[A PDF [http://aspe.hhs.gov/daltcp/reports/2007/07alcomMO.pdf] of only this state's summary also available]
Residential care facilities: Missouri revised statutes §198.003 et. seq.; Missouri code of regulations, Title 19 §30-82, 83, 84, 86, 87 and 88
General Approach and Recent Developments
Legislation (SB 616) passed in 2006 changed the name and requirements for two types of facilities: ALFs and RCFs. New regulations implementing the bill were effective April 30, 2007. The legislation also directed the Department of Health and Senior Services to develop a new tiered payment methodology under the Medicaid state plan. The Department is preparing an HCBS waiver application to cover services in ALFs.
Legislation passed in 2007 (SB 952 and SB 674) requires facilities licensed or completing major renovations after August 28, 2007 to install a sprinkler system. Facilities that serve individuals who cannot evacuate the facility with minimal assistance must have a sprinkler system. A loan fund to install sprinklers was created to help facilities that serve Medicaid beneficiaries.
The licensing agency posts statements of deficiencies on their website. The statements are included in a searchable data base of licensed facilities.
Adult Foster Care
The Department of Health and Senior Services does not regulate homes serving one or two individuals.
|http://www.sos.mo.gov/adrules/csr/current/19csr/19c30-84.pdf||Training for nursing assistant rules|
|http://www.sos.mo.gov/adrules/csr/current/19csr/19c30-86.pdf||Physical plan and other rules|
|http://www.sos.mo.gov/adrules/csr/current/19csr/19c30-88.pdf||Resident rights rules|
|http://www.dhss.mo.gov/showmelongtermcare/longtermcare.html||List, survey results|
|http://www.dhss.mo.gov/NursingHomes/580-2637.pdf||Special care disclosure form|
|Residential care facility*||502||15,661||RCF I 280||6,363||285||6,533|
|Assisted living facility*||114||5,505||RCF II 364||15,434||363||15,106|
|* NOTE: 242 of the 502 RCFs meet the licensing requirements for RCF II in effect prior to the August 28, 2006 effective date of the new legislation. Thirty-one of the 114 ALFs meet the licensing requirements that allow these facilities to admit and retain a resident who requires more than minimal assistance to evacuate the facility.|
Nursing Home Admission Policy
Individuals must have:
- Limitations in three or more ADLs, and require medical treatment or observation;
- Limitations in three or more ADLs, and one or more risk factors;
- Limitations in three or more ADLs, and one or more cognition factors;
- Limitations in one or more ADLs, and one or more cognition factors, and one or more risk factors.
ADLs include bathing, continence, dressing/grooming, eating, mobility, toileting, and transferring. There are three areas of risk factors: behavior, frailty, and safety. Behavior is the ability to act on one's own behalf, including interest or motivation to eat, take medications, care for one's self, participate in social situations and relate to others in a socially appropriate manner. Frailty means the ability to function independently without the presence of a support person. Safety is the availability of adequate housing, including the need for modification or adaptive equipment to assure safety and accessibility; the existence of formal and/or informal supports; and/or the freedom from abuse or neglect. Cognition factors address memory, orientation, communication, and judgment.
Services are to be provided in accordance with resident agreements which maximize resident dignity, autonomy, privacy, and independence. Services include personal care, assistance with ADLs, health maintenance activities, transportation, laundry, housekeeping, financial assistance/ management, behavioral management, case management, shopping, beauty/barber, spiritual services, and activities. Health maintenance activities are defined as non-complex nursing interventions which can safely be performed according to exact directions, which do not require alteration of the standard procedure, and for which the results and resident responses are predictable.
Outcomes in three areas (physical well-being, behavioral/emotional well-being, and consumer satisfaction) are listed that measure whether resident care is being provided in accordance with the resident’s preferences and needs. Each facility must develop and implement a process to measure consumer satisfaction.
Facilities must ensure that daily nutritional needs are met, including special diets ordered by a physician. Written menus must be based on the Food Guide Pyramid, or equivalent, and modified to accommodate special diets. Residents must be monitored for potential nutritional problems by recording weight at admission and if a potential problem is identified, weights are recorded quarterly with follow-up to address or rectify weight gains/losses greater than 7.5% in three months or 10% in six months.
