resident’s per-sonal funds shall be kept and be available tothe resident, his/her designee or legalguardian. III

(9) All written accounts of the resident’sfunds shall be brought current monthly and awritten statement showing the current balanceand all transactions shall be given to the res-ident, his/her designee or legal guardian on aquarterly basis. II/III

(10) The operator shall have a receipt for thefunds and possessions returned to the resi-dent, designee or guardian. Within five (5)days of the discharge of a resident, the resi-dent or his/her designee or guardian shall begiven an up-to-date accounting of the resi-dent’s personal funds and the balance of thefunds and all personal possessions shall bereturned to the resident. II/III

(11) Upon the death of a resident, the opera-tor of the facility shall submit in writing onform MO 886-3103, a complete account ofall the resident’s remaining personal fundsand the name and address of the resident’sguardian, conservator, fiduciary of the resi-dent’s estate or the individual who was desig-nated to receive the quarterly accounting ofall financial transactions made. Personalfunds for the purpose of this regulation shallinclude all the resident’s remaining fundswith the facility, in any account, with what-ever title the account(s) may be known. Thecomplete account of funds shall be submittedwithin sixty (60) days from the date of theresident’s death to the Department of SocialServices, Division of Medical Services, TPLUnit, PNA Recovery, P.O. Box 6500, Jeffer-son City, MO 65102-6500. II/III

(A) None of the resident’s personal fundsshall be paid to a fiduciary, guardian, conser-vation or other person until the operator hasfully complied with section 198.090.1,RSMo except that funeral expenses may bepaid from a resident’s personal funds held bya facility if no other funds are available tocover the cost. If funds are used for this pur-pose, this fact and the amount used shall benoted on the account report submitted to thedepartment and documentation of paymentshall be attached.

(B) Upon receipt of the accounting of theresident’s remaining personal funds on formMO 886-3103, the Department of Social Ser-vices will determine the amount of aid, care,assistance or services paid by the department.The Department of Social Services will noti-fy the operator of the amount determined tohave been paid by the department on behalf ofthe deceased recipient within sixty (60) daysof receipt of the facility operator’s accountingor within fifteen (15) working days if specialrequest is made by the operator for expeditedhandling giving the reason(s) for the request,that is, need to comply with contractual orregulatory obligation of another governmentagency. The amount specified in the notifica-tion shall be considered as a claim upon thefunds held by the operator. The operator shallpay to the Department of Social Services anyremaining personal funds, in the resident’spersonal fund account, up to the amountdetermined by the department. Payment shallbe made by check payable to the Departmentof Social Services within sixty (60) workingdays of the receipt of the demand for pay-ment. Payment shall be made as instructed onthe department’s claim.

(C) The Department of Social Serviceswill notify in writing the resident’s guardian,conservator, fiduciary of the resident’s estateor the individual who was designated toreceive the quarterly accounting of all finan-cial transactions of the amount determined tohave been paid by the department on behalf ofthe deceased resident.

(D) If there are any remaining personalfunds after payment has been issued to theDepartment of Social Services, then thedeceased resident’s remaining funds shall behandled in accordance with section98.090.1(8), RSMo and 13 CSR 15-18.020(12).

(E) Failure of an operator of a facility par-ticipating in the Title XIX (Medicaid) pro-gram to submit within sixty (60) days of thedeath of a resident a complete accounting ofthe remaining personal funds of any residentwho has received aid, care, assistance or ser-vices from the Department of Social Services

shall be a Medicaid program violation under13 CSR 70-3.030, if the operator had knowl-edge of such funds, during the sixty (60)-dayperiod. If additional funds are received by theoperator after the initial report has been filed,the department shall be immediatelyinformed by the operator.

(12) Upon the death of a resident who, to theoperator’s knowledge and as confirmed bythe department, has not received aid or assis-tance from the Department of Social Ser-vices, if personal funds or possessions are notclaimed by a fiduciary within one (1) year ofthe resident’s death, the operator is requiredto comply, within sixty (60) days of the one(1) year anniversary of the death of the resi-dent, with section 198.090.1(8), RSMo.II/III

(A) If, after one (1) year from the date ofdeath, no fiduciary makes claim on funds orpossessions, the operator shall notify theDivision of Aging, Attention: InstitutionalAccounting Section, that the funds remainunclaimed. This notice shall be sent by theoperator within sixty (60) days and includethe resident’s name, Social Security number,date of death and the amount of residentfunds or possessions being held belonging tothe deceased resident.

