PURPOSE: This rule establishes standards for the administration, nursing staff and overall operation of long-term care units in hospitals to provide a high level of care.

1. (1) Requests for deviations from the requirements of this rule shall be in writing to the Department of Health. Approvals for deviations shall be in writing and both requests and approvals shall be made a part of the permanent Department of Health records for a facility.
2. (2) Swing beds located in the acute part of a hospital which may be used intermittently for long-term care are exempt from the requirements of this rule.

3. (3) Administration.

   1. (A) A long-term care unit shall be licensed as part of the hospital in which it is located or attached. The hospital governing body shall be the legal authority for the long-term care unit and shall be responsible for the overall planning, directing, control and management of the activities and functions of the longterm care unit.
   2. (B) The administration of the long-term care unit shall be the responsibility of the chief executive officer of the hospital. This authority may be delegated to a qualified 19 CSR 30-20

assistant in accordance with the governing body bylaws of the hospital.

1. (C) Visiting Hours.

   1. 1. Regular daily visiting hours shall be

established and posted.

1. 2. Relatives or guardians and clergy, if

requested by the resident or family, shall be allowed to see critically-ill residents at any time in keeping with the orders of the physician.

1. (D) Medical records shall comply with 19 CSR 30-20.021(3)(D). All medical orders shall be renewed at least monthly.
2. (E) If the minimum staffing as required in sections (5)–(7) of this rule does not meet the needs of the residents, the Department of Health shall inform the administrator, in writing, how many additional personnel are needed and of what type and shall give the basis for this determination.
3. (F) All residents shall have a comprehensive, accurate, standardized assessment completed within fourteen (14) days of admission. The assessment is to be completed utilizing the resident assessment instrument developed by the Health Care Financing Administration for use in long-term care facilities. The instrument includes a uniform minimum data set (MDS) of care screening and assessment elements, common definitions for these elements and utilization guidelines. The assessment shall be documented on the MDS and shall include applicable resident assessment protocols. An assessment shall become the basis for the care and treatment to be provided.

1. (4) Nursing Assistant Orientation.

   1. (A) The chief executive officer of the hospital shall assure that individuals who are newly employed as nursing assistants in the long-term care unit receive an in-service orientation. At a minimum, the orientation shall include an explanation of: the organizational structure of the long-term care unit, the unit’s policies and procedures, the unit’s philosophy of care, a description of the resident population, job responsibilities and employee rules, information on communicable diseases, infection control procedures, resident rights and emergency protocols. The hours of orientation may be applied to the nursing assistant training course if conducted in accordance with 13 CSR 15-13.010(6)(B).
   2. (B) New employees of long-term care units who are nursing assistant trainees shall be allowed to provide direct nursing care to residents only if they have received training and have demonstrated competency with regard to the specific care being provided. A licensed nurse shall be responsible for verifying the SENIOR SERVICES

competency and for documenting this in the trainee’s personnel file. The in-service orientation program shall be supervised by a licensed nurse who is on duty in the unit at the time the orientation is provided.

1. (C) Nursing assistant trainees shall be clearly identified so that residents, family members, visitors and staff are aware that they are in training.

1. (5) Competency Evaluation of Nursing Assistants. The chief executive officer of the hospital shall be responsible for assuring that all nursing assistants who were employed and trained as nursing assistants before July 1, 1989 complete a competency evaluation program before January 1, 1990.

2. (6) Training and Competency Evaluation Program.

   1. (A) The chief executive officer of the hospital shall be responsible for assuring that all nursing assistants employed in the long-term care unit after July 1, 1989 shall have completed or will complete the training and competency evaluation program.
   2. (B) Individuals may be employed as nursing assistant trainees in a long-term care unit in order to complete the nursing assistant training and competency evaluation program. This period of training cannot exceed four (4) months from the date of employment.

3. (7) Orientation In-Service Training and Continuing Education.

   1. (A) The chief executive officer of the hospital shall assure the development of an inservice orientation and continuing education program offered by qualified instructors for the development of all personnel in the longterm care unit that is appropriate to their job functions. Orientation for all new personnel shall begin the first day of employment in the long-term care unit and shall cover, at a minimum, prevention and control of infection and hospital policies and procedures, including emergency protocol, job responsibilities, lines of authority, confidentiality of patient information, resident’s rights and preservation of patient dignity.
   2. (B) The continuing education program for nursing assistants shall focus on basic nursing skills, personal care skills, mental health and social service needs and basic restorative services.
4. (8) Training Record. Written records of the employee’s training shall be maintained in the employee’s personnel file.

5. (9) Medical Care.

   1. (A) Medical care in long-term care units shall be under the direction of a physician member of the medical staff and appointed by the governing body.
   2. (B) Each resident shall have the privilege of selecting his/her own physician consistent with hospital medical staff bylaws.
   3. (C) Each resident shall be visited by the attending physician as often as medically necessary but no less than every sixty (60) days.
   4. (D) There shall be a mechanism for the review and evaluation on a regular basis of the quality and appropriateness of medical care in the long-term care unit.

