PURPOSE: This rule prescribes requirements for personnel employed in certain community residential facilities as required by section 630.710, RSMo.

1. (1) Each residential facility shall have a chief administrative officer referred to in these rules as the head of the facility. The head of the facility shall—

   1. (A) Be empowered to make decisions regarding the operation of the facility; and
   2. (B) Delegate a capable person who is empowered to act for him/her when absent from the facility.
2. (2) The head of the facility shall report any change in the ownership, management or administration to the department within five
3. (5) days.
4. (3) The head of the facility shall provide business and personal references and shall cooperate with regional center staff in a study of his/her qualifications to manage a community residential facility.
5. (4) At the time of employment and annually after that, all personnel including physical therapists, occupational therapists and volunteers who have frequent (regularly scheduled at least once per week) and direct contact with residents and any member of the household shall have a statement from their physician stating they have been screened for signs and symptoms of contagious diseases. The physician’s statement shall indicate the specific communicable diseases for which the person has been tested.
6. (5) Any employee diagnosed or suspected of having a contagious or infectious disease shall not work directly with residents or food service until a written statement is obtained from a physician that the disease is no longer contagious or is found to be noninfectious.
7. (6) The facility shall give each employee a written job description.
8. (7) The facility shall keep job descriptions for all positions on file.

9. (8) Each facility shall have as a minimum a daily direct care staff to resident ratio as follows, unless program needs or client needs justify otherwise:

   1. (A) For facilities serving children under the age of six (6) years, residents who are severely and profoundly retarded, severely physically disabled or residents who are aggressive, assaultive or security risks, or who manifest severely hyperactive behavior—

      1. 1. One to four (1:4) on the first shift;
      2. 2. One to four (1:4) on the second shift;

and

1. 3. One to eight (1:8) on the third shift;

2. (B) For facilities serving residents who are moderately mentally retarded requiring habit training—

   1. 1. One to sixteen (1:16) on the first

shift;

1. 2. One to eight (1:8) on the second

shift; and

1. 3. One to sixteen (1:16) on the third

shift;

1. (C) For facilities serving residents in vocational training programs and adults who work in sheltered employment situations-

   1. 1. One to thirty-two (1:32) on the first

shift;

1. 2. One to sixteen (1:16) on the second

shift; and

1. 3. One to thirty-two (1:32) on the third

shift;

1. (D) For purposes of this section, shifts are defined as follows:

   1. 1. First shift—approximately 7:00 a.m.

to 3:00 p.m.;

1. 2. Second shift—approximately 3:00

p.m. to 11:00 p.m.; and

1. 3. Third shift—approximately 11:00

p.m. to 7:00 a.m.;

1. (E) The staff/resident ratios are minimum staff requirements and an increase in residents above the maximum allowed in the staff/resident ratio shall require additional staff;
2. (F) Staff required under this section shall be dressed and awake at night as required by residents’ needs and the size of the facility;
3. (G) When residents are absent from the facility, staffing levels may be proportionately reduced;
4. (H) If all residents are absent from the facility, staff are required to be available to the residents for emergencies;

5. (I) Program needs or resident needs may justify alternate staffing levels based on the following considerations:

   1. 1. The physical layout of the facility;
   2. 2. If residents are awake and active at

night;

1. 3. If there are any residents who are

blind or deaf;

1. 4. Qualifications of the staff;
2. 5. The number of individual goals and

objectives for the residents;

1. 6. Obvious indications that staff is

unable to meet the needs of residents being served or is unable to meet minimum housekeeping; and maintenance rules, or both; and

1. 7. The availability of backup staff; and
2. (J) A resident may be at home without the presence of staff, for a specific period of time, if it is documented in the individualized habilitation plan (IHP) or individualized treatment plan (ITP) that the resident has the necessary knowledge and skills to function safely.

1. (9) All staff responsible for direct care of residents shall be eighteen (18) years of age or older.
2. (10) In addition to direct care staff, there shall be sufficient personnel to provide basic services such as food service, housekeeping, laundry and plant maintenance. Volunteers shall not be considered in the computation of adequate staff.
3. (11) A facility which accepts residents in need of considerable nursing care shall employ a registered nurse (RN). Considerable nursing care may include, but not be limited to, injections, inhalation thera- 9 CSR 40-5

py, intravenous fluids, suctioning, ostomy irrigation, lesion dressing, aseptic dressing, catheter irrigation, care for pressure sores and physiotherapy.