An agreement must be negotiated that delineates the services to be provided to meet the resident’s needs as identified during an evaluation. The agreement includes the services provided by the facility and other sources, and how often, when and by whom they will be delivered in order to meet the needs of residents, including those with special needs. Services may not exceed room, board, ADLs, personal care, health maintenance and other supportive services, or those that involve complex nursing interventions allowed by rule. The agreement also specifies the rights and responsibilities of the facility and residents; the costs of services and terms of payment; and the terms and conditions of continued occupancy. The agreement must be reviewed and updated as the resident’s needs change.
Provisions for Serving People with Dementia
Facilities serving special populations must identify resident abilities and special needs; provide staff trained to meet the identified needs; prepare and implement a resident agreement that addresses the special needs; and provide a physical environment that accommodates the needs. Direct care staff have training in the unit’s philosophy and approaches to providing care; the Alzheimer’s disease process; and the skills needed to care for, intervene with, and direct residents.
Facilities must file a disclosure form with the licensing agency that describes: the overall philosophy and mission which reflects the needs of residents afflicted with Alzheimer's disease, dementia, or a related disorder; the process and criteria for placement in, transfer to, or discharge from the unit; the process used for assessment and establishment of the plan of care and its implementation, including the method by which the plan of care evolves and is responsive to changes in condition; staff training and continuing education practices; the physical environment and design features appropriate to support the functioning of cognitively impaired adult residents; the frequency and types of resident activities; the involvement of families and the availability of family support programs; and the costs of care and any additional fees.
Each ALF that specializes in providing care for persons who have Alzheimer’s disease, dementia or a related disorder must provide care and services in accordance with the resident service agreement and the stated mission and philosophy of the facility. Prior to admission the facility must inform the resident in writing of the facility’s criteria for admission, discharge, transfer, resident conduct and responsibilities and maintain a sufficient number of direct care staff with appropriate training and skills to meet the residents’ needs. Staff must remain awake at all times. Facilities may not admit or retain a resident who poses a danger to self or others or requires complex nursing interventions.
Medications may be administered by licensed staff or certified medication aides. Facilities must establish policies to assure that aides demonstrate minimum competency to administer medications and to describe how direction and monitoring will be done based on the route of administration (oral, inhalation, topical, installation, or other routes) and for PRN medications.
Facilities must allow residents to self-administer medications, with or without supervision, when an assessment determines the resident is capable of doing so. Residents who self-administer medications must be at least 19 years of age; have cognitive capacity to make informed decisions about taking medications; be physically able to take or apply a dose of medicine; have the capability or capacity to take the medication as prescribed; and have the capability or capacity to observe and take appropriate action regarding any desired effects, side effects, interactions, and contraindications.
Medications may be stored in the resident’s room if the resident keeps the room locked when not present, or the medications are stored in a secure location or locked container.
Each ALF must provide for a RN to review medication administration policies and procedures and to provide or oversee the training of medication aides. Facility training must cover the procedures for storing, handling and providing medications; facility procedures for documentation of medications; facility procedures for documentation and reporting medication errors and adverse reactions; identification of person(s) responsible for direction and monitoring of medication aides; and other resident-specific training on providing medications in accordance with the limits and conditions of the Medication Aide Act.
A Medicaid HCBS waiver was implemented in July 1998. Waiver assisted living services are available to elders and people with disabilities. The state uses a flat rate system that varies for urban/rural facilities, trust fund facilities and single/double occupancy (see table below). The Assisted Living Waiver Standard of Need is $623 from which beneficiaries retain a PNA of $60 and $563 is paid for room and board. Family supplementation for a larger unit is not allowed.
