PURPOSE: This rule sets forth general licensure and application procedures and outlines the request for an exception procedure related to long-term care facility licensure.

1. (1) Persons wishing to operate a skilled nursing facility, intermediate care facility, residential care facility II or residential care facility I shall submit information to the division as set out in the application for license to operate a long-term care facility form, including all documents listed in that application. The applicant may use one (1) application form, if the operator wishes to license more than one (1) facility on the same premises.

   1. (A) The applicant, shall submit the following documents as listed in the application:

      1. 1. Financial information demonstrating

that the applicant has the financial capacity to operate the facility;

1. 2. A document disclosing the location,

capacity and type of licensure and certification of any support buildings, wings or floors housing residents on the same or adjoining premises or plots of ground;

1. 3. A document disclosing the name,

address and type of license of all other longterm care facilities owned or operated by either the applicant or by the owner of the facility for which the application is being submitted;

1. 4. A copy of any executed management

contracts between the applicant and the manager of the facility;

1. 5. A copy of any executed contract con-

veying the legal right to the facility premises, including, but not limited to, leases, subleases, rental agreements, contracts for deed and any amendments to those contracts;

1. 6. A copy of any contract by which the

facility’s land, building, improvements, furnishings, fixtures or accounts receivable are pledged in whole or in part as security, if the value of the asset pledged is greater than five hundred dollars ($500);

1. 7. A nursing home surety bond or non-

cancelable escrow agreement, if the applicant holds or will hold facility residents’ personal funds in trust;

1. 8. A document disclosing the name,

address, title and percentage of ownership of each affiliate of any general partnership, limited partnership, general business corporation, nonprofit corporation, limited liability company or governmental entity which owns or operates the facility or is an affiliate of an entity which owns or operates the facility; and

1. 9. If applicable, a document stating the

name and nature of any additional businesses in operation on the facility premises and the document issued by the division giving its prior written approval for each business.

1. (B) Every facility that provides specialized Alzheimer’s or dementia care services, as defined in sections 198.500 to 198.515, RSMo Supp. 1997, by means of an Alzheimer’s special care unit or program shall submit to the Division of Aging, as part of the licensure application or renewal, the following:

2. 1. A form entitled “Alzheimer’s Special Care Services Disclosure Form” shall be developed by the Division of Aging which provides information, if applicable, of how the care is different from the rest of the facility in the following areas:

   1. A. The Alzheimer’s special care

unit’s or program’s written statement of its overall philosophy and mission which reflects the needs of residents afflicted with dementia;

1. B. The process and criteria for place-

ment in, or transfer or discharge from, the unit or program;

1. C. The process used for assessment

and establishment of the plan of care and its implementation, including the method by which the plan of care evolves and is responsive to changes in condition;

1. D. Staff training and continuing edu-

cation practices;

1. E. The physical environment and

design features appropriate to support the functioning of cognitively impaired adult residents;

1. F. The frequency and types of resident

activities;

1. G. The involvement of families and

the availability of family support programs;

1. H. The costs of care and any addi-

tional fees; and

1. I. Safety and security measures; and
2. 2. A document developed by and/or

approved by the division which contains, but is not limited to, updated information on selecting an Alzheimer’s special care unit or program.

1. (C) If, after filing an application, the operator identifies an error or if any information changes the issuance of the license, the operator shall—

   1. 1. Submit the correction or additional

information to the division in a letter accom- 13 CSR 15-10

panied by a notarized statement that the information being submitted is true and correct to the best of the operator’s knowledge and belief; or

1. 2. Submit the correction or additional

information to the division by using MO Form 886-2609, entitled: Corrections for LTC Facility License Application.

1. (D) If, as a result of an application review, the division requests a correction or additional information, the operator, within ten (10) working days of receipt of the written request shall—

   1. 1. Submit the correction or additional

information to the division in a letter accompanied by a notarized statement that the information being submitted is true and correct to the best of the operator’s knowledge and belief; or

1. 2. Submit the correction or additional

information to the division by using MO Form 886-2609, entitled: Corrections for LTC Facility License Application.