1. (A) The RN shall be designated the nurse in charge and shall—

   1. 1. Be responsible for twenty-four (24)-

hour nursing care of residents and the maintenance of medical records and nursing records;

1. 2. Share responsibilities with the head of

the facility and attending physician’s responsibility for drug control procedures, environmental health, safety and dietary procedures;

1. 3. Be on call when licensed practical

nurses (LPNs) are on duty; and

1. 4. Have an LPN on duty when the

licensed RN is not present at the facility, except that LPNs are not required if staff on the night shift are trained in emergency medical procedures and medications administration.

1. (B) The required RN may be hired on a consultant basis if—

   1. 1. The needs of the residents do not

require his/her presence at the facility; and

1. 2. S/he assumes the responsibilities out-

lined under paragraphs (11)(A)1. and 2. of this rule.

1. (12) All staff administering medications shall have successfully completed a course on medication administration. This training shall be updated every two (2) years. The initial training and biennial update shall—

   1. (A) Be approved by the regional center or placement office;
   2. (B) Be offered by an instructor who is a LPN certified by the Division of Aging as an instructor, a RN, a pharmacist or a physician;
   3. (C) Not apply to LPNs, RNs or certified medication technicians with lifetime certificates; and
   4. (D) Be documented in the recipient’s personnel file.

2. (13) The course to update training in medication administration shall address at least the following:

   1. (A) Review of Basics.

      1. 1. Medication ordering and storage.

      2. 2. Medication administration.

         1. A. Use of generic drugs.
         2. B. How to pour, chart, administer and

document.

1. C. Information and techniques specif-

ic to the following: inhalers, eye drops, topical medications, insulin injections and suppositories.

1. D. Infection control.
2. 3. Individual rights and refusal of med-

ications and treatment;

1. (B) Issues specific to the facility/program as indicated by the needs of the residents/clients, and the medications and treatments currently being administered.

   1. 1. Emergency response.
   2. 2. Medication allergies.
   3. 3. Corrective actions based on problems

identified by the staff, the trainees or issues identified by regulatory and accrediting bodies, professional consultants or by any other authoritative source; and

1. (C) Updates on new medications or new procedures.

1. (14) Each facility shall make arrangements with a physician and dentist, licensed in the state where the care is provided, to assume overall responsibility for medical and dental care. There shall be provisions for a relief physician.
2. (15) If residents require teaching of dining skills or assistance in eating, the facility shall have adequate staff to meet these needs and to assure that each resident receives an adequate amount of food.
3. (16) The facility shall have sufficient backup staff to provide services to residents and to meet licensing staffing requirements at all times.
4. (17) On initial application, before a final license is granted, the head of the facility and staff designated by the department shall attend an initial training session designed by the department.
5. (18) The head of the facility and staff designated by the department shall attend continuing education provided by the department as required. This training may be obtained through the department or, with prior approval from other sources in the community. Records of attendance shall be kept in the facility’s personnel files and by the department.
6. (19) Each facility shall provide a staff training program that includes orientation for all new employees to acquaint them with the philosophy, organization, program, practices and goals of the facility.
7. (20) All facility staff shall be knowledgeable about the facility’s policies and procedures.
8. (21) Staff shall be trained in the use of cardiopulmonary resuscitation (CPR) and firstaid so that at least one (1) person with these skills is on duty at all times. Depending on the configuration of the building and the number of residents, more than one (1) trained staff person per shift may be required. The training and periodic reviews shall be in accordance with the guidelines of the American Red Cross, the American Heart Association, the National Safety Council, or other nationally recognized training organization.

AUTHORITY: sections 630.050 and 630.705, RSMo (1994).* Emergency rule filed Sept. 20, 1983, effective Oct. 1, 1983, expired Jan. 15, 1984. Original rule filed Oct. 13, 1983, effective Jan. 15, 1984. Amended: Filed March 14, 1984, effective Aug. 15, 1984. Amended: Filed July 15, 1985, effective Feb. 1, 1986. Amended: Filed Jan. 2, 1990, effective June 11, 1990. Amended: Filed April 1, 1993, effective Dec. 9, 1993. Amended: Filed July 17, 1995, effective March 30, 1996. *Original authority: 630.050, RSMo (1980), amended 1993, 1995 and 630.705, RSMo (1980), amended 1982, 1984, 1985, 1990.