19 CSR 30-35

Hospices

This regulation establishes minimum operating standards for state-certified hospice programs in Missouri, covering program operations, direct care in hospice facilities, and state certification management. Hospice operators must maintain interdisciplinary care teams, written plans of care, 24-hour nursing coverage, infection control programs, emergency preparedness plans, volunteer staffing requirements, and clinical recordkeeping systems. Requirements also address patient rights, medication management, contracted services, employee orientation and training, and coordination with nursing facilities when patients reside there.

CODE OF STATE REGULATIONS 1
John R. Ashcroft (2/28/23)
Secretary of State
rules of
Department of Health and Senior 
Services
Division 30—Division of Regulation and Licensure
Chapter 35—Hospices
 Title Page
19 CSR 30-35.010 Hospice Program Operations........................................ 3
19 CSR 30-35.020 Hospice Providing Direct Care in a Hospice Facility ................... 9
19 CSR 30-35.030 State Certification Management ................................... 19
 CODE OF STATE REGULATIONS 3
John R. Ashcroft (2/28/23)
Secretary of State
19 CSR 30-35—DEPARTMENT OF HEALTH AND DIVISION 30—DIVISION OF REGULATION
 SENIOR SERVICES AND LICENSURE
TITLE 19—DEPARTMENT OF HEALTH AND SENIOR 
SERVICES
Division 30—Division of Regulation and Licensure
Chapter 35—Hospices
19 CSR 30-35.010 Hospice Program Operations
PURPOSE: This rule defines the minimum requirements for the 
provision of hospice services by state certified hospice programs.
PUBLISHER’S NOTE: The secretary of state has determined that 
publication of the entire text of the material that is incorporated by 
reference as a portion of this rule would be unduly cumbersome or 
expensive. This material as incorporated by reference in this rule 
shall be maintained by the agency at its headquarters and shall 
be made available to the public for inspection and copying at no 
more than the actual cost of reproduction. This note applies only 
to the reference material. The entire text of the rule is printed here. 
(1) General Provisions. 
(A) Definitions Relating to Hospice Care Agencies. 
1. Attending physician – a person who – 
A. Is licensed as a doctor of medicine or osteopathy in 
Missouri or a bordering state; or 
B. Is recognized by Missouri as a nurse practitioner and 
who complies with the requirements of Chapter 335, RSMo, 20 
CSR 2200-4.200, and 42 CFR 410.75; or 
C. Is licensed as a physician assistant (PA) in Missouri and 
who complies with the requirements in Chapter 334, RSMo, 20 
CSR 2150-7.135, and 42 CFR 410.74(c); and 
D. Is identified by the patient, at the time the patient 
elects to receive hospice care, as having the most significant 
role in the determination and delivery of the patient’s medical 
care. 
2. Automated dispensing system—a mechanical system 
that performs functions that may include, but are not limited 
to, storing, packaging or dispensing medications, and that 
collects, controls and maintains all transaction information.
3. Branch/multiple location—a location from which 
a hospice provides services within a portion of the total 
geographic area served by the parent hospice and the area 
served by the branch/multiple location is contiguous to or part 
of the area served by the parent hospice.
4. Certified medication technician—a person who has 
successfully completed the certified medication technician 
training program and any examination component required 
in compliance with the standards in 19 CSR 30-84.020. The 
certified medication technician shall remain current as a 
certified nursing assistant with the Department of Health and 
Senior Services in order to continue to be current as a certified 
medication technician. 
5. Certified pharmacy technician—a person who is 
credentialed by a nationally recognized pharmacy technician 
credentialing authority.
6. Contracted provider—individuals or entities who 
furnish services to hospice patients under contractual 
arrangements between the hospice and the contracted 
provider.
7. Coordinating provider—any individual or agency 
which independently provides services to the patient in their 
place of residence.
8. Department—the Missouri Department of Health and 
Senior Services. 
9. Dietary counselor—an individual who is a registered 
nurse, registered dietitian, nutritionist, physician assistant or 
physician. 
10. Direct employee—an individual paid directly by the 
hospice.
11. Emergency medication supply—a limited number of 
prescription medications approved by the medical director 
and the pharmacist that may be administered to a patient 
in an emergency situation or for initial doses of a necessary 
medication when a pharmacist cannot provide medication 
services for a patient within a reasonable time based on the 
patient’s clinical needs at the time.
12. Employee—an employee of the hospice or an individual 
under contract who is appropriately trained and assigned 
to the hospice program. Employee also refers to a person 
volunteering for the hospice program.
13. Family—broadly defined to include not only persons 
bound by biology or legalities but also those who function for 
the patient in a familial way.
14. Homemaker—a hospice aide, volunteer or other 
individual who assists the patient/family with light 
housekeeping chores.
15. Hospice—a public agency or private organization or 
subdivision of either that–
A. Is primarily engaged in providing care to dying 
persons and their families; and
B. Meets the standards specified in 19 CSR 30-35.010 and 
in 19 CSR 30-35.030. If it is a hospice that provides inpatient care 
directly in a hospice facility, it must also meet the standards of 
19 CSR 30-35.020 and 19 CSR 30-35.030.
16. Hospice administrator—the employee designated by 
the governing body as responsible for the overall functioning 
of the hospice. Hospice administrators appointed by the 
governing body after July 1, 2023, shall have the following:
A. Be a licensed practical nurse, be a licensed registered 
nurse, or hold an undergraduate degree; and 
B. Have at least one (1) year of administrative experience 
in a related healthcare field.
17. Hospice aide—a person who meets the training and 
skill requirements specified in the Medicare hospice program 
at 42 CFR 418.76 which is incorporated by reference as last 
amended on August 6, 2009, and published by the Office of 
the Federal Register, 732 N. Capitol Street NW, Washington, DC 
20401 or can be found at https://govinfo.gov. This rule does not 
incorporate any subsequent amendments or additions. 
18. Hospice patient—a person with a terminal illness 
or condition for whom the focus of care is on comfort and 
palliation rather than cure.
19. Legal representative—a person who because of the 
patient’s mental or physical incapacity is legally authorized 
in accordance with state law to make health care decisions on 
behalf of the dying person.
20. Licensed practical nurse—a person licensed under 
Chapter 335, RSMo, to engage in the practice of practical 
nursing.
21. Meal preparation—meals planned, offered, or served to 
all patients from prepared menus.
22. Medical director—a person licensed in Missouri or a 
bordering state as a doctor of medicine or osteopathy who 
assumes overall responsibility for the medical component of 
the hospice’s patient care program.
23. Nutritionist—a person who has graduated from an 
accredited four- (4-) year college with a bachelor’s degree 
including or supplemented by at least fifteen (15) semester 
hours in food and nutrition including at least one (1) course in 
diet therapy.
24. Occupational therapist—a person who is licensed 
under Chapter 324, RSMo, as an occupational therapist and 
licensed to practice in Missouri.
4 CODE OF STATE REGULATIONS 
(2/28/23) John R. Ashcroft
Secretary of State
DIVISION 30—DIVISION OF REGULATION 19 CSR 30-35—DEPARTMENT OF HEALTH AND
 AND LICENSURE SENIOR SERVICES
25. Occupational therapy assistant—a person who has 
graduated from an occupational therapy assistant program 
accredited by the Accreditation Council for Occupational 
Therapy Education and licensed to practice in Missouri.
26. Pharmacist—a person licensed as a pharmacist under 
Chapter 338, RSMo.
27. Pharmacy technician—a person who is registered as a 
pharmacy technician under Chapter 338, RSMo.
28. Physical therapist—a person who is licensed as a 
physical therapist under Chapter 334, RSMo.
29. Physical therapy assistant—a person who has 
graduated from at least a two- (2-) year college level program 
accredited by the American Physical Therapy Association and 
licensed to practice in Missouri.
30. Registered nurse—a person licensed under Chapter 
335, RSMo, to engage in the practice of professional nursing.
31. Registered nurse coordinator—a registered nurse, who 
is a direct employee, designated by the hospice to direct the 
overall provisions of clinical services.
32. Skilled nursing—those services which are required by 
law to be provided by a registered nurse or a licensed practical 
nurse.
33. Snack—a single meal or item prepared on demand 
which does not include food items that produce grease-laden 
vapors.
34. Social worker—a person who –
A. Has a Master of Social Work (MSW) degree from a 
school of social work accredited by the Council on Social Work 
Education and has one (1) year of social work experience in a 
health care setting; or
B. Has a baccalaureate degree in social work (BSW) 
from an institution accredited by the Council on Social 
Work Education; is supervised by an MSW as described in 
subparagraph (1)(A)34.A. of this rule and has one (1) year of 
social work experience in a health care setting; or
C. Has a baccalaureate degree from a school of social 
work accredited by the Council on Social Work Education 
and is employed by the hospice before December 2, 2008, and 
therefore is not required to be supervised by an MSW.
35. Speech language pathologist—a person who is 
licensed under Chapter 345, RSMo, as a speech language 
pathologist.
36. Spiritual counselor—a person who has education 
with emphasis in counseling or related subjects and has, 
within ninety (90) days of hire, completed specific training 
to include common spiritual issues in death and dying, belief 
systems of comparative religions related to death and dying, 
spiritual assessment skills, individualizing care to patient 
beliefs, and varied spiritual practices/rituals. 
37. Standing order—An order by an authorized prescriber 
that can be implemented by other health care professionals 
when predetermined criteria are met as per 19 CSR 30-35.010(2)
(E)3.–(2)(E)4.A., B., and C. 
(B) Eligibility Requirements. A hospice shall have written 
admission criteria including the hospice’s policies regarding 
palliative care (that includes treatment modalities such as 
chemotherapy or radiation).
(C) Consent for Hospice Care.
1. A patient who wishes to receive hospice care, shall sign a 
consent form for hospice services. 
2. The consent form shall include the following:
A. Identification of the particular hospice that will 
provide care to the patient;
B. The patient’s or legal representative’s 
acknowledgment that the patient or legal representative has 
been advised and has an understanding of the palliative nature 
of hospice care as it relates to the patient’s terminal illness; and
C. The specific type of care and services that may be 
provided as hospice care during the course of the illness.
