PURPOSE: This rule sets forth definitions and standards for nursing facilities to follow if care is being provided exclusively for persons under twenty-one years of age.

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.

1. (1) Definitions.

   1. (A) Child, any individual under eighteen

2. (18) years of age or in the custody of the Division of Family Services.

   1. (B) Certified child life specialist, a trained and experienced individual as defined by the Association for the Care of Children’s Health.
   2. (C) Food service supervisor, an individual who has successfully completed a course and who has had supervised experience in food service preparation.
   3. (D) Interdisciplinary team, qualified health professionals such as physicians, nurses, rehabilitation therapists, activity and social workers, dietitians and educators who can identify a child’s physical, medical, psychosocial functioning and educational needs, and who can, through appropriate interventions, maintain or improve a child’s medical status, functional abilities, psychosocial or educational status.
   4. (E) Pediatric nursing facility, a skilled nursing facility licensed under Chapter 198, RSMo, which serves only persons under the age of twenty-one (21).
   5. (F) Qualified activity worker, an individual who is a therapeutic recreational therapist who is eligible for registration as a therapeutic recreation specialist by the National Therapeutic Recreation Society.
   6. (G) Staff/resident ratio, the number of direct care nursing staff required in relation to the number of residents in the facility.
   7. (H) Qualified dietitian, an individual who is registered by the American Dietetic Association or who is eligible for registration.
   8. (I) Qualified social worker, an individual who has a master’s degree in social work from a college or university accredited by the Council on Social Work Education.
3. (2) If a long-term care facility wants to specialize in the care of children, the facility shall be licensed as a skilled nursing facility by the Division of Aging and shall meet all the requirements for a skilled nursing facility, unless otherwise indicated in this rule.

4. (3) In addition to meeting the requirements of 13 CSR 15-14.032, the facility shall meet the following requirements related to the physical environment:

   1. (A) Window/clear glass doors in areas where residents are active shall be of shatterproof glass and marked in varying heights to avoid impact; II
   2. (B) Windows shall be securely screened and protected using barriers to prevent residents from falling from open windows; II
   3. (C) Electrical outlets in the residents’ rooms shall be safety-protected and made tamper-resistant; II
   4. (D) Each resident shall be provided with his/her own bed which is appropriate in size for his/her age, height and weight; II and
   5. (E) Separate sleeping rooms shall be provided for boys and girls five (5) years of age or older. II/III

5. (4) In addition to meeting the requirements of 13 CSR 15-14.042, as applicable, the facility shall—

   1. (A) Develop a philosophy or mission statement which shall be posted in a conspicuous location and which shall state the beliefs upon which the facility operates; II/III
   2. (B) Provide orientation and continuing education for the facility’s personnel appropriate to the problems, needs and care of individuals under twenty-one (21) years of age; II/III
   3. (C) Complete an assessment of tuberculosis status on all persons working or volunteering on a regular basis in the facility, which shall be done, with the report on file, before the person assumes his/her work duties in the facility; II/III
   4. (D) Develop and implement policies and procedures applicable to the facility and its 19 CSR 30-89

operation to assure the health, safety and welfare of children and to meet individual needs. There shall be policies covering abuse/ neglect reporting, children’s rights, restraint usage, discipline and control methods, preventative health measures, maintenance of education/schooling and age appropriate recreation and activity programs; II/III

1. (E) Employ personnel in sufficient numbers and sufficiently qualified to meet the needs of residents at all times. I/II The direct care nursing staff ratio to residents per shift shall be—

   Nursing Residents

Days 1 5 Evenings 1 7 Nights 1 10

1. (F) Assess each resident’s physical, mental and psychosocial needs. A written assessment shall be completed by the appropriate interdisciplinary team members within four (4) days of admission of a resident to the facility; II/III
2. (G) Develop a written plan of care based on the assessment information within seven

1. (7) days of the completion of the assessment. The plan of care shall identify the resident’s problems, needs, interventions, goals, time frames and discipline(s) responsible for achieving each outcome; II/III

