This rule defines terms used in Missouri's long-term care facility regulations (19 CSR 30-85 through 30-88), covering skilled nursing facilities, intermediate care facilities, assisted living facilities, and residential care facilities. Operators of these facility types must understand these definitions as they govern key concepts such as restraints, medication control, levels of care, and resident rights applicable across all four licensed long-term care categories.
View official sourceCODE OF STATE REGULATIONS 1ROBIN CARNAHAN (9/30/08) Secretary of State Rules of Department of Health and Senior Services Division 30—Division of Regulation and Licensure Chapter 83—Definition of Terms Title Page 19 CSR 30-83.010 Definition of Terms............................................................................3 Title 19—DEP ARTMENT OF HEALTH AND SENIOR SERVICES Division 30—Division of Regulation and Licensure Chapter 83—Definition of Terms 19 CSR 30-83.010 Definition of Terms PURPOSE: This rule defines terms used in the rules for long-term care facilities as set forth in chapters 19 CSR 30-85, 19 CSR 30- 86, 19 CSR 30-87, and 19 CSR 30-88. (1) Activities of daily living (ADL)—Shall mean one (1) or more of the following: (A) Eating; (B) Dressing; (C) Bathing; (D) Toileting; (E) Transferring; and (F) Walking. (2) Administrator—Shall mean an individual person who is in general administrative charge of a facility. (3) Assisted living facility (ALF)—Shall mean any premises, other than a residential care facility, intermediate care facility, or skilled nursing care facility, that is utilized by its owner, operator, or manager to provide twenty-four (24) hour care and services and protective oversight to three (3) or more res- idents who are provided with shelter, board, and who may need and are provided with the following: (A) Assistance with any activities of daily living and any instrumental activities of daily living; (B) Storage, distribution or administration of medications; and (C) Supervision of health care under the direction of a licensed physician, provided that such services are consistent with a social model of care. (D) The term “assisted living facility” does not include a facility where all of the resi- dents are related within the fourth degree of consanguinity or affinity to the owner, opera- tor, or manager of the facility. (4) Automated dispensing system—Shall mean a mechanical system that performs functions that may include, but are not limit- ed to, storing, packaging or dispensing med- ications, and that collects, controls and main- tains all transaction information. (5) Certified-medication technician—Shall mean a nursing assistant who has completed a course in medication administration approved by the Department of Health and Senior Services. (6) Chemical restraint—Shall mean a psy- chopharmacologic medication that is used for discipline or convenience and not required to treat medical symptoms. (7) Communicable disease—Any illness, dis- ease or condition reportable to the Missouri Department of Health and Senior Services as required by 19 CSR 20-20.010 and 19 CSR 20-20.020 is considered, for the context of these rules, a communicable disease. (8) Community based assessment—Shall mean documented basic information and analysis provided by appropriately trained and qualified individuals describing an indi- vidual’s abilities and needs in activities of daily living, instrumental activities of daily living, vision/hearing, nutrition, social par- ticipation and support, and cognitive func- tioning using an assessment tool approved by the Department of Health and Senior Ser- vices (the department), that is designed for community based services and that is not the nursing home minimum data set. The assess- ment tool may be one developed by the department or one used by a facility which has been approved by the department. (9) Control of medication—Shall mean assuming responsibility by the facility for all facets of control of medication including, but not limited to, acquisition, sto rage, security and administration. (10) Convenience—Shall mean any action taken by the facility to control resident behav- ior or maintain residents with a lesser amount of effort by the facility and not in the resi- dent’s best interest. (11) Dementia—Shall mean a general term for the loss of thinking, remembering, and reasoning so severe that it interferes with an individual’s daily functioning, and may cause symptoms that include changes in personali- ty, mood, and behavior. (12) Designee—Shall mean an individual who has been designated in writing by a res- ident to handle matters and receive reports related to his/her personal possessions and property. (13) Discipline—Shall mean any action taken by the facility for the purpose of punishing or penalizing residents. (14) Emergency medical procedure—Shall mean those written policies and procedures which describe the types and degrees of acci- dents and injuries, how they will be treated, by whom, in which instances the resident’s physician will be notified and how quickly. (15) Emergency medication supply —Shall mean a limited number of dosage units of prescription medications that may be admin- istered to a