(D) Discontinuance of Hospice Care.
1. A patient or legal representative may discontinue the 
patient’s hospice care at any time.
2. If a patient transfers to another provider, including 
another hospice provider, the hospice transferring care shall 
provide to the receiving provider pertinent written information 
which shall include at a minimum—
A. Current medication profile;
B. Advance directive (if applicable); 
C. Problems that require intervention or follow-up; and
D. Current hospice plan of care.
3. The hospice shall have written policies for hospice 
patient discharge which identify specific circumstances in 
which the patient is discharged.
A. The hospice shall immediately notify the patient 
or legal representative and shall include the date that the 
discontinuance is effective.
B. Patient’s/family’s continuing care needs, if any, are 
assessed at discharge, and the patient/family are referred to 
appropriate resources.
4. The attending physician shall be notified in all instances 
of discontinuance of hospice care and such notification shall 
be documented in the patient record.
(E) General Requirements.
1. A hospice shall maintain compliance with the standards 
in 19 CSR 30-35.010 and in 19 CSR 30-35.030. A hospice that 
operates a facility for hospice care shall also maintain 
compliance with 19 CSR 30-35.020.
2. A hospice shall be primarily engaged in providing the 
care and services described in 19 CSR 30-35.010 and in 19 CSR 
30-35.020 of this rule, and shall—
A. Provide twenty-four- (24-) hour nursing coverage for 
telephone consultation and visits as needed;
B. Assure all other services that are reasonable and 
necessary for the palliation and management of terminal 
illness and related conditions are available on a twenty-four- 
(24-) hour basis;
C. Provide bereavement counseling; and
D. Assure services are provided in a manner consistent 
with accepted standards of practice in accordance with local, 
state, and federal law.
3. The hospice shall conduct criminal background checks 
in accordance with state law.
4. The hospice shall adhere to state and federal law relating 
to advance directives.
(F) Patient Rights. The hospice shall have a written 
statement of patient rights which shall include, but need not 
be limited to, those specified herein— 
1. Each patient of a hospice program shall be informed in 
writing of his/her rights as a recipient of hospice services;
2. The hospice shall document that it has informed patients 
of their rights in writing and shall protect and promote the 
exercise of these rights; and
3. The patient’s family, legal representative, or guardian 
may exercise the patient’s rights when all reasonable efforts to 
communicate with the patient have failed. These rights shall 
include—
A. The patient and family’s right for respect of property 
and person, including the right to be free of abuse, neglect, 
and/or misappropriation of funds;
B. The right to voice grievances regarding treatment or 
care that is, or fails to be, furnished or regarding lack of respect 
of property or person by anyone who is furnishing services 
 CODE OF STATE REGULATIONS 5
John R. Ashcroft (2/28/23)
Secretary of State
19 CSR 30-35—DEPARTMENT OF HEALTH AND DIVISION 30—DIVISION OF REGULATION
 SENIOR SERVICES AND LICENSURE
on behalf of the hospice and the patient/family shall not be 
subjected to discrimination or reprisal for doing so;
C. The right to be informed about his/her care 
alternatives available from the hospice and payment resources;
D. The right to participate in the development of the 
plan of care and planning changes in the care;
E. The right to be informed in advance about the care to 
be furnished;
F. The right to be informed in advance of the disciplines 
that will furnish care and the frequency of visits proposed to be 
furnished;
G. The right to be informed in advance of any change in 
the plan of care before the change is made;
H. The right to confidentiality of the clinical records 
maintained by the hospice and to be informed of the hospice’s 
policy for disclosure of clinical records;
I. The right to be informed in writing of the extent to 
which payment may be required from the patient and any 
changes in liability within thirty (30) days of the hospice 
becoming aware of the new amount of the liability; and
J. The right to access the Missouri home health and 
hospice toll-free hotline and to be informed of its telephone 
number, the hours of operations, and its purpose for the receipt 
of complaints and questions regarding hospice services.
(G) Code of Ethics.
1. A hospice shall develop a written code of ethics and 
have a process for reviewing ethical issues.
(H) Twenty-four- (24-) Hour Response.
1. The hospice shall have written policies and procedures 
defining access to all services, medications, equipment, and 
supplies during regular business hours, after hours , and in 
emergency situations including a plan for prompt telephone 
response.
2. Unscheduled non-emergent visits shall be provided as 
agreed upon by the hospice and patient/caregiver. 
3. When clinically indicated, emergent visits shall be made 
within ninety (90) minutes from the time the need is identified. 
(I) Infection Control. 
1. The hospice shall identify person(s) responsible for 
implementing, maintaining, and documenting an infection 
control program for surveillance, identification, prevention, 
control, and investigation of infections and communicable 
diseases.
2. The infection control program shall include a system for 
periodic review and update of infection control policies and 
procedures; infection control education of staff, patients, and 
caregivers; and monitoring for compliance with policies and 
procedures.
3. The infection control policies and procedures shall 
conform with accepted standards of practice, including the 
use of standard precautions, to prevent the transmission of 
infections and communicable diseases.
(J) Safety and Emergency Preparedness.
1. The hospice shall have a safety plan that includes—
A. Policies and procedures for reporting, monitoring, 
and following up on all accidents, injuries, and safety concerns;
B. Documentation of monitoring activity and follow-up 
actions; and
C. A safe and sanitary system for identifying, handling, 
and disposing of hazardous wastes in compliance with all 
federal, state, and local laws.
2. The hospice shall have an emergency preparedness 
program that shall meet all federal, state, and local 
requirements and shall include at a minimum—
A. An emergency plan based on a facility and community 
all-hazards risk assessment;
B. Policies and procedures reviewed and updated at least 
annually;
C. A communication plan;
D. Training of staff; and
E. Annual exercises to test the emergency plan.
(K) Branch/Multiple Locations.
1. If the hospice represents to the public that they have a 
branch/multiple location(s), each location shall be approved 
prior to serving patients. Each branch/multiple location(s) shall 
have a designated interdisciplinary group with documented 
group meetings, on-site maintenance of current active patient 
records, and telephone reception during normal business 
hours.
2. The branch/multiple locations shall be located within 
one hundred (100) miles of the parent office.
3. The standard of care and clinical services shall be the 
same out of the branch/multiple locations as the parent office.
(2) Administration. 
(A) Governing Body.
1. A hospice shall have a governing body that assumes full 
legal responsibility for the hospice’s total operation.
2. The governing body shall meet, at a minimum, once a 
year.
3. The governing body shall designate an administrator in 
writing and list the date the administrator was designated.
(B) Administrator Provisions.
1. The administrator organizes and directs the agency’s 
ongoing functions; maintains ongoing liaison among the 
governing body, the interdisciplinary group(s) and the 
staff; employs qualified personnel; implements an effective 
budgeting and accounting system; and enforces written 
policies and procedures.
2. A person shall be authorized, in writing, to act in the 
absence of the hospice administrator.
3. A registered nurse coordinator shall be designated to 
direct the overall provisions of clinical services.
(C) Contracted Services.
1. A hospice may arrange for another individual or entity 
to furnish services to the hospice’s patients except as otherwise 
provided in these regulations. If services are provided under 
contract, the hospice shall meet the following standards:
A. Assure the continuity of patient/family care in home, 
outpatient, and inpatient settings;
B. Have a written agreement for the provision of 
contracted services. The agreement shall include the following:
(I) Identification of the services to be provided in 
accordance with the plan of care;
(II) The manner in which services are coordinated by 
the hospice to maintain hospice professional management 
responsibility;
(III) Delineation of the role(s) of the hospice and the 
contracted services;
(IV) Assurance that the contracted provider shall be 
appropriately licensed;
(V) Provision for transfer and updating the plan of care 
on inpatient admission (if applicable).
2. Such contracts shall not relieve the hospice of the 
primary responsibility for ensuring patient care or otherwise 
complying with these regulations.
(D) Plan of Care.
1. A written plan of care shall be established for each 
patient by the interdisciplinary group with attending physician 
involvement.
2. The plan shall be established within seven (7) days of 
admission. 
6 CODE OF STATE REGULATIONS 
(2/28/23) John R. Ashcroft
Secretary of State
DIVISION 30—DIVISION OF REGULATION 19 CSR 30-35—DEPARTMENT OF HEALTH AND
 AND LICENSURE SENIOR SERVICES
3. The care provided to a patient shall be in accordance 
with the plan.
4. The plan shall include:
A. Identification of the patient’s/family’s problems and 
needs;
B. The scope and frequency of services needed to meet 
the patient’s and family’s needs and by whom the services 
will be provided, prescribed and required medical equipment, 
supplies, medications, treatments, and the level of care;
C. Realistic and achievable goals; and
D. All physician orders.
5. The plan shall be reviewed and updated by the 
interdisciplinary group at a minimum of every two (2) weeks. 
These reviews shall be documented in the patient record.
6. Documentation on the plan of care shall reflect the 
changing needs of the patient/family and the services required 
to meet those needs.
(E) Authorized Prescriber’s Orders. 
1. Medications, treatments, and procedures shall be 
administered only with an order by an authorized prescriber.
2. Written orders shall be dated and signed at the time of 
writing.
3. Oral orders, including authorization to use a standing 
order, shall be received only by persons authorized within their 
scope of practice, immediately reduced to writing, signed and 
dated by the person receiving the order, and signed and dated 
by the prescriber within thirty (30) days.
4. A standing order may be used as part of the plan of care 
if the following guidelines are met:
A. Standing orders shall be in compliance with all 
applicable state statutes and regulations and shall—
(I) Include the purpose or conditions under which a 
standing order will be implemented;
(II) Be drug, treatment, or procedure specific and not 
allow for non-prescriber’s choice;
(III) Be individualized, signed and dated by the 
prescriber, and included in the patient’s record;
B. Agency policy shall define the time frame for 
authorized prescriber notification when a standing order has 
been implemented; and
C. Standing order content shall be reviewed and 
approved by the medical director at least annually.