1. If unclaimed funds in the resident’sfund accounts or possessions have a value ofless than one hundred fifty dollars ($150),and the operator has complied with 42 CFR483.10(c)(6), if required, the funds or pro-ceeds of the sale of the possessions shall bedeposited after one (1) year in a fund for thebenefit of all residents of the facility forsocial and educational activities.

2. If unclaimed funds in the resident’sfund accounts or possessions have a value ofmore than one hundred fifty dollars ($150)and the operator has complied with 42 CFR483.10(c)(6), if required, for deceased resi-dents funds, the operator shall hold theunclaimed funds for two (2) years from thedate of death. These funds shall then be con-sidered abandoned property under sections447.500–447.585, RSMo and shall bereturned to the state of Missouri within sixty(60) days after two (2) years from the date ofdeath. If the operator is a 501(c)(3) corpora-tion, then it shall comply with section447.540, RSMo. The operator shall contactthe Office of the Treasurer, Unclaimed Prop-erty Administrator, P.O. Box 1272, JeffersonCity, MO 65102-1272 for instructions andforms to return the unclaimed funds and pos-sessions to the state of Missouri. There shallbe an accounting subject to inspection andaudit by the Division of Aging or its autho-rized agents for these unclaimed funds and

possessions returned to the state of Missouri.(B) The operator shall keep an accounting

of these funds with documentation andreceipts and disbursements to these fundswhich will be subject to inspection and auditby the Division of Aging.

(13) Any owner, operator, manager, employ-ee or affiliate of an owner or operator receiv-ing personal property or anything with avalue of ten dollars ($10) or more from a res-ident shall make a written statement givingthe date of receipt, estimated value and thename of the person making the gift. Thesestatements shall be retained by the operatorand made available to the Department ofSocial Services or Department of MentalHealth as appropriate and to the resident,his/her designee or legal guardian. In one (1)calendar year, no owner, operator, manager,employee or affiliate of an owner or operatorshall receive from resident’s personal proper-ty or anything of value over one hundred dol-lars ($100). II/III

(14) The bond required by section 198.096,RSMo for operators holding personal fundsof residents shall be in a form approved bythe Division of Aging and shall provide thatresidents who allege that they have beenwrongfully deprived of moneys held in trustmay bring an action for recovery directlyagainst the surety. The bond shall be in anamount equal to at least one and one-half (11/2) times the average monthly balance of theresident’s personal funds, including pettycash, or the average total of the monthly bal-ances. The average monthly balance(s) shallbe rounded to the nearest one thousand dol-lars ($1,000). One (1) bond may be used tocover the residents’ funds in more than one(1) facility operated by the same operator, ifthe facility is a multilicensed facility on thesame premises. If not on the same premises,then one (1) bond may be used if the bondspecifies the amount of coverage provided foreach individual facility and the coverage foreach facility is a minimum of one thousanddollars ($1,000). II/III The director mayrequire an operator to file a bond in anamount greater than one and one-half (1 1/2)times the average total of the balances if thedivision determines the increase is necessary;the operator is given sixty (60)-days’ noticeand opportunity for hearing prior to requiringthat increase; and the director determines bythe evidence presented at any such hearingthat the increase is necessary.

(15) All records and receipts required to bemaintained under this rule and under section198.090, RSMo shall be maintained for at

least seven (7) years from the end of the fis-cal year during which the records were orig-inally made. II/III

(16) Records related to resident funds shall bemaintained in the facility or shall be availablefor review and copying, in their entirety,within twenty-four (24) hours of a request foraccess by the Division of Aging or its autho-rized representative. Records kept for theprior seven (7) years, as required in section(15) and under section 198.090, RSMo shallbe transferred to a new operator who assumesresponsibility for a facility, and if not trans-ferred in entirety, the Division of Aging shallbe notified immediately by the new operator.II/III

(17) If an operator chooses to place a cashdeposit in a lending institution in lieu of abond as referenced in section 198.096.5.,RSMo, the amount must be equal to theamount of the bond required and shall bedeposited with an insured lending institutionpursuant to a noncancellable escrow agree-ment. The written agreement shall be sub-mitted to the division and shall be approvedprior to license issuance. II