resident in an emergency situation or for initial doses of a necessary medication when a pharmacy cannot provide a prescrip- tion for a resident within a reasonable time based on the resident’s clinical needs at the time. (16) Existing or existing licensed facility— Shall mean a long-term care facility which was licensed and in operation or one whose plans were approved prior to June 10, 1981 for a skilled or intermediate care facility or prior to November 13, 1980 for residential care facilities and assisted living facilities except as otherwise indicated in 19 CSR 30- 86.012, 19 CSR 30-86.022 and 19 CSR 30- 86.032. (17) Exit—Shall mean a door leading to the outside or through a horizontal exit in a fire wall to a fire-safe area in the building. (18) Facility—Shall mean any residential care facility, assisted living facility, intermediate care facility or skilled nursing facility licensed by the department. (19) Fire-resistant construction—For inter- mediate care facilities and skilled nursing facilities, fire-resistant construction shall mean that a facility meets the specifications for Type II (222) or Type II (111) construc- tion as given in the National Fire Protection Association Code 220 . Fire-resistant con- struction for residential care facilities and assisted living facilities is defined in 19 CSR 30-86.022. (20) Hazardous area—Shall mean furnace rooms other than electric forced air furnaces, laundries, kitchens, maintenance shops and storage r ooms of over one hundred (100) square feet and any areas which contain com- bustible materials which will be either easily ignited, burn with an intense flame or result in the production of dense smoke and fumes. (21) Home-like—means a self-contained long-term care setting that integrates the psy- chosocial, organizational and environmental qualities that are associated with being at CODE OF STATE REGULATIONS 3ROBIN CARNAHAN (9/30/08) Secretary of State Chapter 83—Definition of Terms 19 CSR 30-83 home. Home-like may include, but is not lim- ited, to the following: (A) A living room and common use areas for social interactions and activities; (B) Kitchen and family style eating area for use by the residents; (C) Laundry area for use by residents; (D) A toilet room that contains a toilet, lavatory and bathing unit in each resident’s room; (E) Resident room preferences for resi- dents who wish to share a room, and for res- idents who wish to have private bedrooms; (F) Outdoor area for outdoor activities and recreation; and (G) A place where residents can give and receive affection, explore their interests, exercise control over their environment, engage in interactions with others and have privacy, security, familiarity and a sense of belonging. (22) Individualized service plan (ISP)—Shall mean the planning document prepared by an assisted living facility which outlines a resi- dent’s needs and preferences, services to be provided, and the goals expected by the resi- dent or the resident’s legal representative in partnership with the facility. (23) Instrumental activities of daily living (IADL)—Shall mean one (1) or more of the following activities: (A) Preparing meals; (B) Shopping for personal items; (C) Medication management; (D) Managing money; (E) Using the telephone; (F) Housework; and (G) Transportation ability. (24) Intermediate care facility—Shall mean any premises, other than a residential care facility, assisted living facility, or skilled nursing facility, which is utilized by its owner, operator, or manager to provide twen- ty-four (24) hour accommodation, board, personal care, and basic health and nursing care services under the daily supervision of a licensed nurse and under the direction of a licensed physician to three (3) or more resi- dents dependent for care and supervision and who are not related within the fourth degree of consanguinity or affinity to the owner, operator or manager of the facility. (25) Involuntary seclusion—Shall mean sepa- ration of a resident from other residents or from her/his room or confinement to her/his room (with or without roommates) against the resident’s will, or the will of the resi- dent’s legal representative. Emergency or short term monitored separation from other residents will not be considered involuntary seclusion and may be permitted if used for a limited period of time as a therapeutic inter- vention to reduce agitation until professional staff can develop a plan of care to meet the resident’s needs. (26) Keeping residents in place—Shall mean maintaining residents in place during a fire in lieu of evacuation where a building’s occu- pants are not capable of evacuation, where evacuation has a low likelihood of success, or where it is recommended in writing by local fire officials as having a better likelihood of success and/or lower risk of injury. (27) Level I medication aide—Shall mean an individual who has completed a course approved by the department in medication administration in a residential care facility or assisted living facility. (28) Long-term care facility—Shall mean a facility that is licensed either solely or in combination as a skilled nursing facility, an intermediate care facility, a residential care facility, or