(F) Interdisciplinary Group.
1. The hospice shall designate an interdisciplinary group 
or groups composed of qualified individuals who provide or 
supervise the care and services offered by the hospice. The 
interdisciplinary group shall meet as frequently as the patient’s 
condition requires, but no less frequently than every fifteen (15) 
calendar days.
2. The interdisciplinary group shall include at least the 
following individuals who are employees of the hospice:
A. A doctor of medicine or osteopathy (may be 
contracted);
B. A registered nurse;
C. A social worker; and
D. A spiritual counselor.
3. The interdisciplinary group shall be responsible for—
A. Participation in the establishment, review and 
updates of the plan of care;
B. Provision or coordination of hospice care and services; 
and
C. Making recommendations regarding policies 
governing the day-to-day provision of hospice care and 
services.
(G) Clinical Services. The hospice shall routinely provide 
through direct employees the following services:
1. Nursing services.
A. Services shall be provided in accordance with 
recognized standards of practice.
B. Nursing services shall be staffed to assure that the 
nursing needs of patients are met.
C. A registered nurse shall conduct and document 
an initial assessment visit to assess the patient’s immediate 
physical, psychosocial, emotional, and spiritual status and 
needs within forty-eight (48) hours of election. The ongoing 
assessment, planning, and provision of nursing services shall 
be the responsibility of the registered nurse.
D. When nursing services are delegated to a licensed 
practical nurse—
(I) The licensed practical nurse shall be supervised by 
a registered nurse who is available to the licensed practical 
nurse at least by phone during the hours that the licensed 
practical nurse is providing services or is on call; and
(II) The registered nurse shall make on-site supervisory 
visits at least monthly to assess and document that the licensed 
practical nurse is routinely providing nursing services in 
accordance with the plan of care.
E. The registered nurse shall develop a written aide 
assignment based upon the patient’s/family’s needs when 
hospice aide services are provided.
F. When aide services are being provided, a hospice 
registered nurse shall visit the home at least every two (2) 
weeks. The visit shall include an assessment of the aide services.
G. Written documentation shall show that the aide is 
providing services in accordance with the plan of care.
H. When an aide is permanently assigned to a hospice 
facility, the every two- (2-) week supervisory requirement 
does not apply, however there must be evidence of an annual 
performance review in the aide’s personnel file.
2. Medical director services. The medical director shall 
be a direct or contract employee. The medical director’s or 
designee’s services and responsibilities include—
A. Consulting with attending physicians regarding pain 
and symptom control;
B. Reviewing patient appropriateness for hospice 
services;
C. Acting as medical resource for the interdisciplinary 
group;
D. Acting as liaison to physicians in the community;
E. Assuring medical services are provided in the event 
the medical needs of the patient are not met by the attending 
physician; and
F. Routinely attending the interdisciplinary group 
meetings.
3. Medical social services.
A. Medical social services shall be provided in accordance 
with recognized standards of practice.
B. Social services shall be staffed to assure that the 
medical social service needs of each patient and family are 
met.
C. The assessment, planning, and provision of medical 
social services shall be the responsibility of the social worker.
D. The social services assessment visit shall be completed 
within five (5) days of admission or sooner if indicated.
4. Spiritual care services.
A. Spiritual care shall be available to all patients and 
families.
B. The spiritual counselor is responsible for assuring 
there is a documented assessment of the spiritual needs of the 
patient and family within five (5) days of admission or sooner 
if indicated and that spiritual care provided reflects assessed 
needs.
 CODE OF STATE REGULATIONS 7
John R. Ashcroft (2/28/23)
Secretary of State
19 CSR 30-35—DEPARTMENT OF HEALTH AND DIVISION 30—DIVISION OF REGULATION
 SENIOR SERVICES AND LICENSURE
C. The spiritual assessment shall include, at a 
minimum—
(I) The identification of any religious affiliation the 
patient and family may have; and
(II) The nature and scope of any spiritual concerns or 
needs identified.
D. A visit by the spiritual counselor shall be offered to 
each patient. If the patient declines spiritual counselor visits, 
the spiritual counselor will serve as a resource for other 
interdisciplinary team members assessing spiritual needs and 
providing care, and will be available to coordinate with other 
spiritual care providers the patient/family may have identified.
5. Bereavement care services.
A. There shall be an organized program for the provision 
of bereavement services under the supervision of a qualified 
professional who is a person with training or experience 
related to death, dying, and bereavement.
B. Within two (2) months following the patient’s death, 
there shall be an encounter (other than funeral attendance/
visitation) to assess the risk of the bereaved individual(s). A 
plan of care shall be developed that extends for one (1) year 
following the death appropriate to the level of risk assessed.
C. At least one (1) additional bereavement encounter 
shall occur within six (6) months after the death of the patient.
6. Other clinical services. The hospice shall provide the 
following services directly by hospice employees or through a 
contracted provider. The assessment, planning, and provision 
of these services shall be the responsibility of the applicable 
licensed or registered clinician.
A. Dietary counseling, when required, shall be planned 
by a qualified dietary counselor.
B. Physical therapy services, occupational therapy 
services, and speech language pathology services shall be 
offered in a manner consistent with accepted standards of 
practice.
(I) Therapy services delegated to the physical 
therapy assistant or the occupational therapy assistant shall 
be supervised by a licensed physical therapist or registered 
occupational therapist as appropriate who is available to the 
physical therapy assistant or occupational therapy assistant at 
least by phone during the hours that the assistant is providing 
services.
(II) When the assistant is providing services to a 
patient, the licensed or registered therapist shall make a 
supervisory visit to the residence of the patient at least every 
thirty (30) days.
(III) Written documentation shall show that the 
assistant is providing therapy services in accordance with the 
plan of care.
C. Additional counseling services. Any additional 
counseling services provided by the hospice shall be provided 
by qualified personnel, coordinated with all hospice services, 
included in the plan of care and documented in the clinical 
record.
D. Waiver.
(I) These requirements shall be waived by the 
department for areas of the state in which no licensed 
therapists/dietitians/nutritionists are available provided a good 
faith effort to provide the service is being made.
(II) A hospice seeking this waiver shall submit a 
written request to the department along with evidence of 
efforts made by the hospice to provide the service. If approved, 
a request for waiver shall be resubmitted annually for review.
7. Hospice aide and homemaker services. Hospice aide and 
homemaker services shall be available to meet the needs of the 
patients.
A. If homemaker needs are identified, a member of 
the interdisciplinary group shall assign and coordinate the 
services.
B. Hospice aide services shall be provided by a qualified 
person as set forth in this rule at 19 CSR 30-35.010(1)(A)17.
C. A hospice aide is not considered to have completed a 
training and competency program or a competency evaluation 
program if, since the individual’s most recent completion 
of such program(s), there has been a continuous period of 
twenty-four (24) consecutive months during none of which 
the individual furnished services described in 42 CFR 418.76 for 
compensation. 
D. The hospice aide shall follow written instructions 
for patient care which are prepared by a registered nurse who 
has physically assessed the patient. The hospice aide shall 
document care provided. Duties include, but shall not be 
limited to, the duties specified in the regulations pertaining to 
the Medicare hospice aide (42 CFR 418.76).
E. Twelve (12) hours of in-service training per aide per 
twelve- (12-) month period shall be provided or assured by 
the hospice. The hospice shall maintain a record of in-service 
training provided. 
(H) Medications. The hospice shall develop policies and 
procedures for the safe and effective use of medications, 
in accordance with accepted professional standards and 
applicable laws and regulations.
1. A medication list shall be maintained for each patient.
2. Medication orders shall include the medication name, 
dose, frequency, and route of administration.
3. Orders with variable doses or frequencies shall specify a 
maximum dose or frequency and the reason for administration.
4. Medications shall be provided on a timely basis and 
medication services shall be available on a twenty-four- (24-) 
hour basis for emergencies.
5. When controlled substance medications are delivered 
to the patient’s residence by hospice staff, the date, patient 
name, medication name and strength, quantity indicated on 
the prescription container, and signatures of the hospice staff 
member and the receiver shall be documented.
6. The hospice shall identify and document any misuse of 
controlled substances and shall notify the prescriber.
7. Medication use shall be reviewed with the patient, 
family, or both and medication information, counseling, and 
education shall be provided when appropriate.
8. Current medication reference material shall be available 
to professional staff for all medications used.
9. Medications shall be administered by persons who have 
statutory authorization, the patient, or a family member.
10. Administration by the patient or by a family member 
shall be evaluated for appropriateness and ability and this 
evaluation documented by the nurse.
11. Medication incidents, including medication errors 
and adverse medication reactions, shall be reported to 
the prescriber, the registered nurse coordinator, and the 
pharmacist.
12. The hospice shall have a policy for the disposal of 
controlled substances maintained in the patient’s home when 
those medications are no longer needed by the patient. The 
policy shall include at a minimum, information shared with 
family regarding disposition of medications when no longer 
required.
13. Medications shall not be transferred to other patients 
and shall not be removed from the residence by hospice staff.
(I) Medical Supplies and Equipment.
1. The provision of medical supplies and equipment shall 
be coordinated as needed for the palliation and management 
8 CODE OF STATE REGULATIONS 
(2/28/23) John R. Ashcroft
Secretary of State
DIVISION 30—DIVISION OF REGULATION 19 CSR 30-35—DEPARTMENT OF HEALTH AND
 AND LICENSURE SENIOR SERVICES
of the terminal illness and related conditions. Hospices shall 
make every effort to assure that patient needs for medical 
supplies and equipment are met.
2. Hospice shall provide education for patient/family, 
employees, and volunteers on the safe use of medical 
equipment.
3. Hospice shall provide evidence that all hospice-owned 
patient care related equipment has been inspected and 
maintained on an annual basis and in accordance with 
manufacturers specifications.
4. Hospice shall have policies and procedures for cleaning, 
storing, accessing, and distributing hospice-owned equipment.
5. Supplies shall be stored and maintained in a clean and 
proper manner.
(J) Volunteers.