   1. (H) Provide direct medically related social services to the pediatric resident. A qualified social worker shall be capable of identifying the problems which have negatively affected his/her development, behavior and social functioning and be knowledgeable of methods and/or resources to meet the specialized needs of the pediatric resident; II/III
   2. (I) Provide age appropriate recreational activities planned by a qualified activity worker. The qualified activity worker shall develop, coordinate and provide a recreation and activity program to meet the specialized needs of the pediatric resident; II/III and
   3. (J) Maintain and coordinate with a resident’s school system, where applicable, and provide a coordinated educational approach to meet the educational needs of each school age resident. II/III
2. (5) In addition to meeting the dietary requirements of 13 CSR 15-14.052(1), as applicable, each resident shall receive food which meets the daily specialized dietary needs of the resident in accordance with the physician’s order. II/III
3. (6) A qualified dietitian shall be employed by the facility as a consultant to assure the specialized needs of the pediatric resident are being met. II/III SENIOR SERVICES

4. (7) For residents eighteen to twenty-one (18–21) years of age, the facility shall meet the requirements set forth in 13 CSR 15- 18.010 and 13 CSR 15-18.020. For children under the age of eighteen (18) years of age, the facility shall assure the following children’s rights:

   1. (A) The facility shall retain a list of names, addresses and occupations of all individuals who have a property interest in the facility as well as a complete copy of each official notification from the Division of Aging of violations, deficiencies, licensure approval and/or disapprovals and responses. This list is available to facility personnel, the child’s legal representative, the resident if fourteen (14) years of age or older and the general public. This includes, at a minimum, statements of deficiencies, copies of a plan(s) of correction, acceptance or rejection notices regarding the plan(s) of corrections and revisit inspection reports; II/III
   2. (B) Any notice of noncompliance shall be posted in a conspicuous location along with a copy of the most recent inspection reports, as required by sections 198.026 and 198.029, RSMo; II/III
   3. (C) A copy of the most current Division of Aging rules governing the facility shall be kept available and easily accessible in the facility for review by the child’s legal guardian, the resident if fourteen (14) years or older and the public; II/III
   4. (D) Each child admitted to the facility shall have his/her legal guardian informed of the child’s responsibilities as a resident and all facility rules governing the child’s conduct and responsibilities. If a resident is fourteen

5. (14) years of age or older, the facility shall also inform the resident of all the rules governing conduct and responsibilities; II/III

   1. (E) Each resident fourteen (14) years of age or older and every child’s legal guardian shall be provided with a statement of children’s rights along with rules governing conduct and responsibilities in a manner which effectively communicates, in terms the resident and legal guardian reasonably can be expected to understand those rights and responsibilities; II/III
   2. (F) The facility shall document the disclosure of children’s rights information to the child’s legal guardian and the resident, if required; III
   3. (G) Information regarding children’s rights and facility rules shall be posted in a conspicuous location in the facility and copies shall be provided to anyone requesting this information; III
   4. (H) Prior to or at the time of admission and during the child’s stay in the facility, each child’s legal guardian shall be fully informed in writing, of services available in the facility and of related charges, including any charges for services not covered by the facility’s basic per-diem rate or federal or state programs. Information shall include procedures which will be followed by the facility in cases of medical emergency, including transfer agreements and costs. The child’s legal guardian shall also be informed of services outside the facility which may reasonably be made available to the resident; II/III
   5. (I) Each child’s legal guardian and the resident, if appropriate, based on age and mental capacity, shall be afforded the opportunity to participate in the planning of the resident’s total care and medical treatment, to refuse treatment, and to participate in experimental research only upon informed written consent. If the resident’s legal guardian refuses treatment, this refusal shall be documented in the resident’s record and the resident’s legal guardian shall be informed of possible consequences of the child not receiving treatment. The Division of Aging shall be notified if a guardian refuses treatment of a child; II
   6. (J) Each child’s legal guardian shall have the privilege of selecting for the child a physician who will be responsible for his/her total care; II
   7. (K) An advance notice of thirty (30) days shall be given to the child’s legal guardian regarding the involuntary transfer from the facility or discharge, except in an emergency situation as defined in section 198.006(6), RSMo. Room transfer within the facility, except in an emergency situation, requires consultation with the child’s legal guardian and the resident, if fourteen (14) years of age or older, as far ahead of time as possible and shall not be permitted where the transfer would result in any detriment to the resident’s physical, mental or emotional condition; II/III
   8. (L) If a resident is transferred or discharged, there shall be documentation in the resident’s medical record stating the reason(s) why. If resident is to transferred or discharged for the welfare of other residents, the facility shall have first informed the child’s legal guardian and the resident, if fourteen
6. (14) years of age or older, of the applicable rules and how the conduct of the child or legal guardian represents a threat to the health or welfare of the other residents. The child or guardian shall be given at least two

