Residential care facilities: Missouri revised statutes §198.003 et. seq.; Missouri code of regulations, Title 19 § 30-86.012 et seq.; Title 19 §30-88
General Approach and Recent Developments
The Department of Health and Senior Services licenses two levels of residential care facilities. Revisions to the regulations will be submitted to the Board of Health in June. Developed through consultation with a task force, the revisions will address fire safety and evacuation of residents, residential care and administrator requirements. Final rules should be promulgated by the fall. Incidents of assaultive and dangerous behavior have increased as facilities serve more clients of the Departments of Mental Health and Corrections, which are being addressed by the revised rules. Prescription drug issues have also increased as facilities serve more residents with mental health needs and frailer elderly residents using multiple medications. Supply has declined slightly as new construction replaces smaller and older facilities.
Legislation passed in 2003 requiring that protective oversight be available 24 hours a day and includes procedures to ask residents who leave the facility about their whereabouts and expected time of return. The law makes operation of an unlicensed facility a Class D felony if abuse or neglect occurs, requires that all claims of neglect or abuse be investigated within 24 hours, and maintenance of a complaint log.
|Residential care facility I||280||6,363||285||6,533||313||7,030|
|Residential care facility II||364||15,434||363||15,106||364||15,405|
The State covers services in residential care facilities under the Medicaid state plan rather than an HCBS waiver.
Residential care facility I (RCF I) means any premises--other than a residential care facility II, intermediate care facility, or skilled nursing facility--which is utilized by its owner, operator, or manager to provide 24-hour care to three or more residents; who are not related within the fourth degree of consanguinity or affinity to the owner, operator, or manager of the facility; and who need or are provided with shelter, board, and with protective oversight, which may include storage and distribution or administration of medications and care during short-term illness or recuperation.
Residential care facility II (RCF II) adds to the definition of RCF I the supervision of diets, assistance in personal care, and supervision of health care under the direction of a licensed physician. Facilities can be licensed to provide both levels of care within the same facility.
Homes licensed after 1987 must provide 70 square feet of space per resident in both private and multiple-occupancy rooms. A maximum of four residents may share a room. Homes licensed prior to 1987 shall provide a minimum of 60 square feet per resident. One tub/shower must be provided for every 20 residents and one toilet and lavatory for every six residents.
RCFs may admit or retain only residents who are capable mentally and physically of negotiating a normal path to safety using assistance devices or aids when necessary. The rules allow RCFs to admit any resident who can be cared for by the facility directly or in cooperation with community resources or other providers of care with whom it is affiliated or has contracts. Residents must be able to evacuate without physical assistance.
Facilities cannot serve people that are a danger to self or others, are at consistent risk of elopement, require physical or chemical restraint, require more than one person for assistance with activities of daily living (except bathing), or are bedbound or chairbound.
Nursing Home Admission Policy
Eligibility for nursing home and waiver services is determined by a scoring system. Applicants with an assessed level of 18 to 48 points qualify for intermediate care, and higher point levels qualify for skilled nursing care. Residents are assessed in nine areas: mobility; dietary (eating); restorative services; monitoring; medication; behavior; personal care (hygiene, personal grooming including dressing, bathing, oral hygiene, hair and nail care, and shaving) and bowel and bladder functions; and rehabilitation. Each area receives points based on the level of need: no points for no or very limited care; three points for minimal care; six points for moderate assistance; and nine points for maximum assistance. The rules define what qualifies as minimal, moderate, and maximum assistance.
Personal care services are reimbursed through Medicaid for residents who have chronic, stable conditions. Tasks include bathing, hair care, oral hygiene, nail care, dressing, assistance with toileting, walking or transfers, meal preparation, and light housework. Advanced personal care services include assistance for persons with altered body functions who have a catheter or ostomy, who require bowel and bladder routines or range of motion exercises, who need assistance applying prescription lotions or ointments, and/or who need assistance with other tasks requiring a highly trained aide.
At least three meals a day must be served (two must be hot). Modified diets prescribed by a physician can be provided if the resident is monitored by the physician and the diet is reviewed at least quarterly by a consulting nutritionist, dietitian, registered nurse, or physician. The modified diets must be posted in the kitchen.
The residents’ rights regulations requires that residents be fully informed in writing prior to or at admission of the services available; related charges; charges for services not covered in the basic rate; procedures in a medical emergency; services outside the facility which may be available; individual’s right to make treatment decisions; and state laws concerning advance directives.
Provisions for Serving People with Dementia
Rules for Level II facilities serving people with dementia were effective in June 2001. Facilities must complete a disclosure form. RCF II facilities may serve people with Alzheimer’s disease if the resident is physically but not mentally capable of negotiating a normal path to safety using assistive devices or aids when certain conditions are met. They include:
A family member or legal representative in conjunction with a physician and the facility or legal representatives determine the facility can meet the needs of the resident.