1. (E) A new facility shall submit an application for an original license not less than thirty (30) days before the anticipated opening date. The division must approve the application before a licensure inspection is scheduled. Sixty (60) days after its receipt, the division shall consider any application for an original license withdrawn if it is submitted without all the required information and documents. If intending to continue with licensure, the operator shall submit a new application and fee along with all necessary documents.
2. (F) An operator shall submit a relicensure application thirty (30) to ninety (90) days prior to the existing license’s expiration date.
3. (G) If, during the a license’s effective period, an operator which is a partnership, limited partnership or corporation undergoes any of the changes described in section 198.015.3, RSMo, or a new corporation, partnership, limited partnership, limited liability company or other entity assumes facility operation, within ten (10) working days of the effective date of that change, the operator shall submit an application for a new license.
4. (H) The division shall issue each license only for the premises and operator named in the application. This license shall cover the entire premises unless stipulated otherwise and shall not be transferable. If the licensed operator of a facility is replaced by another operator, the new operator shall apply for a new license before the effective date of the change. A change of operator shall include a change in form of business as well as a change of person. Upon receipt of the application and receipt of confirmation that the change of operator has taken place, the division shall grant the new operator a temporary operating permit of sufficient duration to allow the division time to evaluate the application, conduct any necessary inspection(s) to determine substantial compliance with the law and the rules, and to either issue or deny a license to the new operator. The new operator shall be subject to all the terms and conditions under which the previous operator’s license or temporary operating permit was issued. This includes any existing statement of deficiencies, plans of correction and compliance with any additional requirements imposed by the division as a result of any existing substantial noncompliance. The new operator, however, shall apply to the division for renewal in his/her/its name for any exception to the rules that had been granted the previous operator under the provisions of section (3) of this rule.
5. (I) The operator shall accompany each application for a license to operate a longterm care facility (skilled nursing facility, intermediate care facility, residential care facility II or residential care facility I) with a license fee of one hundred dollars ($100) for those facilities which have a resident capacity of at least three (3) but less than twentyfive (25), three hundred dollars ($300) for those facilities which have a resident capacity of twenty-five through one hundred (25–100), and six hundred dollars ($600) for those facilities with a capacity of over one hundred (100+). The operator shall submit a separate fee for each facility’s license application. This fee is nonrefundable unless the facility withdraws the application within ten

1. (10) days of receipt by the division. The division will issue a license for a period of no more than two (2) years for the premises and operator named in the application. If the license is for less than two (2) years, the division will prorate the fees accordingly.

   1. (J) An operator may apply for licenses for two (2) or more different levels of care located on the same premises either by submitting one (1) application or by submitting a separate application for each level of care. If an operator elects to submit one (1) application for two (2) or more levels of care located on the same premises—

      1. 1. The application shall specify sepa-

rately the number of beds of each level of care being applied for;

1. 2. The application shall be accompanied

by a license fee for each level of care applied for, as required by subsection (1)(I) of this rule; and

1. 3. An application for two (2) or more

levels of care on the same premises shall indicate one (1) facility name only.

1. (K) The division shall issue a separate license for each level of care located on the same premises, whether applied for by one

1. (1) application or more than one (1). If the operator uses one (1) application for two (2) or more levels of care on the same premises, the division shall issue licenses with one (1) expiration date. If two (2) or more levels of care have existing licenses with different expiration dates and the operator elects to apply for licenses for the levels of care by submitting one (1) relicensure application, the expiration dates of the licenses issued shall be two (2) years subsequent to the expiration date of the license of the level of care expiring earliest following receipt of the application by the division. Fees for unused portions of licenses resulting from the submission of one (1) application for two (2) or more levels of care are nonrefundable.

   1. (L) After receiving a license application, the division shall review the application, investigate the applicant and the statements sworn to in the application for license and conduct any necessary inspections. A license shall be issued if—

      1. 1. The division has determined that the

application is complete, and that all necessary documents have been filed with the application including an approved nursing home bond or noncancelable escrow agreement if personal funds of residents are held in trust;

1. 2. The division has determined that the

statements in the application are true and correct;

1. 3. The division has determined that the

facility and the operator are in substantial compliance with the provisions of sections 198.003—198.096, RSMo and the corresponding rules;

1. 4. The division has determined that the

applicant has the financial capacity to operate the facility;

1. 5. The division has verified that the

administrator of a residential care facility II, intermediate care facility or skilled nursing facility is currently licensed by the Missouri Board of Nursing Home Administrators under the provisions of Chapter 344, RSMo;