7. (2) week to change the disruptive behavior. III

   1. (M) If the resident is transferred or discharged from the facility, a reasonable effort shall be made to arrange for service to assure continuity of care in meeting the resident’s needs through other resources: II/III
   2. (N) Each resident shall be encourage and assisted, throughout his/her period of stay, to exercise his/her rights as a resident. A child’s legal guardian and the resident, if fourteen

8. (14) years of age or older, shall be free to voice grievances and recommend changes in policies and services to facility personnel or to outside representatives of his/her choice, such as an ombudsman or to any person outside the institution. A staff person shall be designated to receive grievances and the resident’s legal guardian and residents shall be free to voice their complaints and recommendations to the staff designee. Legal guardians and residents shall be informed of and provided a viable format for recommending changes in policy and services; II/III

   1. (O) Each resident who exercises his/her rights, or whose guardian exercises those rights, shall be free from restraint, interference, coercion, discrimination or reprisal; II/III
   2. (P) Residents all be free from mental and physical abuse. I
   3. (Q) Each resident shall be free from chemical and physical restraints except when authorized in writing by a physician for specified periods of time. All instances of physical or chemical restraint usage shall be documented in the residents’ medical record, indicating the behavior or condition necessitating the restraint, how long it is anticipated to be necessary and what alternatives were explored; I/II
   4. (R) A physical restraint may be used when necessary in an emergency to protect the resident from injury to him/herself or others, if authorized by the administrator, licensed nurse or the operator. The action taken shall be reported immediately to the resident’s physician and an order obtained which shall include the length of time the restraint may be used, the type of restraint and what course of action to take. The order shall be signed by the physician and placed in the resident’s record within seven (7) days. II/III
   5. (S) All information contained in a resident’s medical, personal or financial record and information concerning sources of payment shall be held confidential. Facility personnel shall not discuss aspects of the resident’s record of care in front of persons not involved in the resident’s care, other residents, families or legal guardians. Written consent of the child’s legal guardian shall be required for the release of information to persons not otherwise authorized by law to receive it; II/III
   6. (T) Each resident shall be treated with consideration, respect and full recognition of his/her dignity and individuality, including privacy in treatment and care of his/her personal needs. All persons, other than the attending physician, the facility personnel necessary for any treatment or personal care, or the Division of Aging or Department of Mental Health staff, as appropriate, shall be excluded from observing the resident during and time of examination, treatment or care unless consent has been given by the child’s legal guardian; II/III
   7. (U) Residents shall not be required to perform services for the facility. A resident if s/he desires and it is not contraindicated by his/her physician, may perform tasks or services for his/herself or others; II/III
   8. (V) Residents shall be permitted to retain and use personal possessions as space permits. Personal possessions may include furniture and decorations as approved by the facility. The facility shall maintain a record of any personal items accompanying the resident upon admission to the facility, or which are brought to the resident during his/her stay in the facility, which are to be returned to the child or responsible party upon discharge, transfer or death; II/III
   9. (W) Each child’s legal guardian shall be allowed the option of purchasing or renting goods or services not included in the perdiem or monthly rate from a supplier of his/her own choice, provided the quality of goods or services meets the reasonable standards of the facility. Freedom of choice of pharmacy shall be permitted provided the facility’s policy and procedures for packaging specifications are met; II/III and
   10. (X) Residents shall not have their personal lives regulated or controlled beyond reasonable adherence to meal schedules and other written policies which may be necessary for the orderly management of the facility and the personal safety of the residents. II

AUTHORITY: sections 198.009 and 198.079,* RSMo 1986. This rule originally filed as 13 CSR 15-20.010. Original rule filed Nov. 2, 1990, effective April 29, 1991. Moved to 19 CSR 30-89.010, effective Aug. 28, 2001.

*Original authority: 198.009, RSMo 1979, amended 1993, 1995; 198.079, RSMo 1979.