The facility has an automatic sprinkler system that complies with specified codes.
Residents who are mentally incapable of negotiating a path to safety are housed only on the ground floor.
Residents have the opportunity to explore the facility and grounds.
The facility has an appropriate number and type of staffing 24 hours a day to provide proper care. (Every mentally incapable resident counts as three residents in determining staffing capacity.)
Every mentally incapable resident is assessed by a licensed professional on admission, at least every 6 months, and whenever a change in condition occurs as reported by the Minimum Data Set (MDS).
An individual service plan is developed.
Electronic personal monitoring devices are used when recommended by a physician.
Staff receive at least 4 hours of training on a quarterly basis of which 2 hours is targeted on dementia.
All self-care, productive, and leisure activities programs are provided.
New direct-care employees working in the Alzheimer’s unit must be given 24 hours of training within their first 30 days of employment, and 4 hours of in-service training each quarter.
New training requirements were developed by the Department of Health and Senior Services. The MDS form must be completed and individualized service plans developed.
Facilities file a disclosure on a standard form that provides information on philosophy; process and criteria for placement, transfer, or discharge; assessment and care planning process; staff training and continuing education practices; physical environment; activities; role of families; cost of care and additional fees; and safety and security measures.
Medication aides may administer or assist with medications. Injections must be administered by a licensed nurse or physician except that insulin injections may be given by a certified medication technician or a Level I medication aide. Medications must be reviewed by a pharmacist or registered nurse every other month in Level II facilities and every 3 months in Level I facilities.
Personal care and advanced personal care services are reimbursed as a Medicaid state plan service in residential care facilities. The program serves elders, people with disabilities, people with mental retardation and developmental disabilities, and people with mental illness.
|* Unduplicated 2003 count.|
The payment varies by resident based on an assessment and a plan of care completed by a case manager from the Division of Health and Senior Services. Effective July 1, 2003, the payment rate is $13.16 an hour for personal care aides, $15.20 an hour ($14.41 in 2000) for advanced personal care aide services, and $28.07 an hour for nursing visits. The maximum payment in FY2004 is $2,368 a month and is based on the net state cost in a nursing facility. Residents needing only personal care may receive 60 percent of the total cap. Residents who need advanced personal care services may receive the full amount of the cap.
Facilities can set their own rates for room and board. Residents can make payments by various means including SSI, Missouri Cash Grant if eligible, another state agency (such as the Department of Mental Health), and family supplementation. Type I facilities receive a room-and-board payment from SSI and State supplement of $720 a month (less the $25 personal needs allowance [PNA]), and Type II facilities receive a room-and-board payment of $856 a month (less the $25 PNA).
Facilities must have adequate staffing. Minimum ratios are established. For Level I facilities, one employee is required for every 40 residents or portion thereof, and must be awake unless there are 20 or fewer residents. Level II facilities must have one staff for every 15 residents during the day; one to 20 beginning at 3 p.m., and one to 25 on the night shift. One licensed nurse per 30 residents is required at least 8 hours a week.
Administrators. Administrators of RCF II facilities must be licensed nursing home administrators or attend at least 20 hours of continuing education each fiscal year (July through June) given or approved by the Division on Aging. They must also successfully complete a state approved Level I Medication Aide course unless a full-time licensed nurse is available. Licenses are not required for administrators of RCF I facilities, although annual attendance at in-service training sessions is required.
Staff. Prior to or on the first day that a new employee works in the facility, she/he shall receive at least a 1 hour orientation to his/her job function. The minimum orientation includes job responsibilities, how to handle emergency situations, the importance of infection control and hand washing, confidentiality of resident information, preservation of resident dignity, how to report abuse/neglect to the Division on Aging, information regarding the employee Disqualification List, and instruction regarding the rights of residents and protection of property.
A statement must be included in the personnel record of each employee that the employee was instructed on residents’ rights, facility’s policies, and job duties and that orientation was received.
Staff administering medications receive a certificate after completing a designated course developed by the University of Missouri-Columbia.
Administrators. Administrators must not have been convicted of an offense involving the operation of a long-term care facility or similar facility.
Staff. A background check is performed on all employees. Individuals who have been convicted of a Class A or B felony of a crime against a person are not permitted to work or volunteer in the facility in any capacity. In addition, no person listed on the Employee Disqualification List maintained by the Division of Aging shall work or volunteer in the facility in any capacity.
Licensing fees are $100 for facilities of three to 24 beds, $300 for facilities with 25 to 100 beds, and $600 for facilities of more than 100 beds.
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