AUTHORITY: section 198.090, RSMo Supp.1993.* This rule originally filed as 13 CSR15-18.020. Original rule filed July 13, 1983,effective Oct. 13, 1983. Amended: Filed Sept.12, 1984, effective Dec. 13, 1984. Amended:Filed Aug. 1, 1988, effective Nov. 11, 1988.Amended: Filed Jan. 3, 1992, effective Aug.6, 1992. Amended: Filed July 22, 1994,effective Feb. 26, 1995. Moved to 19 CSR 30-88.020, effective Aug. 28, 2001.

*Original authority: 198.090, RSMo 1979, amended1982, 1989, 1992, 1993.



Missouri Revised Statutes

Chapter 344 Nursing Home Administrators

August 28, 2010

Definitions.

344.010. As used in this chapter the following words or phrases mean:

(1) "Board", the Missouri board of nursing home administrators;

(2) "Long-term care facility", any residential care facility, assisted living facility, intermediate care facility or skilled nursingfacility, as defined in section 198.006, or similar facility licensed by states other than Missouri;

(3) "Nursing home", any institution or facility defined as an assisted living facility, residential care facility, intermediatecare facility, or skilled nursing facility for licensing purposes by section 198.006, whether proprietary or nonprofit;

(4) "Nursing home administrator", a person who administers, manages, supervises, or is in general administrative chargeof a nursing home, whether such individual has an ownership interest in the home, and whether his functions and dutiesare shared with one or more individuals.

(L. 1969 3d Ex. Sess. H.B. 33 § 1, A.L. 1980 H.B. 1530 Revision, A.L. 1984 S.B. 451, A.L. 1987 S.B. 277, A.L. 2010 H.B. 2226, et al. merged withS.B. 754)

License required--separate license for assisted living facilities administrators, limitations oflicense.

344.020. No person shall act or serve in the capacity of a nursing home administrator without first procuring a licensefrom the Missouri board of nursing home administrators as provided in sections 344.010 to 344.108. The board mayissue a separate license to administrators of residential care facilities that were licensed as a residential care facility II onor before August 27, 2006, that continue* to meet the licensure standards for a residential care facility II in effect onAugust 27, 2006, and assisted living facilities, as defined in section 198.006. Any individual who receives a license tooperate a residential care facility or an assisted living facility is not thereby authorized to operate any intermediate carefacility or skilled nursing facility as those terms are defined in section 198.006.

(L. 1969 3d Ex. Sess. H.B. 33 § 2, A.L. 1989 S.B. 387, A.L. 2007 H.B. 780, A.L. 2010 H.B. 2226, et al. merged with S.B. 754)

*Word "continues" appears in original rolls of S.B. 754.

License, qualifications, fee, examination, term--reciprocity--emergency license.

344.030. 1. An applicant for an initial license shall file a completed application with the board on a form provided by the

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board, accompanied by an application fee as provided by rule payable to the department of health and senior services.Information provided in the application attested by signature to be true and correct to the best of the applicant'sknowledge and belief.

2. No initial license shall be issued to a person as a nursing home administrator unless:

(1) The applicant provides the board satisfactory proof that the applicant is twenty-one years of age or over, of goodmoral character and a high school graduate or equivalent;

(2) The applicant provides the board satisfactory proof that the applicant has had a minimum of three years' experiencein health care administration or two years of postsecondary education in health care administration or has satisfactorilycompleted a course of instruction and training prescribed by the board, which includes instruction in the needs properlyto be served by nursing homes, the protection of the interests of residents therein, and the elements of good nursing homeadministration, or has presented evidence satisfactory to the board of sufficient education, training, or experience in theforegoing fields to administer, supervise and manage a nursing home; and

(3) The applicant passes the examinations administered by the board. If an applicant fails to make a passing grade oneither of the examinations such applicant may make application for reexamination on a form furnished by the board andmay be retested. If an applicant fails either of the examinations a third time, the applicant shall be required to complete acourse of instruction prescribed and approved by the board. After completion of the board-prescribed course ofinstruction, the applicant may reapply for examination. With regard to the national examination required for licensure, noexamination scores from other states shall be recognized by the board after the applicant has failed his or her thirdattempt at the national examination. There shall be a separate, nonrefundable fee for each examination. The board shallset the amount of the fee for examination by rules and regulations promulgated pursuant to section 536.021. The fee shallbe set at a level to produce revenue which shall not substantially exceed the cost and expense of administering theexamination.