Conversion facilities under the state’s Nursing Facility Conversion Program only receive 95% of the Medicaid service rate. Under this program, the Medicaid payment for services for single occupancy in rural areas is $1,481, and $1,747 in urban areas. Total rates for services and room and board in rural areas is $2,044, and $2,310 in urban areas. The rates include an amount for room and board paid by the resident ($563).
|Nebraska Payment Rates for Assisted Living Facilities (2007)|
|Rural Areas||Urban Areas|
|Single Occupancy||Double Occupancy||Single Occupancy||Double Occupancy|
|Room & board||$563||$563||$563||$563|
|Nebraska Payment Rates for Nursing Facility Conversion Program Facilities (2007)|
|Rural Areas||Urban Areas|
|Single Occupancy||Double Occupancy||Single Occupancy||Double Occupancy|
|Room & board||$563||$563||$563||$563|
A program providing grants or loan guarantees to nursing homes to convert wings or entire facilities was is in the completion phase. The state awarded three rounds of funding, totaling $53 million, for assisted living and money for respite and day care facilities. Awards were made to 74 nursing homes to convert beds to assisted living, including nursing homes that provide a combination of assisted living, ADC services, and respite. Five nursing homes provide ADC services only. The state-funded 967 new assisted living units and de-licensed more an equivalent number of nursing home beds. The state saved an estimated $5.5 million in annual Medicaid program savings.
Grantees must agree to maintain specified occupancy levels of Medicaid beneficiaries for a period of ten years. Grants may cover capital or one-time costs and operating losses for the first year to facilities that have participated in the Medicaid program for at least three years. Non-governmental owned facilities must provide 20% of the cost of conversion. Under the program, facilities may convert existing space or construct additional space to include assisted living or other alternative services. Construction of a new ALF may be funded if the nursing home beds are de-licensed and the construction is more cost effective than conversion of existing space.
The facility must maintain a sufficient number of staff with the required training and skills necessary to meet the resident population’s requirements for personal care, ADLs, health maintenance activities, supervision, and other supportive services.
The facility must have at least one staff person on site at all times when necessary to meet the needs of the residents as required in the resident service agreements.
Administrator. After January 1, 2005, administrators must have completed at least 30 hours of training on topics such as: resident care and services; social services; financial management; administration; gerontology; and the rules, regulations, and standards relating to the operation of an ALF. These requirements do not apply if the administrator holds an active nursing home administrator’s license. Administrators must have 12 hours of on-going training related to care and facility management of the population served.
Staff. Orientation must be given within two weeks to each direct-care staff person of the facility and shall include as a minimum, but is not limited to: residents’ rights; resident service agreement; infection control practices; emergency procedures and information regarding advance directives; information on special care needs; information on abuse, neglect, and misappropriation of money or property of a resident; and disaster plan preparedness.
On-going training must be given to each direct-care staff person and shall consist of at least 12 hours per year on topics appropriate to the employee’s job duties including meeting the physical and mental special care needs of residents.
Criminal background and sex offender registry checks must be completed on all direct care staff. Evidence of contact with the nurse aide registry, adult central registry of abuse and neglect, and the child central registry of abuse and neglect must be obtained to verify no adverse findings concerning abuse, neglect, or misappropriation of resident property. Facilities determine how to use the information in making hiring decisions except that a person with adverse findings on the nurse aide registry may not be employed as a direct care staff. The facility must document the reasons for hiring a person with adverse findings in the background or registry checks.
Additionally, each facility must establish and implement policies and procedures regarding the health status of staff to prevent the transmission of disease to residents. A health history screening of each staff person must be completed prior to assuming job responsibilities. A physical examination is at the discretion of the employer based on results of the health history screening.
The Department may conduct an on-site inspection at any time it deems necessary. Each year a 25% random sample of the licensed facilities is selected for inspection, or more often due to cause or lack of selection over five years.
When an inspection reveals violations that create an imminent danger of death or serious physical harm or have a direct or immediate adverse effect on the health, safety, or security of residents, the Department must impose disciplinary action. The state then conducts a follow-up inspection within 90 days. For violations that do not constitute imminent danger, the Department may request a statement of compliance from the facility. If the statement of compliance fails to address the problem(s), the Department may initiate disciplinary action against the facility.
The Department provides education on the regulations during on-site reviews and participates with state assisted living associations to provide education at conferences.
Facilities may use the peer review organization to facilitate disputes of survey citations.
$950 for 1-10 beds; $1,450 for 11-20 beds; $1,650 for 21-50 beds; and $1,950 for 51 or more beds.
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