1. Each hospice shall document and maintain a volunteer 
staff sufficient to provide administrative and direct patient care 
hours in an amount that, at a minimum, equals five percent 
(5%) of the total patient care hours of all paid hospice employees 
and contract staff. The hospice shall document a continuing 
level of volunteer activity.
2. Care and services through the use of volunteers, 
including the type of services and the time worked, shall be 
recorded.
3. The hospice shall document initial screening and active 
and ongoing efforts to recruit and retain volunteers.
4. The hospice shall provide task-appropriate orientation 
and training consistent with acceptable standards of hospice 
practice, that includes at a minimum—
A. Hospice philosophy, goals, and services;
B. The volunteer role in hospice;
C. Confidentiality;
D. Instruction in the volunteer’s particular duties and 
responsibilities; 
E. Whom to contact if in need of assistance or instruction 
regarding the performance of their specific duties and 
responsibilities; and
F. Documentation and record keeping as related to the 
volunteer’s duties.
5. The hospice shall, in addition, provide orientation for 
patient care volunteers that includes at a minimum—
A. Concepts of death and dying;
B. Communication skills;
C. Care and comfort measures;
D. Psychosocial and spiritual issues related to death and 
dying;
E. The concept of hospice patient and family as the unit 
of care;
F. Procedures to be followed in an emergency or 
following the death of the patient;
G. Concepts of grief and loss;
H. Universal precautions;
I. Safety;
J. Patient/family rights;
K. Hospice and the nursing home; and
L. Alzheimer’s disease and dementia-specific training as 
specified at 19 CSR 30-35.010(2)(M)1.B.(XIII).
6. The hospice shall document orientation and ongoing in-
services.
7. Volunteers functioning in accordance with professional 
practice acts shall show evidence of current professional 
standing and licensure, if applicable.
(K) Clinical Records.
1. In accordance with accepted principles of practice, the 
hospice shall establish and maintain a clinical record for every 
patient receiving care and services.
2. The record shall be complete, legible, readily 
accessible, and systematically organized to facilitate retrieval. 
Documentation shall be prompt and accurate.
3. Each clinical record shall be a comprehensive 
compilation of information. Entries shall be made for all 
services provided. 
4. Entries shall be made and signed by the person 
providing the services.
5. The record shall include all services whether furnished 
directly or through contracted providers. Each clinical record 
shall contain—
A. Physician’s orders;
B. Complete documentation of all assessments, 
services, visits, and events;
C. The plan of care and updates to the plan of care;
D. Identification data;
E. Consent form;
F. Pertinent medical history;
G. Determination of financial responsibility; and
H. Documentation of communication with coordinating 
providers.
6. The hospice shall safeguard the clinical record against 
loss, destruction, and unauthorized use.
(L) Facility Resident.
1. When the hospice patient resides in a nursing facility, 
the hospice collaborates with the nursing facility providing 
care to the patient/family to ensure coordination of services. 
2. Collaboration activities shall include the following:
A. There shall be a coordinated single plan of care in 
the nursing facility which may be multiple documents, that—
(I) Reflects coordination and input from both the 
hospice and the nursing facility;
(II) Identifies the care and services which each shall 
provide; and
(III) Is updated to reflect changes in patient/family 
condition, needs, and care.
B. Services usually identified as hospice services shall 
remain the responsibility of the hospice, and are provided or 
arranged by the hospice to meet the needs of the patient at 
the same level that the hospice normally furnishes to patients 
in their homes.
C. A registered nurse is designated from the hospice 
to coordinate the implementation of the plan of care, and to 
respond to questions and concerns from the nursing facility.
D. The hospice shall provide education to nursing 
facility staff that includes at a minimum—
(I) The purpose and nature of hospice care;
(II) Services provided by the hospice;
(III) Care plan coordination;
(IV) When and how to contact hospice staff.
3. The hospice shall document education provided and/or 
education offered and declined by the nursing home.
4. The hospice shall enter into arrangements only with 
nursing facilities which are appropriately licensed.
(M) Employee Training and Orientation.
1. Each hospice shall provide initial orientation for each 
direct employee that is specific to the employee’s job duties.
A. All employees shall be oriented to—
(I) Hospice philosophy, goals, and services;
(II) Confidentiality;
(III) Specific job duties;
(IV) Hospice policies and procedures as appropriate to 
the position.
B. Patient care employees shall also be oriented to—
(I) Interdisciplinary group function and responsibility;
(II) Communication skills;
(III) Physical, psychosocial, and spiritual assessment;
 CODE OF STATE REGULATIONS 9
John R. Ashcroft (2/28/23)
Secretary of State
19 CSR 30-35—DEPARTMENT OF HEALTH AND DIVISION 30—DIVISION OF REGULATION
 SENIOR SERVICES AND LICENSURE
(IV) Plan of care;
(V) Symptom management;
(VI) Universal precautions;
(VII) Patient/family safety issues;
(VIII) Patient/family rights;
(IX) Documentation; 
(X) Concepts of grief and loss;
(XI) Facility resident care;
(XII) Levels of hospice care; and
(XIII) Alzheimer’s disease and related dementias. 
Hospice agencies shall provide dementia-specific training 
about Alzheimer’s disease and related dementias to their 
employees and those persons working as independent 
contractors who provide direct care to or may have daily 
contact with residents, patients, clients, or consumers with 
Alzheimer’s disease or related dementias.
(a) At a minimum, the training required shall 
address the following areas:
I. An overview of Alzheimer’s disease and related 
dementias;
II. Communicating with persons with dementia;
III. Behavior management;
IV . Promoting independence in activities of daily 
living; and
V . Understanding and dealing with family issues.
(b) Employees or independent contractors who do 
not provide direct care for, but may have daily contact with, 
persons with Alzheimer’s disease or related dementias shall 
receive dementia-specific training that includes at a minimum—
I. An overview of Alzheimer’s disease and related 
dementias; and
II. Communicating with persons with dementia.
(c) Dementia-specific training about Alzheimer’s 
disease and related dementias shall be incorporated into 
orientation for—
I. New employees with direct patient contact; 
II. Independent contractors with direct patient 
contact; and 
III. Employees who do not provide direct care 
for, but may have daily contact with, persons with Alzheimer’s 
disease or related dementias. The training shall be provided 
annually and updated as needed.
C. Ongoing in-service training shall include a broad 
range of topics that reflect identified educational needs.
D. The hospice shall document initial orientation and in-
service topics presented.
2. Volunteers are exempt from these provisions, except for 
dementia-specific training as specified at 19 CSR 30-35.010 (2)
(M)1.B.(XIII), as their orientation and in-service requirements 
are defined in 19 CSR 30-35.010(2)(J)4., 5., and 6.
3. Contract employees shall receive orientation to 
dementia-specific training as specified at 19 CSR 30-35.010(2)
(M)1.B.(XIII), confidentiality, hospice philosophy, and to their 
specific job duties.
(N) Quality Assessment and Performance Improvement.
1. The hospice shall follow a written plan for assessing and 
improving program operations which includes—
A. Goals and objectives;
B. The identity of the person responsible for the program; 
and
C. A method for resolving identified problems.
2. The plan and performance improvement activities shall 
be reviewed at least annually by a designated group and the 
governing body and revised as appropriate.
3. When problems are identified in the provision of 
hospice services, the hospice shall document any evidence 
of corrective actions taken, including ongoing monitoring, 
revisions of policies and procedures, educational intervention, 
and changes in the provision of services.
4. The effectiveness of actions taken to improve services or 
correct identified problems shall be evaluated.
5. A designated group shall review and document the 
quality assessment and performance improvement activities 
and monitor corrective actions.
AUTHORITY: sections 192.2000 and 197.270, RSMo 2016.* Original 
rule filed March 8, 1996, effective Oct. 30, 1996. Rescinded and 
readopted: Filed Jan. 3, 2001, effective Aug. 30, 2001. Amended: 
Filed Sept. 11, 2007, effective March 30, 2008. ** Amended: Filed 
July 9, 2020, effective Jan. 30, 2021. Amended: Filed Sept. 15, 2022, 
effective March 30, 2023.
*Original authority: 192.2000, RSMo 1984, 1988, 1992, 1993, 1995, 2001, 2014, and 
197.270, RSMo 1992, amended 1993.
**Pursuant to Executive Order 21-07, 19 CSR 30-35.010, part (2)(M)1.B.(XIII) was suspended from 
April 22, 2020 through August 31, 2021. Pursuant to Executive Order 21-09, 19 CSR 30-35.010, 
paragraph (1)(A)1. was suspended from April 9, 2020 through December 31, 2021.
19 CSR 30-35.020 Hospice Providing Direct Care in a Hospice 
Facility
PURPOSE: This rule defines the minimum requirements necessary 
for the construction and operation of hospice inpatient facilities in 
order to be certified as part of the hospice program.
(1) A hospice that delivers care in a facility operated by the 
hospice and not otherwise licensed shall comply with this rule 
in addition to 19 CSR 30-35.010 and 19 CSR 30-35.030.
(2) Each patient shall receive treatment, medications and 
diet as prescribed and shall be kept comfortable, clean, well-
groomed and protected from accident, injury and infection.
(3) Organization and Management of Hospice Facilities.
(A) 24-Hour Staffing.
1. The hospice shall provide 24-hour staffing which is 
sufficient to meet the patients’ total needs in accordance with 
the patient plan of care.
2. All hospices shall employ qualified staff at the ratio of no 
less than one for every ten (1:10) patients per shift, per patient 
unit, 24 hours a day.
3. Staffing personnel shall be on duty at all times on each 
patient-occupied floor, with no less than two staff personnel in 
a facility at all times.
4. Minimum staff personnel shall be no less qualified 
than one home health aide or companion/volunteer and one 
licensed practical nurse.
5. A registered nurse shall be available for telephone 
consultation or on-site visit as needed, 24 hours a day.
6. Facility personnel shall have a telephone access to 
administrative staff, 24 hours a day.
(B) Disaster Preparedness.