3. The board may issue a license through reciprocity to any person who is regularly licensed as a nursing homeadministrator in any other state, territory, or the District of Columbia, if the regulations for securing such license areequivalent to those required in the state of Missouri. However, no license by reciprocity shall be issued until the applicantpasses a special examination approved by the board, which will examine the applicant's knowledge of specific provisionsof Missouri statutes and regulations pertaining to nursing homes. The applicant shall furnish satisfactory evidence thatsuch applicant is of good moral character and has acted in the capacity of a nursing home administrator in such state,territory, or the District of Columbia at least one year after the securing of the license. The board, in its discretion, mayenter into written reciprocal agreements pursuant to this section with other states which have equivalent laws andregulations.

4. Nothing in sections 344.010 to 344.108, or the rules or regulations thereunder shall be construed to require anapplicant for a license as a nursing home administrator, who is employed by an institution listed and certified by theCommission for Accreditation of Christian Science Nursing Organizations/Facilities, Inc., to administer institutionscertified by such commission for the care and treatment of the sick in accordance with the creed or tenets of arecognized church or religious denomination, to demonstrate proficiency in any techniques or to meet any educationalqualifications or standards not in accord with the remedial care and treatment provided in such institutions. Theapplicant's license shall be endorsed to confine the applicant's practice to such institutions.

5. The board may issue a temporary emergency license for a period not to exceed ninety days to a person twenty-oneyears of age or over, of good moral character and a high school graduate or equivalent to serve as an acting nursinghome administrator, provided such person is replacing a licensed nursing home administrator who has died, has beenremoved or has vacated the nursing home administrator's position. No temporary emergency license may be issued to aperson who has had a nursing home administrator's license denied, suspended or revoked. A temporary emergency

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license may be renewed for one additional ninety-day period upon a showing that the person seeking the renewal of atemporary emergency license meets the qualifications for licensure and has filed an application for a regular license,accompanied by the application fee, and the applicant has taken the examination or examinations but the results have notbeen received by the board. No temporary emergency license may be renewed more than one time.

(L. 1969 3d Ex. Sess. H.B. 33 § 3, A.L. 1979 S.B. 145, A.L. 1987 S.B. 277, A.L. 1988 S.B. 602, A.L. 1989 S.B. 387, A.L. 1996 H.B. 905 merged withH.B. 1362, A.L. 2007 H.B. 780)

License renewal, application for, fee--late renewal, effect--additional disciplinary actionauthorized, when.

344.040. 1. Every license issued under this chapter shall expire on June thirtieth of the year following the year of issuanceand every other year thereafter, provided that licenses issued or renewed during the year 2006 may be issued orrenewed by the board for a period of either one or two years, as provided by rule. Licensees seeking renewal shall,during the month of May of the year of renewal, file an application for renewal on forms furnished by the board, whichshall include evidence satisfactory to the board of completion of the approved continuing education hours required by theboard, and shall be accompanied by a renewal fee as provided by rule payable to the department of health and seniorservices.

2. Upon receipt of an incomplete application for renewal, the board shall grant the applicant a temporary permit whichshall be in effect for thirty days. The applicant is required to submit the required documentation or fee within the thirty-day period, or the board may refuse to renew his or her application. The thirty-day period can be extended for goodcause shown for an additional thirty days. Upon receipt of the approved continuing education credits or other requireddocumentation or fee within the appropriate time period, the board shall issue a license.

3. The board shall renew the license of an applicant who has met all of the requirements for renewal.

4. As a requirement for renewal of license, the board may require not more than forty-eight clock hours of continuingeducation a year. The continuing education provided for under this section shall be approved by the board. There shallbe a separate, nonrefundable fee for each single offering provider. The board shall set the amount of fee for any singleoffering provided by rules and regulations promulgated pursuant to section 536.021. The fee shall be set at a level toproduce revenue which shall not substantially exceed the cost and expense in administering and reviewing any singleoffering.

