PURPOSE: This rule establishes the minimum requirements for operating an adult day care program and providing care to participants.

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) The adult day care provider shall neither knowingly admit, nor continue to care for, participants whose needs cannot be met by the program directly or in cooperation with outside resources.
2. (2) Each provider shall have a written emergency medical plan which assures transportation to a hospital or other type of facility providing emergency care. A written agreement, signed by each participant or legal guardian, shall be on file in the facility granting permission to transport the participant in need of emergency care to the designated hospital or other type of facility. Notes in the participant’s record shall be made immediately of any accident, injury or illness and emergency procedures taken. Emergency telephone numbers for each participant shall be available to staff at all times. At least one (1) staff member certified in first aid and cardiopulmonary resuscitation (CPR) shall be on the premises at all times that participants are present. Certification in first aid shall be renewed every three (3) years and certification in CPR shall be renewed annually. First-aid training shall be taken from the American Red Cross or from another comparable source. At a minimum, those first-aid supplies recommended by the Red Cross in Standard First Aid and Personal Safety shall be readily available.
3. (3) The provider shall require a medical assessment by the participant’s physician of the participant’s medical condition to include activity needs and restrictions, dietary modifications, indicated therapies and medication as applicable prior to the first day of participation, signed by the physician within five (5) working days of the first day of participation.
4. (4) The provider shall develop a written individual plan of care for each participant within five (5) contact days following the entry of the participant into the adult day care program. The plan shall be designed to maintain the participant at, or to restore to, optimal capability for self-care. The plan shall be based on a functional assessment and information obtained from the participant, participant’s family, physician and the person or agency referring the participant. The plan shall address the participant’s physical, social and psychological needs, goals and means of goal accomplishment to the degree that the program is designed and the staff is qualified to meet these goals. The plan shall identify names of persons responsible for specific, individualized activities provided for the participant that are not documented by the regularly scheduled plan of activities for the program. The plan of care shall identify the participant’s regularly scheduled days for attendance, including arrival and departure times. The plan of care shall be revised as frequently as warranted by the participant’s condition, but shall be reviewed at least every six (6) months and updated as necessary.
5. (5) The director, or a designated staff person, shall maintain communication with participants and their families or other responsible persons to solve day-to-day problems which confront the participants. Referrals to other community resources should be made and services coordinated as needed.
6. (6) Participants who are responsible for taking their own medication at home shall be permitted and encouraged to continue to be responsible for taking their own medication during the hours spent in the center. If a participant is unable to self-administer medication, then the adult day care provider may assume responsibility in accordance with 13 CSR 15-8.050(10)(D) of this rule.
7. (7) There shall be a safe, effective system of handling and storing participants’ medications.
8. (8) The provider shall report any suspected incidents of physical or mental abuse, neglect, exploitation, or a combination of these, of its participants to the Elderly Abuse Hotline (1-800-392-0210).

9. (9) The adult day care provider shall offer at least the following services:

   1. (A) Activities of Daily Living. The adult day care program shall provide assistance and training in walking, toileting, feeding, personal care and other activities of daily living in accordance with each participant’s individual plan of care;
   2. (B) Planned Group Activities. The adult day care program shall provide planned activities during at least fifty percent (50%) of the time that the program is open for daily operation, with a maximum four (4) hours of planned activities required. Activities shall be suited to the needs and interests of participants and designed to stimulate interest, rekindle motivation and encourage physical exercise. Activities shall be conducted individually and in small and large groups. Planned activities include meals, rest periods, exercise, recreation and social activities. Physical exercise shall be designed in relation to each individual’s needs, impairments and abilities and shall be alternated with rest periods or quiet activities. In an associated program some, but not all, activities may be conducted cooperatively with the residents or participants of the other program;
   3. (C) Food Service. The adult day care program shall assure the availability of meals and supplemental snacks in accordance with each participant’s individual plan of care. Meals served by the provider shall provide at least one-third (1/3) of the recommended dietary allowance of the National Research Council. Supplemental snacks shall consist of nourishing food and beverages. Food may be prepared, stored, served, or any combination of these, on-site if the requirements of the local health department or applicable rule established by the Missouri Department of Health (19 CSR 20-1.010) are met. Food prepared away from the site shall be prepared in a facility which meets the requirements of the local health department or applicable rules established by the Missouri Department of Health (19 CSR 20-1.010). The provider shall arrange for special diets and other diet modifications as ordered by a physician. Diets shall be served as ordered by the participant’s physician and food preparation and service shall be reviewed by a qualified dietitian, physician or nurse at least every six (6) months. Modified diets shall be in effect for the specified number of days indicated in the physician’s order. If no time is specified, the period may not exceed one (1) calendar year when another order from the physician shall be obtained; and
   4. (D) Observation. The health, functional and psychosocial status of each participant shall be observed and documented in the participant’s record at least monthly by the adult day care program director or other designated professional staff.

