PURPOSE: This rule establishes the additional standards for those residential care facilities II which admit or continue to care for residents who are physically capable but mentally incapable of negotiating a pathway to safety due to Alzheimer’s disease or other dementia.

PUBLISHER’S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. Therefore, the material which is so incorporated is on file with the agency who filed this rule, and with the Office of the Secretary of State. Any interested person may view this material at either agency’s headquarters or the same will be made available at the Office of the Secretary of State at a cost not to exceed actual cost of copy reproduction. The entire text of the rule is printed here. This note refers only to the incorporated by reference material.

EDITOR’S NOTE: All rules relating to long-term care facilities licensed by the Division of Aging are followed by a Roman Numeral notation which refers to the class (either Class I, II or III) of standard as designated in section 198.085.1, RSMo.

1. (1) Definitions. For the purposes of this rule, the following definitions shall apply:

   1. (A) Activities of daily living (ADLs) mean a resident’s ability to eat, bathe, toilet, dress, transfer and ambulate.
   2. (B) Chemical restraint means a psychopharmacologic drug that is used for discipline or convenience and is not required to treat medical symptoms.
   3. (C) Convenience means any action taken by the facility to control resident behavior or maintain residents with a lesser amount of effort by the facility and not in the resident’s best interests.
   4. (D) Discipline means any action taken by the facility for the purpose of punishing or penalizing residents.
   5. (E) Individual service plan means the planning document which outlines and describes the services to be provided and the outcomes expected in order to meet the resident’s needs.

   6. (F) Licensed professional means any of the following:

      1. 1. Physician, as defined in and licensed

under the provisions of Chapter 334, RSMo; 19 CSR 30-86

1. 2. Nurse, as defined in and licensed

under the provisions of Chapter 335, RSMo;

1. 3. Psychologist, as defined in and

licensed under the provisions of Chapter 337, RSMo;

1. 4. Professional counselor, as defined in

and licensed under the provisions of Chapter 337, RSMo; and

1. 5. Clinical social worker, as defined in

and licensed under the provisions of Chapter 337, RSMo.

1. (G) Physical restraint means any physically applied method, or mechanical device which the resident cannot easily remove, that restricts the free movement or normal functioning of any portion of the resident’s body, or the resident’s normal access to common areas and his or her personal spaces.
2. (H) Resident, only for the purpose of this rule, means an individual who is mentally incapable of negotiating a pathway to safety due to Alzheimer’s disease or other dementia, who is admitted to or continues to be cared for in the facility under the provisions of this rule.
3. (I) Significant change means any change in the resident’s physical, emotional or psychosocial condition or behavior that would require an adjustment or modification in the resident’s treatment or services.

1. (2) General Requirements.

   1. (A) A residential care facility II which admits or continues to care for persons who have been diagnosed with Alzheimer’s disease or other dementia who are physically capable but mentally incapable of negotiating a pathway to safety with the use of assistive devices or aids when necessary, shall not care for such residents unless:

      1. 1. The resident has been diagnosed with

Alzheimer’s disease or other dementia by a physician licensed to practice medicine; and

1. 2. The facility is able to provide appro-

priate services for and meet the needs of the resident. I/II

1. (B) A residential care facility II may admit or continue to care for residents who have been diagnosed with Alzheimer’s disease or other dementia if the residents are physically capable but mentally incapable of negotiating a pathway to safety with the use of assistive devices or aids when necessary, providing the facility is in substantial compliance with the provisions of Chapter 198, RSMo and all regulations under which the facility is licensed by the Division of Aging. I/II
2. (C) A residential care facility II which admits or continues to care for persons who have been diagnosed with Alzheimer’s disease or other dementia who are physically capable but mentally incapable of negotiating SENIOR SERVICES

a pathway to safety with the use of assistive devices or aids when necessary, shall comply with the provisions of the Alzheimer’s Special Care Disclosure Act pursuant to sections 198.500 to 198.515, RSMo. The facility shall complete, and submit to the Division of Aging, an Alzheimer’s Special Care Services Disclosure form (MO Form 886-3548), which is incorporated by reference in this rule. II

1. (D) A residential care facility II which admits or continues to care for persons who have been diagnosed with Alzheimer’s disease or other dementia who are physically capable but mentally incapable of negotiating a pathway to safety with the use of assistive devices or aids when necessary, shall not admit, retain or continue to care for any resident who is mentally incapable of negotiating a pathway to safety with the use of assistive devices or aids who:

   1. 1. Has exhibited behaviors which indi-

cate that the resident is a danger to self or others;

1. 2. Is at constant risk of elopement and,

despite repeated interventions which have not altered the resident’s behavior, continues to be a danger to self;

1. 3. Requires physical or chemical

restraint as defined in this rule;

1. 4. Requires skilled nursing services as

defined in section 198.006(17), RSMo for which the facility is not licensed or able to provide;

1. 5. Requires more than one person to

simultaneously provide physical assistance to the resident with any activity of daily living, with the exception of bathing; or

1. 6. Is bed-bound or chair-bound and is

unable to ambulate due to a debilitating or chronic condition. I/II

1. (3) Physical Design and Fire Safety Requirements.

   1. (A) The facility shall be equipped with a complete sprinkler system installed and maintained in accordance with the 1996 edition of the National Fire Protection Association (NFPA) 13, Standard for the Installation of Sprinkler Systems, or the 1996 edition of NFPA 13R, Sprinkler Systems in Residential Occupancies Up To and Including Four Stories in Height, which are incorporated by reference in this rule. I/II
   2. (B) The facility shall be equipped with a complete electrically supervised fire alarm system in accordance with the provisions of the 1997 Life Safety Code for Existing Health Care Occupancy, incorporated by reference in this rule. The system shall include smoke detectors located no more than thirty feet (30') apart in corridors with no point in the corridor located more than fifteen feet (15') from a smoke detector. The fire alarm system shall be equipped to automatically transmit an alarm to the fire department. I/II
   3. (C) Each floor used for resident bedrooms shall be divided into at least two (2) smoke sections by one (1)-hour rated smoke stop partitions. No smoke section shall exceed one hundred fifty feet (150') in length. If, however, neither the length nor width of a floor exceeds seventy-five feet (75'), no smoke stop partitions are required. Openings in smoke stop partitions shall be protected by one and three-fourths inches (1 3/4")-thick solid core wood doors or metal doors with an equivalent fire rating. The doors shall be equipped with closers and magnetic hold-open devices. Any duct passing through this smoke wall shall be equipped with automatic resetting smoke dampers that are activated by the fire alarm system. Smoke partitions shall extend from outside wall-to-outside wall and from floor-to-floor or floor-to-roof deck. II
   4. (D) In a multilevel facility, residents who are mentally incapable of negotiating a pathway to safety shall be housed only on a ground floor. The ground floor shall be any floor that has at least one exit at grade. All other required exits shall be at grade, or with no more than two steps to grade, or with a ramp to grade. The ramp shall have a maximum slope of one to twelve (1:12) leading to grade. II
   5. (E) When a resident resides among the entire general population of the facility, the facility shall take necessary measures to provide such residents with the opportunity to explore the facility and, if appropriate, its grounds. When a resident resides within a designated, separated area that is secured by limited access, the facility shall take necessary measures to provide such residents with the opportunity to explore the separated area and, if appropriate, its grounds. If enclosed or fenced courtyards are provided, residents shall have reasonable access to such courtyards. Enclosed or fenced courtyards that are accessible through a required exit door shall be large enough to provide an area of refuge for fire safety at least thirty feet (30') from the building. Enclosed or fenced courtyards that are accessible through a door other than a required exit shall have no size requirements. II
   6. (F) The facility shall provide freedom of movement for the residents to common areas and to their personal spaces. The facility shall not lock residents out of or inside their rooms. I/II
   7. (G) The facility may allow resident room doors to be locked providing the residents request to lock their doors. Any lock on a resident room door shall not require the use of a key, tool, special knowledge or effort to lock or unlock the door from inside the resident’s room. Only one (1) lock shall be permitted on each door. The facility shall ensure that facility staff have the means or mechanisms necessary to open resident room doors in case of an emergency. I/II
   8. (H) Every facility shall use a personal electronic monitoring device for any resident whose physician recommends the use of such device. II

   9. (I) The facility may provide a designated, separated area where residents, who are mentally incapable of negotiating a pathway to safety, reside and receive services and which is secured by limited access if the following conditions are met:

      1. 1. Dining rooms, living rooms, activity

rooms, and other such common areas shall be provided within the designated, separated area. The total area for common areas within the designated, separated area shall be equal to at least forty (40) square feet per resident; II/III