assisted living facility. (29) Long-term care services—Shall mean the assistance and support that a resident receives in a residential care facility, assisted living facility, intermediate care facility, and skilled nursing care facility, to meet the resi- dent’s individual need for nursing care, pro- tective oversight, monitoring, medication management, social interactions, cooking, housekeeping, laundry, and recreational activ- ities. (30) Major fraction thereof—Shall mean any- thing over fifty percent (50%) of the number of occupied beds. (31) Major remodeling—Shall mean any remodeling of a long-term care facility which involves the addition of resident-use rooms, which affects fire safety or the structure of the building. (32) Multistory building—Shall mean any building with more than one (1) floor entire- ly above the grade. A floor that is partially below grade will be counted as the first story to determine sprinkler requirements only if it contains resident sleeping rooms. (33) New or newly licensed facility—Shall mean a long-term care facility whose plans are approved or which is licensed after June 10, 1981 for a skilled nursing or intermediate care facility or after November 13, 1980 for residential care facility or assisted living facility except as otherwise indicated in 19 CSR 30-86.012, 19 CSR 30-86.022, and 19 CSR 30-86.032. (34) Nursing personnel—Shall include any employee, including a nurse’s aide or an orderly, who provides or assists in the provi- sion of direct resident health care services. (35) Operator—Shall mean any person licensed or required to be licensed under the provisions of sections 198.003–198.096, RSMo, in order to establish, conduct, or maintain a facility. The term person required to be licensed shall mean any person having the following, as determined by the depart- ment: (A) Ultimate responsibility for making and implementing decisions regarding the opera- tion of the facility; (B) Ultimate financial control of the oper- ation of a facility; and (C) Legal right to possession of the premises on which a facility is located. (36) Person—Shall mean any individual, or any entity, including, but not limited to, a corporation, limited liability company, part- nership, association, nonprofit organization, fraternal organization, church, or political subdivision of the state of Missouri. (37) Physical restraint—Shall mean any man- ual method or physical or mechanical device, material or equipment attached to or adjacent to the resident’s body that the individual can- not remove easily which restricts freedom of movement or normal access to one’s body. Physical restraints include, but are not limit- ed to, leg restraints, arm restraints, hand mitts, soft ties or vests, lap cushions, and lap trays the resident cannot remove easily. Phys- ical restraints also include facility practices that meet the definition of a restraint, such as the following: (A) Using side rails that keep a resident from voluntarily getting out of bed; (B) Tucking in or using V elcro to hold a sheet, fabric, or clothing tightly so that a res- ident’s movement is restricted; (C) Using devices in conjunction with a chair, such as trays, tables, bars, or belts, that the resident cannot remove easily, that pre- vent the resident from rising; (D) Placing the resident in a chair that pre- vents a resident from rising; and (E) Placing a chair or bed so close to a wall that the wall prevents the resident from rising out of the chair or voluntarily getting out of bed. 4 CODE OF STATE REGULATIONS (9/30/08) R OBIN CARNAHAN Secretary of State 19 CSR 30-83—DEPARTMENT OF HEALTH AND SENIOR SERVICES Division 30—Division of Regulation and Licensure (38) Physician—Shall mean an individual licensed to practice medicine in the state of Missouri under Chapter 334, RSMo. (39) Premises—Shall mean any structures that are in close proximity one to the other and which are located on a single piece of property. (40) Protective oversight—Shall mean an awareness twenty-four (24) hours a day of the location of a resident, the ability to intervene on behalf of the resident, supervision of nutrition, medication, or actual provisions of care, and the responsibility for the welfare of the resident, except where the resident is on voluntary leave. (41) Qualified dietitian—Shall mean an indi- vidual who is registered by the American Dietetic Association or who is eligible for registration. (42) Qualified therapist—Shall mean an indi- vidual who is either registered or is eligible for registration by the national accrediting association for that therapy or, if applicable, is licensed by the state of Missouri for the practice of the profession in which s/he is engaged. (43) Qualified therapy assistant—Shall mean an individual who would be qualified as an occupational therapy or physical therapist assistant as outlined in 42 CFR 484.4. (44) Residential care facility (RCF)—Shall mean any premises, other than an assisted living facility, intermediate care facility, or skilled nursing facility, which is utilized by its owner, operator, or manager to provide twen- ty-four (24) hour care to three (3) or more residents, who are not related within the fourth degree of consanguinity or affinity