1. 6. The division has received the fee

required by subsection (1)(I) of this rule;

1. 7. The applicant meets the definition of

operator as defined by 13 CSR 15- 11.010(19);

1. 8. The applicant has received a

Certificate of Need, if required, or has received a determination from the Certificate of Need Program that no certificate is required, has completed construction, and is in substantial compliance with the licensure rules and laws;

1. 9. The division has determined that the

operator, owner or any principals in the operation of the facility have ever been convicted of an offense concerning the operation of a long-term care facility or other health care facility or, while acting in a management capacity, ever knowingly acted or knowingly failed to perform any duty which materially and adversely affected the health, safety, welfare or property of a resident;

1. 10. The division has determined that the

operator, owner or any principals in the operation of the facility are excluded from participation in the Title XVIII (Medicare) or Title XIX (Medicaid) program or any state or territory;

1. 11. The division has determined that the

operator, owner or any principals in the operation of the facility have ever been convicted of a felony in any state or federal court concerning conduct involving either management of a long-term care facility or the provision or receipt of health care services; and

1. 12. The division has determined that all

fees due the state have been paid.

1. (M) If, during the period in which a license is in effect, a change occurs which causes the statements in the application to no longer be correct, including change of administrator, or if any document is executed which replaces, succeeds or amends any of the documents filed with the application, within ten

1. (10) working days of the effective date of the change, the operator shall—

   1. 1. Submit a letter to the division that

contains a correction of the application with notification of the effective date of the change and a copy of any new documents. The operator must ensure the letter is accompanied by a notarized statement that the information being submitted is true and correct to the best of the operator’s knowledge and belief; or

1. 2. Submit to the division a correction of

the application and a copy of any new document by using MO Form 886-2609; entitled: Corrections for LTC Facility License Application.

1. (N) If from an analysis of financial information submitted with the application, or if from information obtained during the term of a license, the operator appears insolvent or a tendency toward insolvency, the division shall have the right to request additional financial information from the operator. Within ten

1. (10) working days after receiving a written request from the division, the operator shall—

   1. 1. Submit to the division the additional

information requested in a letter accompanied by a notarized statement that the information being submitted is true and correct to the best of the operator’s knowledge and belief; or

1. 2. Submit the financial information to

the division by using MO Form 886-2609.

1. (O) A license applicant’s financial information, data and records submitted to the division as required by this rule, including, but not limited to, copies of any Internal Revenue Service forms, shall be open for inspection and be released only—

   1. 1. To designated employees of the divi-

sion;

1. 2. To the applicant furnishing this infor-

mation or to his/her representative as designated in writing;

1. 3. To the director of the Department of

Social Services or to his/her representative as designated in writing;

1. 4. To the state auditor or his/her repre-

sentative as designated in writing;

1. 5. To appropriate committees of the gen-

eral assembly or their representatives as designated in writing;

1. 6. In any judicial or administrative pro-

ceeding brought under the Omnibus Nursing Home Act; or

1. 7. When so ordered by a court of com-

petent jurisdiction.

1. (P) To obtain a license for an additional level of care on the premises, the licensed operator shall submit a written request to the division for the issuance of a license for the desired level of care. The request shall indicate the level of care, the number of beds desired, the name and address of the facility, the name and address of the operator, and shall include the notarized signature of the operator. The licensure fee shall accompany this request. Requests are subject to division approval. The operator shall submit this request no less than sixty (60) days prior to the initiation date of the new level of care. The division shall coordinate this license’s expiration date with that of the original license and the division shall prorate the license fee accordingly.

2. (Q) To request issuance of an amended license or temporary operating permit currently in effect, the operator shall—

   1. 1. Submit a written request to the divi-

sion containing the request for amendment, the date the operator would like the amendment to be effective, and the number of the license or temporary operating permit to be amended; and

1. 2. Submit a fee for the issuance of the

amended license or temporary operating permit as required by subsection (1)(R) of this rule.