5. By April first of each year, the board shall mail an application for renewal of license to every person whose licenseshall be renewed during the current year. The applicant must submit such information as will enable the board todetermine if the applicant's license should be renewed. Information provided in the application shall be attested bysignature to be true and correct to the best of the applicant's knowledge and belief.

6. Any licensee who fails to apply to renew his or her license by June thirtieth of the licensee's year of renewal may berelicensed by the board if he meets the requirements set forth by the board pursuant to sections 344.010 to 344.108 andpays the renewal fee required by rule, plus a penalty of twenty-five dollars. No action shall be taken by the board inaddition to a penalty of twenty-five dollars imposed by this section against any such licensee whose license has notexpired for a period of more than two months, and who has had no action in the preceding five years taken against themby the board, and who has met all other licensure requirements by June thirtieth of the year of renewal; provided,however, that nothing in this section shall prevent the board from taking any other disciplinary action against a licensee ifthere shall exist a cause for discipline pursuant to section 344.050. A person whose license has expired for a period ofmore than twelve months must meet the requirements set out in section 344.030 for initial licensure.

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(L. 1969 3d Ex. Sess. H.B. 33 § 4, A.L. 1979 S.B. 145, A.L. 1987 S.B. 277, A.L. 1989 S.B. 387, A.L. 2000 H.B. 1591, A.L. 2005 S.B. 177, A.L. 2007H.B. 780)

Suspension--revocation--probation--refusal to issue or renew license--grounds--procedure--right of review by administrative hearing commission.

344.050. 1. The board may refuse to issue or renew any certificate of registration or authority, permit or license requiredpursuant to this chapter for one or any combination of causes stated in subsection 2 of this section. The board shall notifythe applicant in writing of the reasons for the refusal and shall advise the applicant of his or her right to file a complaintwith the administrative hearing commission as provided by chapter 621. As an alternative to refusal to issue or renew anycertificate, registration or authority, permit or license, the board may, at its discretion, issue a license which is subject toprobation for any one or any combination of causes stated in subsection 2 of this section. The board's order of probationshall contain a statement of the discipline imposed, the basis therefor*, the date such action shall become effective, and astatement that the applicant has thirty days to request in writing a hearing before the administrative hearing commission. Ifthe board issues a probationary license to an applicant for licensure, the applicant may file a written petition with theadministrative hearing commission within thirty days of the effective date of the probationary license seeking review ofwhether cause exists to discipline the licensee under subsection 2 of this section. If no written request for a hearing isreceived by the administrative hearing commission within the thirty-day period, the right to seek review of the board'sdecision shall be waived.

2. The board may cause a complaint to be filed with the administrative hearing commission as provided by chapter 621against any holder of any certificate of registration or authority, permit or license required by this chapter or any personwho has failed to renew or has surrendered his or her certificate of registration or authority, permit or license for any oneor any combination of the following causes:

(1) Use or unlawful possession of any controlled substance, as defined in chapter 195, or alcoholic beverage to an extentthat such use impairs a person's ability to perform the work of any profession licensed or regulated by this chapter;

(2) The person has been finally adjudicated and found guilty, or entered a plea of guilty or nolo contendere, pursuant tocriminal prosecution under the laws of any state or of the United States, for any offense reasonably related to thequalifications, functions or duties of any profession licensed or regulated under this chapter, for any offense an essentialelement of which is fraud, dishonesty or an act of violence, or for any offense involving moral turpitude, whether or notsentence is imposed;

(3) Use of fraud, deception, misrepresentation or bribery in securing any certificate of registration or authority, permit orlicense issued pursuant to this chapter or in obtaining permission to take any examination given or required pursuant tothis chapter;

(4) Obtaining or attempting to obtain any fee, charge, tuition or other compensation by fraud, deception ormisrepresentation;

(5) Incompetency, misconduct, gross negligence, fraud, misrepresentation or dishonesty in the performance of thefunctions or duties of any profession licensed or regulated by this chapter;

(6) Violation of, or assisting or enabling any person to violate, any provision of this chapter, or of any lawful rule orregulation adopted pursuant to this chapter;

(7) Violation of, or assisting or enabling any person to violate, any provision of chapter 198 or any lawful rule orregulation promulgated thereunder;