1. 2. Doors separating the designated, sep-

arated area from the remainder of the facility or building shall not be equipped with locks that require a key to open; I/II

1. 3. If locking devices are used on exit

doors egressing the facility or on doors accessing the designated, separated area, delayed egress magnetic locks shall be used. These delayed egress devices shall comply with the following:

1. A. The lock must unlock when the

fire alarm is activated;

1. B. The lock must unlock when the

power fails;

1. C. The lock must unlock within thir-

ty (30) seconds after the release device has been pushed for at least three (3) seconds, and an alarm must sound adjacent to the door;

1. D. The lock must be manually reset

and cannot automatically reset; and

1. E. A sign shall be posted on the door

that reads: PUSH UNTIL ALARM SOUNDS, DOOR CAN BE OPENED IN 30 SECONDS. I/II

1. 4. The delayed egress magnetic locks

may also be released by a key pad located adjacent to the door for routine use by staff. I/II

1. (4) Staffing Requirements.

   1. (A) The facility shall be staffed twenty-four (24) hours a day by the adequate number and type of personnel necessary for the proper care of residents and upkeep of the facility in accordance with the staffing requirements found in 13 CSR 15-15.042. In meeting such staffing requirements, every resident who is mentally incapable of negotiating a pathway to safety shall count as three

2. (3) residents. I/II

   1. (B) All on-duty staff of the facility shall, at all times, be awake, dressed in on-duty work attire, and prepared to assist residents in case of emergency. I/II

3. (5) Assessments and Individual Service Plans.

   1. (A) Prior to admitting or continuing to care for a resident diagnosed with Alzheimer’s disease or other dementia, a family member or legal representative of the resident, in consultation with the resident’s primary physician, shall meet with a facility representative to determine if the facility can meet the needs of the resident. The facility shall document the decisions regarding admission or continued placement in the facility through written verification by the family member, physician and the facility representative. II
   2. (B) After consultation, if the facility admits or continues to care for the resident, a Minimum Data Set (MDS) assessment shall be completed on an MDS form provided by the Division of Aging to assess the needs of each resident who is mentally incapable of negotiating a pathway to safety. II/III

   3. (C) Each resident shall be assessed by a licensed professional, as defined in subsection (1)(F) of this rule, by use of the MDS:

      1. 1. Within ten (10) days of admission;

and

1. 2. Every one hundred eighty (180) days

thereafter; or

1. 3. Whenever a significant change occurs

in the resident’s condition as defined in subsection (1)(I) of this rule. I/II

1. (D) Based on the MDS assessment, an interdisciplinary team shall develop an individual service plan for each resident who is mentally incapable of negotiating a pathway to safety. Whenever possible and appropriate, the resident, family members or other individuals instrumental in identifying the needs of, or providing treatment or services to, the resident shall be involved in the development or revision of the individual service plan. Every individual service plan shall be signed by each person participating in its development. II/III
2. (E) An individual service plan shall be completed and implemented within twenty

1. (20) days after the completion of an MDS assessment of a resident. I/II

   1. (F) An individual service plan shall describe the resident’s needs and preferences, the specific methods and services to meet those needs, desired outcomes or interventions, and the names of the staff, service provider, and if applicable, family members who are primarily responsible for implementing the individual service plan. At a minimum, the individual service plan for each resident shall identify:

      1. 1. The resident’s capabilities, strengths,

potential, preferences and customary behaviors;

1. 2. The resident’s behavioral, medical

and social needs based on the assessment;

1. 3. The services provided to meet the

needs of the resident;

1. 4. The expected outcomes of the ser-

vices provided; and

1. 5. Staff or other persons responsible for

providing the services to meet the needs of the resident. II/III

1. (G) The facility shall make each resident’s individual service plan available for use to all persons providing services to that resident. II/III

1. (6) Staff Training and Orientation.

   1. (A) All facility personnel who provide direct care to residents who are mentally incapable of negotiating a pathway to safety shall receive at least twenty-four (24) hours of training within the first thirty (30) days of employment.