10. (10) The adult day care provider may offer the following services:

    1. (A) Transportation. If transportation services are offered, directly or contracted for, they shall meet the requirements of 13 CSR 15-6.165;
    2. (B) Counseling Services. If counseling services are offered, they shall be provided by qualified professional personnel;
    3. (C) Rehabilitation Services. If rehabilitation services are offered, they shall be prescribed by a physician and performed by qualified therapists. Orders for the various therapies and treatments shall be in effect for the specified number of days indicated by the physician’s written order. If no time period is specified, then the time period shall not exceed sixty (60) days and a new order by the physician must be obtained. Therapy services provided shall be summarized in the participant’s record and progress noted at least monthly by the therapist;

    4. (D) Medical Services. If medical services are offered, a licensed nurse shall be available at all times that the program is in operation. Medical services shall be provided in accordance with the particular needs of each participant. The licensed nurse shall be the only individual authorized to receive, control and manage the medication and drug program. The licensed nurse shall be responsible for the following:

       1. 1. Administration of medications and

treatments, including the following requirements:

1. A. Medications or treatments may not

be administered without an order signed by a licensed physician. Physician’s phone orders may be taken only by a licensed nurse. Phone orders shall be written into the participant’s record by the licensed nurse receiving them and shall be signed by that person. The physician shall sign and date the order within five (5) working days after giving the phone order;

1. B. Orders concerning treatments and

medications shall be in effect for a specified number of days as indicated by the physician. If not specified, the period may not exceed sixty (60) days;

1. C. The licensed nurse shall communi-

cate as indicated with the participant’s physician to report observed changes in health status, including reaction to medications and treatments. If an adverse reaction to medications, treatments or diet is observed, the participant’s physician shall be called immediately. If contact cannot be made with the personal physician, emergency medical procedures shall be followed; and

1. D. All medications, including over-

the-counter medications, shall be packaged and labeled in accordance with applicable professional pharmacy standards, state and federal drug laws and regulations and the United States Pharmacopeia (USP) labeling shall include accessory and cautionary instructions as well as the expiration date, when applicable and the name of the medication as specified in the physician’s order. Over-the-counter medications for individual participants shall be labeled with at least the participant’s name; and

1. 2. Medication storage and records. The

provider shall have a safe, secure, locked placed for storing medications or drugs and make them available to the participant according to the instructions of his/her personal physician. Schedule II drugs (chapter 197, RSMo and 19 CSR 30-1.010) shall be kept in a locked box. Medications requiring refrigeration shall be kept refrigerated in a locked room or in a separate locked refrigerator or in a locked box within the refrigerator or in a refrigerator in a locked room. Nonprescription medicines may be retained in the facility for administration as ordered by the participant’s physician. The system for administering and storing medications shall be reviewed not less than every three (3) months by a licensed nurse. A written record of medications administered shall be maintained. Records shall be kept of all Schedule II drugs.

AUTHORITY: sections 660.050, RSMo Supp. 1992 and 660.418, RSMo 1986. This rule originally filed as 13 CSR 15-8.050. Original rule filed Oct. 15, 1984, effective Jan. 11, 1985. Moved to 19 CSR 30-90.050, effective Aug. 28, 2001. *Original authority: 660.050, RSMo 1984, amended 1988, 1992 and 660.418, RSMo 1984.