to the owner, operator, or manager of the facili- ty and who need or are provided with shelter, board, and with protective oversight, which may include sto rage and distribution or administration of medications and care during short-term illness or recuperation, except that, for purposes of eligible residents of facilities formerly licensed as residential care facilities II receiving supplemental welfare assistance payments, any residential care facility that was licensed as a residential care facility II on or before August 27, 2006 that continues to meet the licensure standards for a residential care facility II in effect on August 27, 2006 shall be considered a resi- dential care facility II for purposes of its eli- gible residents receiving the cash grant pay- ment amount allocated immediately prior to August 28, 2006 for residents of a residential care facility II pursuant to section 208.030, RSMo. (45) Responsible party—Shall mean an indi- vidual who has been designated in writing by the resident to handle matters and receive reports related to his/her general condition. (46) Self-administration of medication—Shall mean the act of actually taking or applying medication to oneself. (47) Self-control of medication—Shall mean assuming immediate responsibility by a resi- dent for the sto rage and administration of medication for oneself while the facility retains ultimate control of medication. (48) Skilled nursing care—Shall mean ser- vices furnished pursuant to physicians’ orders which require the skills of licensed nurses and which are provided directly by or under the on-site supervision of these personnel. Examples of skilled nursing care may include, but are not limited to: administration of levine tube or gastrostomy tube feedings; nasopharyngeal and tracheotomy aspiration; insertion of medicated or sterile irrigation solutions and replacement of catheters; administration of parenteral fluids; inhalation therapy treatments; administration of other treatments requiring aseptic technique; and administration of injectable medication other than insulin. (49) Skilled nursing facility—Shall mean any premises, other than a residential care facili- ty, assisted living facility, or an intermediate care facility, which is utilized by its owner, operator, or manager to provide for twenty- four (24) hour accommodation, board and skilled nursing care and treatment services to at least three (3) residents who are not relat- ed within the fourth degree of consanguinity or affinity to the owner, operator, or manag- er of the facility. Skilled nursing care and treatment services are those services com- monly performed by or under the supervision of a registered professional nurse for individ- uals requiring twenty-four (24) hours a day care by licensed nursing personnel including acts of observation, care, and counsel of the aged, ill, injured, or infirm, the administra- tion of medications and treatments as pre- scribed by a licensed physician or dentist, and other nursing functions requiring substantial specialized judgment and skill. (50) Social model of care—means long-term care services based on the abilities, desires, and functional needs of the individual deliv- ered in a setting that is more home-like than institutional, that promote the dignity, indi- viduality, privacy, independence, and autono- my of the individual, that respects residents’ differences and promotes residents’ choices. (51) V oluntary leave—Shall mean an off- premises leave initiated by: a) a resident that has not been declared mentally incompetent or incapacitated by a court; or b) a legal guardian of a resident that has been declared mentally incompetent or incapacitated by a court. (52) Vulnerable person—Shall mean any per- son in the custody, care, or control of the Department of Mental Health that is receiv- ing services from an operated, funded, licensed, or certified program. AUTHORITY: sections 198.009, RSMo 2000, and section 198.073, RSMo Supp. 2007.* Emergency rule filed Sept. 7, 1979, effective Sept. 28, 1979, expired Jan. 24, 1980. This rule originally filed as 13 CSR 15-1 1.010. Original rule filed Sept. 7, 1979, effective Jan. 12, 1980. Amended: Filed Dec. 10, 1980, effective June 1 1, 1981. Amended: Filed Dec. 10, 1981, effective May 1 1, 1982. Rescinded and readopted: Filed July 13, 1983, effective Oct. 13, 1983. Amended: Filed Nov. 9, 1983, effective Feb. 1 1, 1984. Emergency amendment filed Aug. 1, 1984, effective Aug. 13, 1984, expired Dec. 10, 1984. Amended: Filed Sept. 12, 1984, effec- tive Dec. 13, 1984. Amended: Filed Aug. 1, 1988, effective Nov. 1 1, 1988. Moved to 19 CSR 30-83.010, effective Aug. 28, 2001. Emergency amendment filed Sept. 12, 2003, effective Sept. 22, 2003, expired March 19, 2004. Amended: Filed Sept. 12, 2003, effec- tive Feb. 29, 2004. Amended: Filed Sept. 14, 2004, effective March 30, 2005. Amended: Filed Aug. 23, 2006, effective April 30, 2007. Amended: Filed March 13, 2008, effective Oct. 30, 2008. *Original authority: 198.009, RSMo 1979, amended 1993, 1995 and 198.073, RSMo 1979, amended 1984, 1992, 1999, 2006, 2007. CODE OF STATE REGULATIONS 5ROBIN CARNAHAN (9/30/08) Secretary of State Chapter 83—Definition of Terms 19 CSR 30-83