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(8) Impersonation of any person holding a certificate of registration or authority, permit or license, or allowing any personto use such person's certificate of registration or authority, permit, license or diploma from any school;

(9) Disciplinary action against the holder of a license or other right to practice any profession regulated by this chaptergranted by another state, territory, federal agency or country upon grounds for which revocation or suspension isauthorized in this state;

(10) A person is finally adjudged incapacitated or disabled by a court of competent jurisdiction;

(11) Assisting or enabling any person to practice or offer to practice any profession licensed or regulated by this chapterwho is not registered and currently eligible to practice under this chapter;

(12) Issuance of a certificate of registration or authority, permit or license based upon a material mistake of fact;

(13) Violation of the drug laws or rules and regulations of this state, any other state or the federal government;

(14) Knowingly failing to report abuse or neglect of a resident in a long-term care facility, as required by section198.070, of which he or she has actual knowledge that it is abuse or neglect;

(15) Violation of any professional trust or confidence;

(16) Having served as the administrator, operator, or any principal involved in the operation of a facility licensed underchapter 198 and during such time the facility has had its license revoked under section 198.036, has entered into aconsent agreement to obtain a probationary license under subsection 5 of section 198.026, has had a license deniedunder subsection 2 of section 198.022, or has surrendered its license while under investigation.

3. The administrative hearing commission shall have no authority to require issuance of a license, pending a finaldetermination by the commission, in any case in which an applicant is seeking initial licensure.

4. No license may be suspended or revoked and no application for renewal of a license may be denied under this sectionuntil the licensee has been afforded an opportunity for hearing after due notice as provided in sections 621.015 to621.205.

5. Upon a finding by the administrative hearing commission that the grounds, provided in subsection 2 of this section, fordisciplinary action are met, the board may, singly or in combination, censure or place the person named in the complainton probation on such terms as the board deems appropriate, or may suspend or revoke the certificate, permit or license.The board may exclude any application for up to five years for any person who has had his or her license revoked by theboard or has surrendered his or her license to the board.

(L. 1969 3d Ex. Sess. H.B. 33 § 5, A.L. 1979 S.B. 145, A.L. 1980 H.B. 1530 Revision, A.L. 1987 S.B. 277, A.L. 1989 S.B. 387, A.L. 2007 H.B. 780)

*Word "therefore" appears in original rolls.

Board, membership, qualifications, terms, removed how, hearing.

344.060. 1. The director of the department of health and senior services shall appoint ten suitable persons who togetherwith the director of the department of health and senior services or the director's designee shall constitute the "MissouriBoard of Nursing Home Administrators" which is hereby created within the department of health and senior services andwhich shall have the functions, powers and duties prescribed by sections 344.010 to 344.108.

2. In addition to the director of the department of health and senior services or the director's designee the membership of

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the board shall consist of one licensed physician, two licensed health professionals, one person from the field of healthcare education, four persons who have been in general administrative charge of a licensed nursing home for a period ofat least five years immediately preceding their appointment, and two public members. In addition to these qualifications,the physician, the two licensed health care professionals, and the health care educator shall be citizens of the UnitedStates and taxpaying residents of the state of Missouri for one year preceding their appointments. The four appointeeswho have been in general administrative charge of a licensed nursing home shall be citizens of the United States andeither residents of the state of Missouri for one year preceding their appointments or persons who have been licensed bythe board and whose five years of employment in a licensed nursing home immediately preceding their appointment haveoccurred in the state of Missouri. The public members shall be citizens of the United States, residents of the state ofMissouri for one year preceding their appointment, and registered voters. The public members shall be persons who arenot, or never were, licensed nursing home administrators or the spouse of such persons, or persons who do not have ornever have had a material, financial interest in either the providing of licensed nursing home services or in an activity ororganization directly related to licensed nursing home administration. Neither the one licensed physician, the two licensedhealth professionals, nor the person from the health care education field shall have any financial interest in a licensednursing home.

3. The members of the board shall be appointed for three-year terms or until their successors are appointed and qualifiedprovided that no more than four members' terms shall expire in the same year. All members appointed prior toSeptember 28, 1979, shall serve the term for which they were appointed. The governor shall fill any vacancies on theboard as necessary. Appointment to fill an unexpired term shall not be considered an appointment for a full term. Boardmembership, continued until successors are appointed and qualified, shall not constitute an extension of the three-yearterm and the successors shall serve only the remainder of the term.