6. (10) Skilled Nursing Unit.

   1. (A) A skilled nursing unit as defined in 19 CSR 30-20.040(10) shall have a registered nurse on duty eight (8) hours a day and seven

7. (7) days a week.

   1. (B) The nursing service administrator shall be responsible for the quality of nursing care supervision of personnel providing nursing care and for a program of in-service education for nursing personnel.
   2. (C) Skilled nursing units shall employ nursing personnel in sufficient numbers and sufficiently qualified to meet the needs of the residents. Exclusive of supervisory staff, the minimum ratio of nursing staff engaged in direct patient care and treatment to residents shall be as follows:

   Time Ratio of Staff to Residents*

7 a.m. to 3 p.m. 1 staff person for each 10 resi-

1. (day) dents plus 1 additional staff person for any remainder of 6 or more residents 3 p.m. to 11 p.m. 1 staff person for each 15 resi- (evening) dents plus 1 additional staff person for any remainder of 8 or more residents 11 p.m. to 7 a.m. 1 staff person for each 20 resi- (night) dents plus 1 additional staff person for any remainder of 11 or more residents. *The number of residents is based on occupied beds.
2. (D) On the day shift there shall be a registered nurse on duty; on both evening and night shifts there shall be a licensed practical nurse or a registered nurse on duty.
3. (E) A registered nurse shall be available in the hospital to assist during the time a licensed practical nurse is in charge.
4. (F) In a multi-story facility, at least one (1) direct-care staff person shall be on duty at all times for each occupied floor.
5. (G) All skilled nursing units shall comply with subsections (11)(G)–(I) of this rule.

1. (11) Intermediate Care Unit.

   1. (A) An intermediate care unit as defined in 19 CSR 30-20.040(2) shall have either a registered nurse or a licensed practical nurse in charge of the unit.
   2. (B) When the person in charge is a licensed practical nurse, a registered nurse shall be available in the hospital for the supervision of patient care.
   3. (C) A licensed nurse shall be available in the hospital for assistance to the unit twentyfour (24) hours a day, seven (7) days a week.
   4. (D) The minimum ratios of staff engaged in direct patient care, exclusive of supervisory staff, shall be the minimum ratios required in subsection (5)(C) of this rule.
   5. (E) One (1) of the nursing personnel on the day shift shall be a licensed nurse.
   6. (F) In a multi-story facility, at least one (1) direct-care staff shall be on duty at all times on each occupied floor.
   7. (G) All medications shall be administered by a licensed nurse or physician.
   8. (H) A physical examination by a physician shall be completed and recorded on the clinical record of each resident, preferably before admission, but not later than seven (7) days after admission, unless the resident is accompanied on admission from a hospital or other long-term care unit by a record of a physical examination completed within the past six (6) months. Physical examinations shall be performed at least annually.
   9. (I) The unit shall not knowingly admit or continue to care for residents whose needs cannot be met by the unit directly or in cooperation with community resources or other providers of care with which it is affiliated or has contracts. Seriously disturbed mentallyill residents shall not be admitted or retained unless the unit can provide the care the resident needs. Provision shall be made for the care of residents with a communicable disease either in the hospital or in a suitable room in the unit. Infection control policies and procedures shall be followed.

2. (12) Residential Care Units.

   1. (A) Policies and procedures shall be written to include at least medications, medical treatment and outside privileges.
   2. (B) Nursing personnel shall have access to the legal name of each resident and the name and telephone number of each resident’s physician and next of kin or responsible party in the event of emergency.
   3. (C) At least one (1) staff person at least eighteen (18) years of age shall be on duty at all times.
   4. (D) There shall be one (1) licensed nurse on duty at least (8) hours per week for every thirty (30) residents plus one (1) additional licensed nurse on duty at least eight (8) hours per week for any remainder of sixteen (16) or more residents.
   5. (E) Only ambulatory residents shall be admitted to the residential care unit.
   6. (F) Those residents who require the use of a walker or wheelchair shall be housed on a floor which has direct exit at grade or which has a ramp with a slope not greater than one to twelve (1:12) leading to grade or which has no more than two (2) steps to grade. The steps shall have a handrail. Those residents who use a wheelchair shall be able to reach the equipment unassisted and demonstrate the ability to transfer to and from a wheelchair without assistance.

3. (13) Resident’s Rights and Grievance Procedures for Long-Term Care Units.