1. The hospice shall have a written plan, annually rehearsed 
with staff, which includes procedures to be followed in the 
event of an internal or external disaster and for the care of 
casualties arising from disasters.
2. Each facility shall conduct quarterly fire drills so that 
each shift participates at least annually.
(C) Meals Service Menu Planning and Supervision. The 
hospice shall:
1. Make available a practical freedom of choice diet 
offering at least three meals and snacks, or their equivalent, 
that accommodate patient’s needs and preferences each day 
10 CODE OF STATE REGULATIONS 
(2/28/23) John R. Ashcroft
Secretary of State
DIVISION 30—DIVISION OF REGULATION 19 CSR 30-35—DEPARTMENT OF HEALTH AND
 AND LICENSURE SENIOR SERVICES
at regular times, with not more than 14 hours between a 
substantial evening meal and breakfast;
2. Prepare and serve foods using methods that conserve 
nutritive value, flavor and appearance;
3. Give special attention to the texture of food served to 
patients who have chewing difficulty;
4. Provide assurance that hot food is served hot and cold 
food is served cold;
5. Give a minimum of 30 minutes for eating meals. 
Patients who eat slowly or who need assistance shall be given 
as much time to eat as necessary;
6. Make tray service and dining room service attractive 
for patients and ensure that each patient receives appropriate 
table service;
7. Provide each patient who is served meals in bed or 
in a chair not within the dining area with either a table, an 
overbed table or an overbed tray of sturdy construction which 
is positioned so that the patient can eat comfortably;
8. Provide assistance upon tray delivery to all patients 
requiring assistance at mealtimes, whether it be preparation 
of the food items or actual feeding. Dining room supervision 
shall be provided during meals;
9. Establish an identification system to assure that each 
patient receives the diet as ordered;
10. Provide sufficient equipment and personnel trained in 
their duties to assure adequate preparation and serving of food 
if meals are prepared on-site;
11. Review menus for special prescribed diets and approve 
in writing by either a qualified dietitian, a registered nurse, or 
a physician;
12. Keep a current record of purchased food to show the 
kind and amount of food purchased each month, if meals are 
prepared on-site;
13. Plan menus for all diets at least two weeks in advance 
if meals are prepared on-site. If cycle menus are used, the cycle 
shall cover a minimum of three weeks and shall be different 
each day of the week;
14. Make fresh water readily accessible to all patients at 
all times;
15. Procure, store, prepare, distribute and serve all food 
under sanitary conditions;
16. Permit family to bring, prepare and serve food to their 
loved one; and
17. Permit staff to prepare a single patient snack upon 
request.
(D) Patient Areas.
1. The hospice shall design and equip areas for the comfort 
and privacy of each patient and family member.
2. The hospice shall have accommodations for family 
privacy after a patient’s death that do not infringe on other 
patients’ rights and decor which is homelike in design and 
function;
3. Patients shall be permitted to receive visitors, including 
small children, at any hour;
4. The facility shall have a policy regarding pets; and
5. Smoking may be permitted in the hospice consistent 
with the smoking policy of the facility. Smoking may be 
permitted in the patient’s room and in designated smoking 
areas. Individual patients may be permitted to smoke in their 
rooms with the consent of any other patients occupying the 
room and with the permission of his/her attending physician. 
If a patient is confined to bed or classified as not being 
responsible, smoking is permitted only under the direct 
supervision of an authorized individual.
(E) Infection Control.
1. The hospice shall make disease-specific provision for 
isolating patients with infectious diseases.
2. Infectious waste management control.
A. Every inpatient hospice facility shall write an 
infectious waste management plan with an annual review 
identifying infectious waste generated on-site, the scope of 
the infectious waste program and policies and procedures 
to implement the infectious waste program. The plan shall 
include at the least the following: administrator’s endorsement 
letter; introduction and purpose; objectives; phone number of 
responsible individuals; definition of those wastes handled 
by the facility; identification of responsible individuals; 
procedures for waste identification, segregation, containment, 
transport, treatment and disposal; emergency and contingency 
procedures and training; and educational procedures.
B. Infectious waste shall be segregated from other 
wastes at the point of generation and shall be placed in 
distinctive, clearly marked, leakproof containers or plastic bags 
appropriate for the characteristics of the infectious waste.
C. Containers for infectious waste shall be identified 
with the universal biological waste symbol. All packaging shall 
maintain its integrity during storage and transport. Infectious 
waste shall not be placed in a gravity disposal chute.
D. Pending disposal, infectious waste shall be stored 
separately from other wastes in a room limited to staff access.
E. When transported off the premises of the hospice, 
all infectious waste shall be packaged and transported as 
provided in sections 260.200–260.245, RSMo.
F. Hospices generating 100 kilograms or less of infectious 
waste per month must comply with section 260.203.10, RSMo.
3. Written policies and procedures shall define and 
describe the scope and conduct of laundry and linen services. 
There shall be a mechanism for the review and evaluation on 
an annual basis of the quality of laundry services.
4. Written policies and procedures shall define and 
describe the scope and conduct of on-site cleaning of dietary 
ware. There shall be a mechanism for the review and evaluation 
on an annual basis of the quality of dietary-ware sanitizing 
services provided.
(F) Pharmacy Services. The hospice shall comply with all 
provisions of 19 CSR 30-35.010 regarding medications.
1. The hospice shall employ or contract with a pharmacist.
A. The pharmacist shall assist in the development 
of policies and procedures for medication use, shall advise 
the hospice on all other matters pertaining to the use of 
medications, shall serve as a member of, or consultant to, 
the interdisciplinary team and shall provide medication 
information to professional staff as required.
B. A pharmacist shall be available on a twenty-four (24)-
hour basis for emergencies.
2. Medication acquisition and labeling.
A. Prescription medications shall be maintained as 
individual patient prescriptions or in an automated dispensing 
system. 
B. Each facility shall maintain an emergency medication 
supply. When the emergency medication supply is separate 
from an automated dispensing system and contains controlled 
substances the facility shall be registered with the Missouri 
Bureau of Narcotics and Dangerous Drugs.
C. Automated dispensing systems may be controlled 
by the facility or may be controlled on-site or remotely by a 
pharmacy.
(I) When an automated dispensing system is controlled 
by the facility:
(a) A pharmacist shall be responsible for the 
operation of the automated dispensing system and training of 
 CODE OF STATE REGULATIONS 11
John R. Ashcroft (2/28/23)
Secretary of State
19 CSR 30-35—DEPARTMENT OF HEALTH AND DIVISION 30—DIVISION OF REGULATION
 SENIOR SERVICES AND LICENSURE
facility staff in its use;
(b) A pharmacist shall review and confirm each new 
medication order prior to administration of the first dose;
(c) The facility shall have a policy and procedure 
to allow removal of initial doses of approved emergency 
medication supply medications in lieu of maintaining a 
separate emergency medication supply;
(d) A pharmacist or pharmacy technician shall place 
medications in the automated dispensing system. Medications 
to be placed in the automated dispensing system shall be 
checked and approved by a pharmacist;
(e) When the automated dispensing system contains 
controlled substances, the facility shall be registered with the 
Missouri Bureau of Narcotics and Dangerous Drugs and the 
Drug Enforcement Administration; and
(f) When the automated dispensing system is for 
the purpose of an emergency medication supply only, subparts 
(b) and (c) of this part shall not apply and the facility shall 
not be required to be registered with the Drug Enforcement 
Administration.
(II) When an automated dispensing system is 
controlled by a pharmacy:
(a) A pharmacist shall review and confirm each new 
medication order prior to releasing the medication from the 
system;
(b) The pharmacy and the facility shall have a 
policy and procedure to allow removal of initial doses of 
approved emergency medication supply medications when the 
automated dispensing system is used in lieu of maintaining a 
separate emergency medication supply;
(c) A pharmacist or pharmacy technician shall place 
medications in the automated dispensing system. Medications 
to be placed in the automated dispensing system shall be 
checked and approved by a pharmacist;
(d) The pharmacy shall comply with all requirements 
of paragraph 3. of this subsection;
(e) The automated dispensing system shall be 
licensed by the Board of Pharmacy and shall be used in 
compliance with 20 CSR 2220-2.900;
(f) When the automated dispensing system contains 
controlled substances it shall be registered with the Missouri 
Bureau of Narcotics and Dangerous Drugs and the Drug 
Enforcement Administration; and
(g) When the automated dispensing system is for 
the purpose of an emergency medication supply only, subparts 
(a) and (e) of this part shall not apply and it shall not be required 
to be registered with the Drug Enforcement Administration.
(III) A facility employee who registers with the Board of 
Pharmacy as a pharmacy technician shall be a nurse, certified 
pharmacy technician, or certified medication technician. 
The pharmacist shall be responsible for the training of the 
employee and shall supervise the employee in compliance 
with 20 CSR 2220-2.700 when pharmacy technician functions 
are being performed.
D. Patient prescription medications shall be labeled with 
at least the patient name, medication name, strength and date 
dispensed. They shall also contain accessory information and 
the expiration date when applicable.
E. Prescription medication labels shall not be altered 
by hospice staff and medications shall not be repackaged by 
hospice staff except as allowed by (3)(F)4.E.
F. When the patient’s own medications are used, they 
shall be examined prior to use for suitability and positively 
identified by a pharmacist or nurse in writing.
G. Non-prescription medications may be obtained 
as stock or individual patient supplies. They shall not be 
repackaged, except as allowed by (3)(F)4.E., and supplies for 
individual patients shall be labeled with the patient’s name.
3. Medication storage and control.
A. All medications shall be stored in locked compartments 
under proper temperature controls, separate from food 
and other substances. Medications shall be accessible only 
to persons authorized to administer them, pharmacists or 
pharmacy technicians.
B. Controlled substances shall be stored in locked 
compartments separate from other medications.
C. The pharmacist shall inspect medication storage 
areas and the emergency medication supply monthly and shall 
document this inspection.
D. Records of receipt and disposition of all controlled 
substances shall be maintained separate from other records.