4. Every member shall receive a certificate of appointment; and every appointee, before entering upon his or her duties,shall take the oath of office required by article VII, section 11, of the Constitution of Missouri.

5. Any member of the board may be removed by the director of the department of health and senior services formisconduct, incompetency or neglect to duty after first being given an opportunity to be heard in his or her own behalf.

(L. 1969 3d Ex. Sess. H.B. 33 § 6, A.L. 1979 S.B. 145, A.L. 2002 H.B. 1953, A.L. 2007 H.B. 780)

Board officers, how selected--duties and powers of board--rules and regulations, procedure.

344.070. 1. The board shall annually elect one of its members as president, another as vice president, and another assecretary. It shall adopt an official seal. It shall file and preserve all written applications, petitions, complaints, charges orrequests made or presented to it. It shall cause to be kept accurate records and minutes of its proceedings, and shallmaintain a register of the names and addresses of all persons holding licenses as nursing home administrators. A copy ofany entry in the register, or of any records or minutes of the board, certified by the president or secretary of the boardunder its seal, shall be received in evidence, to all intents and purposes as the original. The board may employ such part-or full-time clerical assistance, purchase such equipment and supplies, employ legal counsel, employ a part- or full-timeinvestigator, and incur travel and other expense, within the limits of its appropriations.

2. The board shall adopt, amend and repeal rules and regulations necessary to carry out the provisions of sections344.020 to 344.108. Any rule or regulation under the authority of sections 344.020 to 344.108 shall be promulgated inaccordance with chapter 536. The committee on administrative rules may file a complaint in accordance with theprovisions of chapter 536 before the commission contesting the validity of any rule purportedly promulgated under theauthority of sections 344.020 to 344.108. On filing any complaint in accordance with this section, the administrativehearing commission shall immediately suspend that portion of the rule which is challenged until the commission has

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determined the matter. The commission shall hold a hearing within ten days of the filing to determine the matter. No ruleor portion of a rule promulgated under the authority of this chapter shall become effective unless it has been promulgatedpursuant to the provisions of section 536.024.

3. The board shall examine, license, and renew the license of duly qualified applicants, and shall conduct hearingsaffording due process of law, upon charges calling for discipline of a licensee. The board shall refer to the appropriateprosecuting attorney information regarding any persons violating the provisions of sections 344.010 to 344.108 and mayincur necessary expenses therefor.

(L. 1969 3d Ex. Sess. H.B. 33 § 7, A.L. 1979 S.B. 145, A.L. 1993 S.B. 52, A.L. 1995 S.B. 3, A.L. 2007 H.B. 686 merged with H.B. 780)

Compensation of board members, exception.

344.080. The members of the board, other than the director of the department of health and senior services or hisdesignee, shall receive as compensation for their services fifty dollars for each day devoted to the affairs of the board,and shall be entitled to reimbursement for their expenses necessarily incurred in the discharge of their official duties.

(L. 1969 3d Ex. Sess. H.B. 33 § 8, A.L. 1979 S.B. 145, A.L. 1987 S.B. 277, A.L. 2007 H.B. 780)

Acting as nursing home administrator without license, penalty.

344.100. Any person who acts or serves in the capacity of a nursing home administrator without being properly licensedby the Missouri board of nursing home administrators as provided in sections 344.010 to 344.100 is guilty of amisdemeanor and, upon conviction, shall be punished as provided by law. The board shall immediately notify thelicensing authority for nursing homes whenever a proceeding has been initiated to suspend or revoke the license of anursing home administrator and whenever the license of a nursing home administrator is suspended, revoked, or notrenewed.

(L. 1969 3d Ex. Sess. H.B. 33 § 10, A.L. 1979 S.B. 145)

Retired licenses permitted, when, procedure.