   1. (A) A complete copy of each official notification from the Department of Health of violations, deficiencies, licensure approvals, disapprovals and responses shall be retained and made available at the unit for inspection when requested by staff, residents, families or legal representatives of the residents and the public.
   2. (B) Each resident shall be informed of his/her rights and responsibilities as a resident and of all rules governing resident conduct and responsibilities. A copy of all the information shall be posted in a conspicuous location in the facility and copies shall be available to anyone requesting the information. Prior to or at the time of admission, a copy of the information shall be provided to each resident or his/her designee, next of kin or legal guardian.
   3. (C) Each resident shall be informed in writing, prior to or at the time of admission and during his/her stay, of services available in the unit and of related charges, including any charges for services not covered under the federal or state programs or not covered by the facility’s per-diem rate.
   4. (D) Each resident shall be informed by a physician of his/her health and medical condition unless medically contraindicated (as documented by a physician in the resident’s record); shall be given the opportunity to participate in the planning of his/her total care and medical treatment and to refuse treatment; and shall participate in experimental research only upon his/her informed written consent.
   5. (E) Each resident shall be transferred or discharged only for medical reasons, for his/her welfare or that of other residents or for nonpayment for his/her stay.
   6. (F) Each resident shall be encouraged and assisted, throughout his/her period of stay, to exercise his/her rights as a resident and as a citizen and to this end may voice grievances and recommend changes in policies and services to facility staff or to outside representatives of his/her choice and shall be free from restraint, interference, coercion, discrimination or reprisal.
   7. (G) Each resident may manage his/her personal financial affairs and, to the extent that the facility assists in the management, may have his/her personal financial affairs managed in accordance with section (9) of this rule.
   8. (H) No resident shall be mentally or physically abused. Each resident shall be free from chemical and physical restraints except when the restraints are authorized in writing by a physician for a specific period of time or when the restraints are necessary in an emergency to protect the resident from injury to him/herself or others. In an emergency, physical restraints may be authorized by a registered nurse. This action shall be reported promptly to a physician, always within twenty-four (24) hours.
   9. (I) Each resident shall be assured confidential treatment of all information contained in his/her records, including information contained in an automatic data bank; his/her written consent shall be required for the release of information to persons not otherwise authorized under law to receive it.
   10. (J) Each resident shall be treated with consideration, respect and full recognition of his/her dignity and individuality, including privacy in treatment and in care for his/her personal needs.
   11. (K) No resident shall be required to perform services for the unit that are not included for therapeutic purposes in the plan of care.
   12. (L) Each resident may communicate, associate and meet privately with persons of his/her choice, unless to do so would infringe upon the rights of other residents. Each resident may send and receive his/her personal mail unopened.
   13. (M) Each resident may participate in activities of social, religious and community groups at his/her discretion, unless contraindicated for reasons documented by a physician in the resident’s medical record.
   14. (N) Each resident may retain and use his/her personal clothing and possessions as space permits.
   15. (O) If married, a resident shall be insured privacy for visits by his/her other spouse; if both are residents in the facility, they shall be permitted to share a room unless medically contraindicated.
   16. (P) Each resident shall be allowed to purchase or rent any goods or services not included in the per-diem or monthly rate as 19 CSR 30-20

long as the quality and delivery of those goods or services conform with policies and procedures of the hospital.

1. (14) Personal Funds and Property of Residents.

   1. (A) No hospital shall be required to hold any personal funds or money in trust unless some other governmental agency placing residents in the facility makes this requirement.
   2. (B) Authorizations by the resident, his/her designee or legal guardian for the hospital to use the personal funds of the resident shall be in writing and kept with the resident’s record or with the personal funds account.
   3. (C) When a resident is admitted, s/he and his/her next of kin or legal guardian shall be provided with a statement explaining the resident’s rights regarding personal funds.
   4. (D) Resident’s personal funds that are held in trust shall be kept separate from the hospital funds.
   5. (E) There shall be a written account for each resident showing receipts to and disbursements from the personal funds of each resident.
   6. (F) A written statement of all receipts and disbursements showing the current balance shall be given on a quarterly basis to the resident, his/her designee or legal guardian.
   7. (G) When personal funds and possessions held in trust by the hospital are returned to the resident or his/her designee or guardian before or after the resident’s discharge, the resident or his/her designee or guardian shall give the hospital a receipt for the funds and possessions returned.
   8. (H) There is no duty on the part of the hospital to invest a resident’s funds held in trust or to increase the principal.
   9. (I) Any owner, manager, employee or affiliate of an owner who receives any personal property or anything else with a value of ten dollars ($10) or more from a resident shall give the resident a written statement giving the date it was received, from whom it was received and its estimated value.
   10. (J) No owner, manager, employee or affiliate of an owner, in one (1) calendar year, shall receive any personal property or anything else with a total value exceeding one hundred dollars ($100) from a resident of any facility. This does not apply to bequests.
   11. (K) The recordkeeping and other requirements of section (14) of this rule apply only to those personal possessions and funds which the facility accepts to hold in trust for the resident and does not apply to other possessions residents have in their rooms or bring into the facility. SENIOR SERVICES

AUTHORITY: sections 192.005.2 and 197.080, RSMo 1986.* This rule was previously filed as 13 CSR 50-20.050 and 19 CSR 10-20.050. Original rule filed Nov. 29, 1982, effective March 11, 1983. Amended: Filed May 31, 1989, effective Aug. 24, 1989. Amended: Filed July 12, 1991, effective Feb. 6, 1992. *Original authority: 192.005.2, RSMo 1985 and 197.080, RSMo 1953.