      1. 1. At least twelve (12) hours of the twen-

ty-four (24) hours of training shall be classroom instructions; and

1. 2. Six (6) classroom instruction hours

and two (2) on-the-job training hours shall be related to the special needs, care and safety of residents with dementia. II

1. (B) The in-service training requirements for personnel in a facility that provides services for residents who are mentally incapable of negotiating a pathway to safety, shall be determined as follows:

   1. 1. If the residents reside among the

entire general population of the facility, all facility personnel, whether or not such personnel provide direct care to these residents, shall receive at least four (4) hours of in-service training on a quarterly basis, with at least two (2) such hours relating to the care and safety of residents who are mentally incapable of negotiating a pathway to safety; or

1. 2. If the residents reside within a desig-

nated, separated area that is secured by limited access, those personnel who have or could have contact with these residents, shall receive at least four (4) hours of in-service training on a quarterly basis, with at least two (2) such hours relating to the care and safety of residents who are mentally incapable of negotiating a pathway to safety. II

1. (C) Any training related to the special needs, treatment and safety of residents with 19 CSR 30-86

dementia shall include, but not be limited to, the following:

1. 1. An overview of Alzheimer’s disease

and other dementia;

1. 2. Communication techniques which are

effective in enhancing and maintaining communication skills for residents with dementia;

1. 3. Components of or techniques for cre-

ating a safe, secure and socially oriented environment for residents with dementia;

1. 4. Provision of structure, stability and a

sense of routine for residents based on their needs;

1. 5. Effective management of different or

difficult behaviors; and

1. 6. Issues involving families and care

givers. II/III

1. (D) The initial twenty-four (24) hours of training required within the first thirty (30) days of employment shall include, at a minimum, all of the components in subsection (6)(C) of this rule. II
2. (E) The in-service training to be provided on a quarterly basis shall include at least four

1. (4) hours of in-service training, with at least two (2) such hours relating to the care and safety of residents who are mentally incapable of negotiating a pathway to safety. Each component listed in subsection (6)(C) of this rule must be included over the course of each twelve (12)-month period. II

   1. (F) All in-service or orientation training relating to the special needs, care and safety of residents who are mentally incapable of negotiating a pathway to safety shall be conducted, presented or provided by a training instructor who is qualified by education, experience or knowledge in the care of individuals with Alzheimer’s disease or other dementia. II/III

2. (7) Programs and Services for Residents Who are Mentally Incapable of Negotiating a Pathway to Safety.

   1. (A) Each facility shall make available and implement self-care, productive and leisure activity programs for persons with dementia which maximize and encourage the resident’s optimal functional ability. The facility shall provide activities that are appropriate to the resident’s individual needs, preferences, background and culture. Individual or group activity programs may consist of the following:

      1. 1. Gross motor activities, such as exer-

cise, dancing, gardening, cooking and chores;

1. 2. Self-care activities, such as dressing,

grooming and personal hygiene;

1. 3. Social and leisure activities, such as

games, music and reminiscing; SENIOR SERVICES

1. 4. Sensory enhancement activities, such

as auditory, olfactory, visual and tactile stimulation;

1. 5. Outdoor activities, such as walking

and field trips;

1. 6. Creative arts; or
2. 7. Other social, leisure or therapeutic

activities that encourage mental and physical stimulation or enhance the resident’s well-being. II/III

1. (B) The facility shall develop and implement written policies and procedures which address, at a minimum:

   1. 1. The facility’s admission, transfer and

discharge criteria taking into account the individual’s needs and the facility’s ability to meet those needs;

1. 2. The basic services provided or

offered to residents with Alzheimer’s disease or other dementia;

1. 3. The procedures and actions to be

taken in the event of resident elopement;

1. 4. The development and implementation

of individual service plans;

1. 5. The assignment of staff to residents

based on the resident’s needs which minimize resident confusion and maintain familiarity with environment;

1. 6. Staff orientation and in-service train-

ing relating to the special needs, care and safety of residents with dementia;

1. 7. Fire drill and emergency evacuation

procedures for residents who are mentally incapable of negotiating a pathway to safety; and

1. 8. The protection of the rights, privacy

and safety of residents and the prevention of financial exploitation of residents. II/III

AUTHORITY: section 198.073, RSMo 2000.* This rule originally filed as 13 CSR 15- 15.045. Emergency rule filed Dec. 14, 2000, effective Jan. 2, 2001, expired June 30, 2001. Original rule filed Dec. 14, 2000, effective June 30, 2001. Moved to 19 CSR 30-86.045, effective Aug. 28, 2001. *Original authority: 198.073; RSMo 1979, amended 1984, 1992, 1999.