344.105. 1. Any nursing home administrator possessing a current license to practice as a nursing home administrator inthis state who has maintained an active license for at least ten years may retire his or her license by filing an affidavit withthe board which states the date on which the licensee retired from such practice and such other facts as tend to verify theretirement as the board may deem necessary. The affidavit shall be accompanied by a fee as provided by rule, madepayable to the department of health and senior services. Such request for retired status may also be accomplished bysigning the request for retired status that appears on the nursing home administrator's application for license renewal andreturning such application to the board prior to June thirtieth of the year of renewal of the administrator's active license,accompanied by a fee as provided by rule, made payable to the department of health and senior services. Informationprovided in the request for retired status shall be given under oath subject to the penalties for the making of a falseaffidavit.

2. An individual who requests retired license status shall return his or her original wall license and all other indicia oflicensure to the board. Once the board has received the original wall license from the licensee or evidence satisfactory tothe board that the license has been lost, stolen, or destroyed, and the other requirements for requesting retired status

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have been met, the board shall issue a new license to the licensee indicating that the licensee is retired.

3. A retired license may be reactivated within five years of the granting of the retired license by filing with the boardevidence satisfactory to the board of the completion of twenty clock hours of continuing education for each calendaryear the license was retired accompanied by a fee as provided by rule made payable to the department of health andsenior services. All clock hours of continuing education shall be completed prior to the filing of the affidavit or renewalform requesting reactivation of the retired license. If more than five years have passed since the issuance of a retiredlicense to a licensee, the licensee shall follow the procedures for initial licensure stated in section 344.030.

4. No person shall practice as a nursing home administrator in this state or hold himself or herself out as a nursing homeadministrator if his or her license is retired.

5. Retired licensees shall remain subject to disciplinary action for violations of this chapter and the rules promulgatedthereunder.

(L. 2000 H.B. 1591, A.L. 2007 H.B. 780)

Inactive status of license permitted, when--reactivation, procedure.

344.108. 1. Any nursing home administrator possessing a current license to practice as a nursing home administrator inthis state may place such license on inactive status by filing a written signed request for inactive status with the board,accompanied by evidence satisfactory to the board of completion of ten clock hours of continuing education in the areaof patient care and a fee as provided by rule made payable to the department of health and senior services. This requestmay also be accomplished by signing the request for inactive status that appears on the nursing home administrator'sapplication for license renewal and returning such application to the board prior to June thirtieth of the year of renewal ofthe administrator's active license, accompanied by evidence satisfactory to the board of the completion of ten clockhours of continuing education in the area of patient care and a fee as provided by rule made payable to the department ofhealth and senior services. Information provided in the request for inactive status shall be given under oath subject to thepenalties of making a false affidavit.

2. An individual who requests that his or her license be placed on inactive status shall return all indicia of licensure to theboard or submit evidence satisfactory to the board that the license has been lost, stolen, or destroyed.

3. An inactive license shall expire on June thirtieth of the second year following the year of issuance and every other yearthereafter. Licensees seeking to renew shall, during the month of May of the year of renewal, file an application forrenewal on forms furnished by the board that include evidence satisfactory to the board of the completion of ten clockhours of continuing education in the area of patient care and shall be accompanied by a renewal fee as provided by rule,payable to the department of health and senior services.

4. A license may be carried in inactive status for up to six years from the date of issuance. If the licensee does notreactivate the license during the six-year period, the license shall expire on the last day of the six-year period.

5. A holder of an inactive license may reactivate the license by submitting a written request to the board, accompaniedby evidence satisfactory to the board of the completion or plan for completion of forty clock hours of continuingeducation and a fee as provided by rule made payable to the department of health and senior services. The forty clockhours of continuing education shall be earned no earlier than six months prior to the request for reactivation and no laterthan twelve months after the inactive license has been reactivated. If the holder of an inactive license requests reactivationprior to completing the forty clock hours of continuing education, the board shall issue a six- month interim license to thelicensee. The interim license shall expire six months from the date of issuance or at such earlier time as the licensee earns

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the forty clock hours of continuing education and submits evidence satisfactory to the board of completion of therequired hours.

6. A request for reactivation of an inactive license shall show, under oath or affirmation of the nursing homeadministrator, a statement that the nursing home administrator has not practiced during the inactive period and is notpresently practicing in this state.

7. No person shall practice as a nursing home administrator or hold himself or herself out as a nursing home administratorin this state while his or her license is inactive.

8. Inactive licensees shall remain subject to discipline for violations of this chapter and the rules promulgated thereunder.

(L. 2007 H.B. 780)

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