1. (R) If an operator initiates a request to amend a license or temporary operating permit currently in effect, the division requires the following fees:

   1. 1. If the request is for an increase in bed

capacity, the operator shall submit a fee with the request which is the greater of—

1. A. The amount that would have been

required by subsection (1)(I) of this rule if the increase in bed capacity has been included in the application, less any amount actually paid under that subsection; or

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

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

1. (S) The division shall approve all requests for bed changes prior to issuance of an amended license or temporary operating permit. The effective date of the amended license or temporary operating permit shall be no earlier than the date the division approved the request for bed change.
2. (T) If the division issues a temporary operating permit, and then issues a regular license later, the licensing period shall include the period of operation under the temporary operating permit. The licensing period shall also include any period during which the department was enjoined or stayed from revoking or denying a license or rendering the temporary operating permit null and void.
3. (U) Unless an operator indicates otherwise, all the rooms and space on the premises and all persons eighteen (18) years of age and over living on the premises shall be considered as part of the facility and its licensed capacity or staff and shall be subject to compliance with all rules governing the operation of a licensed facility. If an operator, when applying or reapplying for a license, wants to exclude some portion of the premises from being licensed or wants to exclude a relative as a resident, a notarized statement to that effect shall be filed as a separate document indicating the use which will be made of that area of the premises and who or what occupies the area, and what the relationship is of the relative(s) being excluded.
4. (V) The operator shall not provide care in any area on the premises to any related person who requires protective oversight unless there has been a written request to the division to consider any portion of the facility for private use and that indicates facility staff shall not be used at any time to care for the relative(s). Prior to the area being used in that manner, the operator shall submit the request for the division’s approval. The division, after investigation, shall approve or disapprove the request in writing within thirty

1. (30) days and shall issue or reissue the license indicating clearly which portion of the premises is excluded from licensure or which 13 CSR 15-10

specific relative(s) is/are not considered a resident(s).

1. (2) If a facility was licensed under Chapter 197 or 198, RSMo and was in operation before September 28, 1979, or if an application was on file or construction plans were approved prior to September 28, 1979, the facility shall comply with construction, fire safety and physical plant rules applicable to an existing or existing licensed facility provided there has been continuous operation of the facility under a license or temporary operating permit issued by the division. If, however, there was an interruption in the operation of the facility due to license denial, license revocation or voluntary closure, the facility may be relicensed utilizing the same fire safety, construction and physical plant rules that were applicable prior to the license denial, license revocation or voluntary closure; provided that the facility reapplies for a license within one (1) year of the date of the denial, revocation or voluntary closure.

   1. (A) If a facility changes from a skilled nursing or intermediate care facility to any other level, or if the facility changes from a residential care facility II to a residential care facility I, the facility shall comply with construction, fire safety and physical plant rules applicable to an existing or existing licensed facility as defined in 13 CSR 15-11.010(8).
   2. (B) If the facility changes from a residential care facility I to any other level or if a residential care facility II changes to an intermediate care or skilled nursing facility, the facility shall comply with construction, fire safety and physical plant rules applicable to a new or newly licensed facility as defined in 13 CSR 15-11.010(17).
   3. (C) The facility shall comply with the rules applicable to a new or newly licensed facility if an application for relicensure has not been filed with the Division of Aging within one
2. (1) year of the license denial, license revocation or voluntary closure.
3. (3) If a licensed facility discontinues operation as evidenced by the fact that no residents are in care or at any time the division is unable to freely gain entry into the facility to conduct an inspection, unless the facility operator has made special arrangements with the division for temporary closure, the facility shall be considered closed. The division shall notify the operator in writing requesting the voluntary surrender of the license. If the division does not receive the license within thirty (30) days, it shall be void. Later, if operation is to resume, the operator shall file a new application and fee and the provisions of section (1) shall apply.

4. (4) The division may grant exceptions for specified periods of time to any rule imposed by the division if the division has determined that the exception to the rule would not potentially jeopardize the health, safety or welfare of any residents of a long-term care facility.

   1. (A) The owner or operator of the facility shall make requests for exceptions in writing to the director of the division. These requests shall contain—

      1. 1. A copy of the latest Statement of

Deficiencies which indicates a violation of the rule being cited, if the exception request is being made as a result of a deficiency issued during an inspection of the facility;

1. 2. The section number and text of the

rule being cited;

1. 3. If applicable, specific reasons why

compliance with the rule would impose an undue hardship on the operator, including an estimate of any additional cost that might be involved;

1. 4. An explanation of any extenuating

factors that may be relevant; and

1. 5. A complete description of the indi-

vidual characteristics of the facility or residents, or of any other factors that would safeguard the health, safety and welfare of the residents if the exception were granted.