(I) Inventories of Schedule II controlled substances 
shall be reconciled each shift when they are not maintained in 
an automated dispensing system.
(II) Inventories of Schedule III–V controlled substances 
shall be reconciled daily when they are not maintained in an 
automated dispensing system.
(III) Inventories of controlled substances shall be 
reconciled at least every seventy-two (72) hours when they are 
maintained in an automated dispensing system.
(IV) Receipt records shall include the date, source 
of supply, patient name and prescription number when 
applicable, medication name and strength, quantity and 
signatures of the supplier and receiver.
(V) Administration records shall include the date, 
time, patient name, medication name, dose administered and 
signature of the person administering.
(VI) Documentation of waste at the time of 
administration shall also include the reason for the waste and 
the signature of an authorized employee witness.
E. The pharmacist shall review controlled substance 
record keeping monthly.
F. All variances of controlled substance records shall 
be reported to the registered nurse coordinator and the 
pharmacist for review and investigation.
G. All losses of controlled substances shall be reported to 
the Missouri Bureau of Narcotics and Dangerous Drugs and to 
other federal, state and local authorities when required.
H. All controlled substance records shall be maintained 
for two (2) years.
4. Medication administration.
A. Medication administration by the patient or a family 
member shall be ordered by the physician. Instructions for 
administration shall be provided.
B. Non-controlled substances may be stored in a locked 
compartment in the patient’s room.
C. Single doses of controlled substances may be placed 
in the locked compartment or provided directly to the patient 
or family member prior to the time of administration.
D. Administration of the patient’s own medications 
brought to the facility shall be ordered by the authorized 
prescriber.
E. Medications for administration when a patient 
temporarily leaves the facility shall be labeled by the pharmacy 
with instructions for administration, except that a single 
dose of each medication may be provided by the nurse 
in containers labeled with the patient’s name, medication 
name and strength, instructions for administration, and other 
necessary information.
F. Medication administration shall be documented on 
a separate record. Administration by the patient or a family 
member shall be monitored by nursing staff and documented.
12 CODE OF STATE REGULATIONS 
(2/28/23) John R. Ashcroft
Secretary of State
DIVISION 30—DIVISION OF REGULATION 19 CSR 30-35—DEPARTMENT OF HEALTH AND
 AND LICENSURE SENIOR SERVICES
5. Other medication disposition.
A. Medications may be sent with a patient at the time 
of discharge only if they have been labeled by the dispensing 
pharmacy with instructions for administration and ordered by 
the authorized prescriber.
B. Records of this disposition shall include the date, 
patient name, prescription number, drug name and strength, 
quantity and signatures of the persons releasing and receiving 
the medications.
C. Patient prescription medications that have been 
discontinued shall be destroyed within sixty (60) days if 
they are controlled substances or if they are not in unit-dose 
packaging.
D. Patient prescription medications of expired patients 
shall be destroyed within five (5) days if they are controlled 
substances or if they are not in unit-dose packaging or if they 
were brought from home.
E. Other expired or nonusable medications shall be 
destroyed within five (5) days.
F. Medications shall be destroyed by a pharmacist 
and a nurse or two (2) nurses, and a record of destruction 
shall be maintained which includes the date, patient name, 
prescription number, medication name and strength, quantity, 
method of destruction and signatures of the persons destroying 
the medications.
G. Unit-dose packaged medications returnable to the 
pharmacy shall be returned within ten (10) days.
H. Medications shall not be transferred to other patients 
and shall not be removed from the facility by hospice staff, 
except those being returned to the pharmacy.
(4) General Design and Construction Standards for New 
Inpatient Hospice Facilities.
(A) Health and Safety Laws. The hospice shall meet all 
federal, state and local laws, ordinances, regulations and 
codes pertaining to health and safety, including but not 
limited to, provisions regulating construction, maintenance 
and equipment.
1. General Requirements.
A. After October 30, 1996, a new hospice facility shall 
submit plans for approval to the Department of Health for the 
construction of a new facility, expansion or renovation of an 
existing state certified hospice or the conversion of an existing 
facility not previously and continuously state certified and 
operated as a hospice facility under section 197.250, RSMo.
B. New hospice facilities shall be designed and 
constructed in conformance with this rule.
C. This rule is not intended to restrict innovations 
and improvements in design or construction techniques. 
Accordingly, the Department of Health may approve plans and 
specifications which contain deviations from this rule. Requests 
for deviations from requirements on physical facilities shall 
be in writing to the Department of Health and shall contain 
information which determines that the respective intent or 
objectives of this rule have been met. Approvals for deviations 
shall be in writing and both requests and approvals shall be 
made a part of the permanent Department of Health records 
for the hospice.
D. Where renovation or replacement work is done within 
an existing licensed facility, all new work, additions, or both, 
shall comply with the applicable sections of this rule. Where 
existing major structural elements make total compliance 
impractical or impossible, alternative proposals which result in 
an equivalency may be considered by the department.
E. In renovation projects and additions to existing 
state certified hospice facilities, only that portion of the total 
facility affected by the project shall comply with the applicable 
sections of this rule. However, upon construction completion, 
the facility shall satisfy all functional requirements for state 
certified hospices.
F. Those existing portions of the facility which are not 
included in the renovation but which are essential to the 
functioning of the complete facility as well as existing state 
certified building areas that receive less than substantial 
amounts of new work shall, at a minimum, comply with 
the state certification requirements which were in effect at 
the time that the existing portion of the building was state 
certified.
G. All required fire exits shall be maintained throughout 
the construction and the work shall be phased as necessary to 
minimize disruption of the existing hospice operation.
2. Planning and Construction Procedures.
A. Any hospice facility constructed or renovated after 
October 30, 1996 shall have plans and specifications prepared 
in conformance with Chapter 327, RSMo by an architect or 
engineer duly registered in Missouri. The owner of each 
new facility or the owner of an existing licensed inpatient 
hospice being added to or undergoing major alterations shall 
provide a program—scope of services—which describes space 
requirements, staffing patterns, departmental relationships 
and other basic information relating to the objectives of the 
facility. The program may be general but it shall include a 
description of each function to be performed, approximate 
space needed for these functions and the interrelationship 
of various functions and spaces. The program shall describe 
how essential services can be expanded in the future as the 
demand increases. Appropriate modifications or deletions in 
space requirements may be made when services are shared or 
purchased, provided the program indicates where the services 
are available and how they are to be provided. This program 
shall be submitted to the Department of Health for review 
along with the plans developed for the project. Schematic and 
preliminary plans showing the basic layout of the building and 
the general types of construction, mechanical and electrical 
systems and details may be submitted to the department 
before the larger and more complicated working drawings 
and specifications so that necessary corrections can be easily 
made before final plans are completed. Working drawings and 
specifications, complete in all respects, shall be prepared and 
submitted to the Department of Health for approval. These plans 
shall cover all phases of the construction project, including site 
preparation: paving; general construction; mechanical work, 
including plumbing, heating, ventilating and air conditioning; 
electrical work; and all built-in equipment, including elevators, 
kitchen equipment, cabinet work, and the like.
B. The Department of Health shall be notified in writing 
within five (5) days after construction begins. Construction 
shall be in conformance with plans and specifications approved 
by the Department of Health. The department may elect 
to inspect the construction of hospice projects at any time 
during the development of the project. If construction of the 
project is not started within one (1) year or completed within 
a period of three (3) years after the date of the approval of the 
plans and specifications, the plans and specifications shall be 
resubmitted to the Department of Health for its approval and 
shall be amended, if necessary, to comply with the then current 
rules before construction work is started or continued.
C. References in this rule to National Fire Protection 
Association (NFPA) publications are those contained 
in the 12-volume 1994 Compilation of NFPA Codes, Stand-
ards, Recommended Practices and Guides. Where there are 
discrepancies between referenced NFPA publication 
 CODE OF STATE REGULATIONS 13
John R. Ashcroft (2/28/23)
Secretary of State
19 CSR 30-35—DEPARTMENT OF HEALTH AND DIVISION 30—DIVISION OF REGULATION
 SENIOR SERVICES AND LICENSURE
requirements and this rule, the requirements of this rule shall 
apply. 
D. The design and construction of hospices shall conform 
to the most stringent requirements of this rule and the local 
governing building code and zoning ordinances.
3. Site.
A. Adequate paved pedestrian access shall be provided 
within the lot lines to the main entrance. Loading and 
unloading space for delivery vehicles shall be paved.
B. Adequate paved parking shall be provided. Parking 
space needs shall be determined by the local zoning 
requirement and the operational program but shall not be less 
than one (1) space for each of the maximum number of staff 
persons on duty at any given time plus one (1) parking space 
for each licensed inpatient bed in the facility.
C. Fire lanes shall be provided as required by local 
authority and kept clear to provide immediate access for fire 
fighting equipment.
D. The site shall provide reasonable access for those 
individuals to be served by the facility. The facility shall be 
on an all-weather road for easy access by vehicular traffic. 
Consideration should be given to locating the hospice to 
provide easy access to public transportation services which 
may be available in the community.
E. The site shall be located within the service area of a 
public fire department.
4. Roads, parking facilities, walks, ramps and entrances 
shall be accessible and usable by persons with various physical 
handicaps.
A. At least one toilet, telephone and drinking fountain 
shall be provided on each floor of a hospice which is accessible 
for use by handicapped public and staff.
B. Elevator controls and alarms shall be accessible 
to wheelchair occupants and shall be provided with tactile 
signage for the visually impaired.
C. Design details for handicapped accessible facilities 
should be consistent with the Guidebook to: The Minimum 
Federal Guidelines of Requirements for Accessible Design 
published January 6, 1981, by the U.S. Architectural and 
Transportation Barriers Compliance Board.
D. At least ten percent (10%) of the patient beds shall be 
located in handicapped-accessible rooms with accessible toilet 
rooms which open directly into the patient room. All other 
clinical areas to which patients have common access shall be 
handicapped-accessible.
5. Administrative and public areas shall be provided.
A. All hospices shall provide adequate work areas to 
support the administrative personnel and governing body. 