1. (B) With the advice of the division’s licensure inspection field staff, the division will consider any requests that contain all the information required in subsection (4)(A). The division shall notify the operator, in writing, of the decision on any request for an exception, stating the reason(s) for acceptance or denial, and, if granted, the length of time the exception is to be in effect and any additional corrective factors upon which acceptance may be conditioned.
2. (C) The division shall only grant exceptions to licensure requirements set out in rules imposed by the division and cannot grant exceptions to requirements established by state statute or federal regulations. Operators wishing to obtain waivers of regulations under Title XVIII or Title XIX of the Social Security Act shall follow procedures established by the Health Care Financing Administration (HCFA).

1. (5) When the division issues a notice of noncompliance to a facility pursuant to the Omnibus Nursing Home Act (section 198.026, RSMo), the division, only after affording the facility operator a reasonable opportunity to remedy the situation, shall—

   1. (A) Make every reasonable effort to provide residents of the facility or their responsible parties, if any—

      1. 1. A written notice of the noncompli-

ance;

1. 2. A list of other licensed facilities

appropriate to the resident’s needs; and

1. 3. A list of agencies that will assist the

resident if he/she moves from the facility; and

1. (B) After providing the information required by subsection (5)(A) and allowing a time period for the residents of the facility to relocate if they wish, notify the Social Security Administration in writing that a notice of noncompliance has been issued to the facility, and the effective date of the notice. If the facility achieves substantial compliance with standards and rules later, the division shall notify the Social Security Administration of the effective date of the facility’s substantial compliance.

1. (6) A licensed facility shall comply with the provisions of Title VI of the Civil Rights Act 1964, as amended; Section 504 of the Rehabilitation Act of 1973; Title IX of the Education Amendment of 1972; the Age Discrimination Act of 1975; the Omnibus Budget and Reconciliation Act of 1982; the Americans with Disabilities Act of 1990; and the Keyes Amendment to the Social Security Act. No person shall be denied admission to, be denied benefits of, or be subjected to discrimination under any program, activity or service provided by the facility based on his/her race, color, national origin, sex, religion, age or disability, including Human Immunodeficiency Virus (HIV) or Acquired Immunodeficiency Syndrome (AIDS). Every licensed facility shall complete and sign an Assurance of Compliance (MO Form 886- 3131) and file it with the Division of Aging. The facility shall submit the signed assurance form with the application for license or with the first application for relicensure submitted after December 31, 1998.

2. (7) The division’s central office in Jefferson City shall make available to interested individuals without charge a single copy of—

   1. (A) A complete set of the standards promulgated for each type of facility;
   2. (B) An explanation of the procedures used in the state to ensure the enforcement of standards;
   3. (C) A list of any facilities granted exception from a standard, including the justification for the exception; and
   4. (D) A list of any facilities issued notices of noncompliance, including the details of the noncompliance.
3. (8) Every skilled nursing facility, intermediate care facility and residential care facility issued a license or temporary operating permit by the division shall submit the required certificate of need quarterly surveys to the division on or before the fifteenth day of the first month following the previous Social Security quarter. (For example, for the Social Security quarter ending December 31, the due date is by January 15; for the Social Security quarter ending March 31, the due date is by April 15; for the Social Security quarter ending June 30, the due date is by July 15; and for the Social Security quarter ending September 30, the due date is by October 15). The information shall be submitted on the ICF/SNF Certificate of Need Quarterly Survey form or the RCF Certificate of Need Quarterly Survey form (MO Form 886-9001).

AUTHORITY: Executive Order 77-9 of the Governor filed Jan. 31, 1979, effective Sept. 28, 1979, Chapter 198, sections 207.020, 208.152, 251.070 and 536.023, RSMo 1994 and Supp. 1997.* Emergency rule filed Aug. 13, 1979, effective Oct. 1, 1979, expired Jan. 25, 1980. Original rule filed Aug. 13, 1979, effective Dec. 13, 1979. Emergency amendment filed Oct. 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, effective July 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, expired Dec. 25, 1992. Rescinded and readopted: Filed April 14, 1993, effective Oct. 10, 1993. Amended: Filed Feb. 13, 1998, effective Sept. 30, 1998.

*Original authority see Missouri Revised Statutes 1994 and Supp. 1997.