The facilities shall allow business to be conducted in a setting 
which provides confidentiality and privacy as required. The 
administrative offices may be located remotely from a hospice 
inpatient unit or may be housed within the inpatient facility.
B. Where administration is included within the inpatient 
facility, the following shall be provided:
(I) Administrator’s office;
(II) Business office including a work area for quality 
assurance;
(III) Storage and work area for archived medical 
records;
(IV) Conference room for governing board meetings 
and personnel in-service training; and
(V) Office for director of patient-care services.
C. Each inpatient hospice facility shall provide the 
following public areas in a location separated from the clinical 
and service areas of the facility:
(I) Lobby/waiting room with reception;
(II) Wheelchair accessible public toilet;
(III) Wheelchair accessible public drinking fountain; 
and
(IV) Wheelchair accessible public phone.
6. Design of patient-care units.
A. One or more patient-care units shall be provided. 
Each unit shall not exceed a maximum of twenty (20) beds.
B. Each patient-care unit shall be a continuous area 
which does not require patient-care traffic to traverse other 
areas and shall be restricted to only one (1) floor level. If 
justified by the program submitted under subparagraph (2)
(A)2.A. of this rule, the department may consider approval of 
designs which provide for larger capacity patient-care units.
C. The bed area in a patient room exclusive of toilet 
rooms, closets, alcoves or vestibules, shall not be less than one 
hundred twenty (120) square feet in a private room and not 
less than two hundred (200) square feet in a semi-private room. 
Heating units and lavatories may protrude into this space.
D. No dimension for the bed area in any patient room 
shall be less than ten (10) feet.
E. No patient room shall house more than two (2) 
patients.
F. Each patient-care unit shall have not greater than 
fifty percent (50%) of its beds housed in semi-private rooms 
and the remaining rooms shall be limited to occupancy by 
one (1) patient. If justified by the program submitted under 
subparagraph (2)(A)2.A. of this rule, the department may 
consider approval of designs which provide other ratios of 
semi-private to private patient rooms.
G. Each patient shall have access to a toilet room 
without entering the general corridor area.
H. One (1) toilet may serve not more than two (2) 
adjacent rooms.
I. The toilet room shall contain a lavatory and water 
closet and shall be sized to permit access for the patient and 
an assisting member of the staff. The lavatory may be omitted 
from the toilet room if a lavatory is provided in the patient 
room.
J. At least one (1) patient room per patient-care unit shall 
be provided to be used for isolation. This unit shall have a 
toilet room equipped with a bathing facility which serves this 
room exclusively.
K. Mirrors shall be provided in each patient room or 
adjoining toilet room. Mirrors shall be at least three (3) feet 
high located with the bottom edge no more than three feet 
four inches (3'4") above the floor.
L. Patients shall have separate wardrobes, lockers or 
closets located within their respective patient rooms. A clothes 
rod and shelf shall be provided.
M. One or more windows shall be provided, with the 
sash not more than three (3) feet above the floor and with a 
gross area of not less than ten percent (10%) of the floor area 
of the room. In each patient room at least one (1) window 
to the outside shall be operable. Patient room windows 
shall be exposed to an outside area not less than thirty (30) 
feet horizontally opposite the window which contains no 
construction or grading which would further diminish the 
view and the exposure of the window to natural light.
N. Social spaces (dining, recreation, meditation) shall 
be provided throughout the facility with a cumulative area of 
not less than thirty (30) square feet per patient bed. One social 
space may serve more than one patient-care unit provided it is 
directly accessible from each unit and is sized proportionate to 
the total number of patient beds it serves. No social space shall 
be smaller than one hundred fifty (150) square feet in area.
14 CODE OF STATE REGULATIONS 
(2/28/23) John R. Ashcroft
Secretary of State
DIVISION 30—DIVISION OF REGULATION 19 CSR 30-35—DEPARTMENT OF HEALTH AND
 AND LICENSURE SENIOR SERVICES
O. Unless bathing facilities are included in the toilets 
serving each patient room, central bathing facilities shall be 
provided in each patient-care unit at a ratio of not fewer than 
one for each ten (1:10) beds.
P . Each bathing facility shall be located in its own room 
and shall be directly accessible from the general corridor. The 
bathing facility may be either a tub, shower or tub/shower 
combination.
Q. However, at least one (1) handicapped accessible 
shower shall be provided on each patient unit.
R. A locked cabinet for the storage of cleaning supplies 
shall be available in or near each bathroom.
7. Support and services areas. The following staff support 
and service areas shall be located directly accessible to each 
patient care unit:
A. Clean work and storage facilities shall be equipped 
with counter and sink and storage space provided for clean 
linen and supplies;
B. A separate soiled/decontamination utility room shall 
be equipped with a clinic sink (this fixture is not required 
where bedpan-flushing devices have been installed at each 
patient toilet), counter and sink and sufficient floor space shall 
be provided to accommodate storage containers for soiled 
linen, trash and infectious waste;
C. Space shall be provided for secure storage of staff 
personal items;
D. A staff station shall be located to provide visual 
supervision of the patient-care unit corridors. The station shall 
consist of a work counter and secure storage space for charts;
E. A medication storage and preparation station which 
has a means of locked storage for all medications shall be 
equipped with a work counter, sink, and refrigerator;
F. Separate locked storage facilities shall be provided in 
the station for controlled substances;
G. If medications are held in each patient room, the 
room shall include separate locked storage facilities for each 
patient’s medications;
H. A nourishment station shall be equipped with a work 
counter, sink, and refrigerator and shall be provided physically 
remote from the medication preparation station;
I. Storage space shall be provided for mobile equipment 
used on the unit;
J. A janitor’s closet shall be provided which is equipped 
with a mop sink and has sufficient space for the cleaning 
equipment and open supplies used to maintain the patient-
care unit; and
K. All clean support functions may be located in one 
clean workroom provided the room is carefully designed to 
provide adequate storage and function separations.
8. Food service facilities shall be designed and equipped 
to meet the requirements of the scope of services outlined as 
follows:
A. Dietary facilities shall comply with 19 CSR 20-1.010;
B. In hospice facilities where food is prepared on-site, the 
dietary facilities shall, as a minimum, have—a storage space 
including cold storage for four-day supply, space and equipment 
for food preparation to facilitate efficient food preparation and 
to provide for a safe and sanitary environment, conveniently 
located handwashing facilities, space for preparing food for 
distribution to patients, warewashing facilities which are 
isolated from the food preparation and serving area, and 
storage facilities for waste which is inaccessible for insects and 
rodents and accessible to the outside for pickup or disposal.
C. The warewashing processes shall produce dietary 
ware which is free of pathogenic organisms; and
D. In hospice facilities where the food service is 
provided through a vendor contract, dietary facilities shall, as 
a minimum, include space for receiving and holding the food 
transport equipment, utility connections for food transport 
equipment to maintain appropriate serving temperatures, and 
a holding area for soiled dietary ware transport equipment 
which is out of the patient area and located near the service 
entrance for pick-up.
(B) Service Facilities Shall Meet the Following Standards:
1. Services including linen service.
A. Service facilities shall be provided in each inpatient 
hospice facility and located to be out of the normal public and 
clinical traffic flow.
B. A weather-protected service entrance shall be 
provided separate from entrances used by public and patients.
C. Space and facilities shall be provided for the sanitary 
storage and disposal of waste. Exterior dumpsters will suffice 
provided they can be accessed under the protection provided 
at the service entrance.
D. A general storage room shall be provided with an area 
not less than ten (10) square feet per bed for the first fifty (50) 
beds, plus eight (8) square feet per bed for the next twenty-
five (25) beds, plus five square feet per bed for any additional 
beds over seventy-five (75). No storage room shall be less than 
one hundred (100) square feet of floor space. Off-site storage 
is acceptable, however, one half (1/2) of the required storage 
space shall be located in the inpatient hospice facility. General 
storage shall be concentrated in one area.
E. Space shall be provided to house mechanical 
equipment. The space shall be adequate for initial installation 
and ongoing maintenance access for each component of the 
systems housed in it. Mechanical equipment shall not be 
installed in rooms designated to house other functions.
F. A housekeeping room shall be provided with a 
janitor’s sink and space to store opened containers of cleaning 
supplies and housekeeping equipment used to maintain the 
facility. This room is not required if the hospice is maintained 
by a contract cleaning service which transports the necessary 
cleaning supplies and equipment to the facility on a daily 
basis.
G. An oxygen storage room shall be provided. This room 
shall be enclosed with one-hour rated construction and shall 
have a powered or gravity vent to the outside. Permanent 
racks or fasteners shall be provided and used in the oxygen 
storage room to prevent accidental damage or dislocation of 
oxygen cylinders. In facilities storing quantities of oxygen less 
than one thousand five hundred (1,500) cubic feet in total, a 
power ventilated storage cabinet will comply. No ventilated 
gas storage facilities are required in hospices which store no 
medical gases within the building.
H. Laundry services may be provided by the hospice 
operator or may be obtained through contract with a linen 
service vendor. If laundry for the facility is done commercially, 
either entirely or in part, space shall be provided for the 
sorting, processing and storing of both soiled and clean linen. 
Storage space shall be located to facilitate convenient pickup 
and delivery by commercial laundry personnel. Hospices with 
only one patient-care unit may accommodate these functions 
within the utility facilities provided in the unit’s staff support 
area.
I. Hospice-operated laundry facilities shall be designed 
and procedures instituted to prevent cross-contamination of 
clean and dirty linen. The laundry room shall be in a separate 
room from the kitchen, patients’ rooms, the dining room and 
the bathrooms or the nursing utility room. Adequate space 
shall be provided in the laundry room for the storing, sorting 
and processing of soiled linen. The processes of the laundry 
 CODE OF STATE REGULATIONS 15
John R. Ashcroft (2/28/23)
Secretary of State
19 CSR 30-35—DEPARTMENT OF HEALTH AND DIVISION 30—DIVISION OF REGULATION
 SENIOR SERVICES AND LICENSURE
operation shall be appropriate to the production of patient 
linens which are free of pathogenic organisms. Space shall be 
provided for the storage of clean linen in a separate room from 
the laundry.
J. As may be required by the program, laundry facilities 
provided for cleaning patients’ clothing exclusively shall 
be located in the patient-care unit but in a room separate 
from other functions. A residential-style laundry equipment 
installation is acceptable.
K. As required by the program, living and sleeping 
quarters, separate from patients’ facilities, shall be provided for 
the employees and their families who may reside in the facility;
2. Elevators.
A. All inpatient hospice facilities having patient-care 
facilities located on any floor other than the main entrance 
floor shall have at least one (1) electric or electrohydraulic 
elevator. Hospice facilities with more than thirty (30) beds 
located on any floor other than the main entrance floor shall 
have at least two (2) elevators. Hospice facilities with more 
than two hundred (200) beds located on any floor other 
than the main entrance floor shall provide passenger and 
service elevators in numbers and at locations determined by a 
professionally conducted study of the hospice operation and its 
estimated vertical transportation needs.
B. Inside dimensions of patient-use elevators shall be 
not less than five feet four inches (5'4") by eight feet (8')with a 
capacity of 3,500 pounds. Cab and hoistway doors shall be not 
less than three feet ten inches (3'10") clear opening.
C. Elevators shall be equipped with an automatic 
leveling device of the two-way automatic maintaining type 
with an accuracy of plus or minus one-half inch.
D. Elevator call buttons, controls and door safety stops 
shall be of a type that will not be activated by heat or smoke.
E. Elevator controls, alarm buttons and telephones shall 
be accessible to wheelchair occupants and usable by others 
with various physical disabilities.
F. Elevator hoistway doors shall be fire rated to maintain 
the integrity of the fire-rated shaft enclosure;
3. Chutes and dumbwaiters.
A. Chutes and dumbwaiters may be installed in hospice 
facilities as required by the operational program.
B. Linen and trash chutes shall be of fire-resistant 
material and shall be installed with flushing ring, vent to 
atmosphere and floor drain at the floor of the chute discharge. 
An automatic sprinkler shall be provided at the top of each 
linen and trash chute.
C. Service openings to chutes shall not be located in 
corridors or passageways but shall be located in a room having 
a fire-resistant construction of not less than one hour. Doors 
to the rooms shall be not less than 3/4-hour labeled doors 
equipped with an automatic closing device.
D. Service openings to chutes and other vertical openings 
shall have an approved self-closing labeled fire door rating not 
less than the fire-resistant rating of the shaft in which the 
chute is installed.
E. Chutes shall discharge directly into collection rooms 
separate from the incinerator, laundry or other services. 
Separate collection rooms shall be provided for trash and for 
linen. These rooms shall have a fire-resistant construction 
of not less than one hour. Doors to these rooms shall be not 
less than 3/4-hour labeled doors equipped with an automatic 
closing device.
F. Dumbwaiters, conveyors and material-handling 
systems shall not open directly into a corridor or exitway but 
shall open into a room enclosed by construction having a fire 
resistance of not less than one hour and provided with a 3/4-
hour labeled fire door with a self-closing device.
G. Where horizontal conveyors and material-handling 
systems penetrate fire-rated walls or smoke walls, the 
penetrations shall be protected to maintain the integrity of 
the wall;
4. General design, finish and life safety requirements.
A. A continuous system of unobstructed corridors, 
referred to as required corridors, shall extend through the 
enclosed portion of each story of the building, connecting 
all rooms and spaces with each other and with all entrances, 
exitways and elevators, with the following exceptions: work 
suites such as the administrative suite and dietary area, 
which are occupied primarily by employed personnel, may 
have within them corridors or aisles as considered advisable, 
but are not subject to the regulations applicable to required 
corridors. Areas may be open to the required corridor system as 
permitted by NFPA 101 (1994), The Life Safety Code.
B. The arrangement of the physical plant shall provide 
for separation of the administrative/business, service and 
public areas from patient service areas.
C. Ceilings shall be at a height of at least eight feet. 
Ceilings in corridors, storage rooms, toilet rooms and other 
minor rooms shall not be less than seven feet six inches (7'6"). 
Suspended fixtures located in the path of normal traffic shall 
not be less than six feet eight inches (6'8") above the floor.
D. Handrails may be provided on both sides of all 
corridors and aisles used by patients and, if provided, corridor 
handrails shall have ends return to the wall.
E. New inpatient hospice facilities shall be designed 
and constructed in compliance with Chapters Five through 
Seven and Chapter Twelve of NFPA 101 (1994), Life Safety Code 
and NFPA 99 (1993) Standard for Health Care Facilities, NFPA 13 
(1994) Standard for Installation of Sprinkler Systems and NFPA 
90A (1993) Standard for the Installation of Air Conditioning and 
Ventilation Systems. Section 12-6 of NFPA 101 shall not apply to 
these facilities.
F. Hardware on toilet room doors shall be operable from 
both the inside and the outside. All toilet room doors shall 
provide a net clear opening of not less than 32 inches.
G. The corridor doors from all patient-use areas as well 
as all doors through which patients may need to pass for 
emergency exit shall be not less than thirty-six (36) inches 
wide.
H. Every window in patient-use areas shall be provided 
with shades, curtains or drapes. Curtains and drapes shall be 
made of fabric which is treated to be or is inherently flame-
retardant.
I. The floors of toilets, baths, utility rooms and janitor’s 
closets shall have smooth, waterproof surfaces which are wear-
resistant. The floors of kitchens and food preparation areas 
shall be waterproof, greaseproof, smooth and resistant to heavy 
wear.
J. The walls of all rooms where food and drink are 
prepared, served or stored shall have a smooth surface with 
painted or equally washable finish. At the base they shall be 
waterproof and free from spaces which may harbor insects. 
The walls of kitchens, utility rooms, baths, warewashing rooms, 
janitor’s closets and spaces with sinks shall have waterproof, 
painted, glazed, or similar finishes to a point above the splash 
and spray line.
K. The ceilings of all kitchens, sculleries and other rooms 
where food and drink are prepared shall be painted with 
washable paint.
L. All casework in the facility shall be finished with 
at least a sealer on all interior surfaces. Casework with sinks 
16 CODE OF STATE REGULATIONS 
(2/28/23) John R. Ashcroft
Secretary of State
DIVISION 30—DIVISION OF REGULATION 19 CSR 30-35—DEPARTMENT OF HEALTH AND
 AND LICENSURE SENIOR SERVICES
installed in the counter shall be caulked to provide a watertight 
joint between the backsplash and the wall.
M. All floor covering used in inpatient hospice facilities 
shall have either Class A or B fire ratings as required by Chapter 
Twelve of NFPA 101 (1994), The Life Safety Code.
N. Stairways, ramps, elevator hoistways, light or 
ventilation shafts, chutes and other vertical openings between 
stories shall be enclosed with construction which is equal 
to or greater than the required floor assembly rating of the 
building’s construction type.
O. The number of stories in a building housing a 
hospice facility shall be determined by counting the number 
of occupiable levels in the building regardless of their location 
at, above or below grade.
P . Each room or patient-use area shall be conspicuously 
and unmistakably identifiable at its entrance by patients, 
visitors and staff.
Q. All signage within six feet (6') of the floor shall be 
tactile to be usable by visually impaired persons.
R. Fire-resistant ratings—
(I) Definitions—
(a) Fire-separation distance is the distance in feet 
measured from the building face to the closest interior lot line, 
to the centerline of a street or public way or to an imaginary 
line between two (2) buildings on the same property.
(b) Fire-protection rating is the time in hours, or 
fractions of an hour, that an opening protective assembly will 
resist fire exposure as determined in accordance with the test 
procedures set forth in ASTM E119.
(II) Exterior walls with a fire-separation distance less 
than five feet (5') shall have a fire-resistant rating of one (1) 
hour.
(III) In exterior walls with a fire-separation distance of 
three feet or less, no openings will be allowed, from three feet 
(3') to five feet (5') no unprotected openings will be allowed, 
and protected openings will be allowed with a total aggregate 
area of fifteen percent (15%) of the wall surface.
(IV) Approved fire protective assemblies shall be fixed, 
self-closing or equipped with approved automatic-closing 
devices, a fire-resistant rating of not less than three-quarters 
(3/4) of an hour shall be required.
(V) Fire protective assemblies are not required where 
outside automatic sprinklers are installed for the protection 
of the exterior openings. The sprinklers shall be installed in 
accordance with NFPA 13;
5. Structural design.
A. All new facilities and additions to all areas of existing 
licensed facilities which undergo major remodeling, in all 
their parts, shall be of sufficient strength to resist all stresses 
imposed by dead loads, live loads and lateral or uplift forces 
such as wind, without exceeding, in any of the structural 
materials, the allowable working stress established for these 
materials by generally accepted good engineering practice.
B. Foundations shall rest on solid ground or properly 
compacted fill and shall be carried to a depth of not less 
than one foot below the estimated frost line or shall rest on 
leveled rock or load-bearing piles when solid ground is not 
encountered. When engineered fill is used, site preparation 
and placement of fill shall be done under the direct full-time 
supervision of the soils engineer. The soils engineer shall issue 
a final report on the compacted fill operation and certify its 
compliance with the job specifications. Reasonable care shall 
be taken to establish proper soil-bearing values for soil at the 
building site. If the bearing capacity of the soil is in question, 
a recognized load test may be used to determine the safe 
bearing value. Footings, piers and foundation walls shall be 
adequately protected against deterioration from the action of 
groundwater;
6. Electrical systems.
A. The entire electrical system shall be designed, 
installed and tested in compliance with NFPA 70 (1993) The 
National Electrical Code and NFPA 99 (1993) Standard for Health 
Care Facilities.
B. Emergency lighting shall be provided for exits, 
stairs and exit access corridors which shall be supplied by an 
emergency service and automatic electric generator or battery 
lighting system. This emergency lighting system shall be 
equipped with an automatic transfer switch. If battery lights 
are used, they shall be wet cell units or other rechargeable-type 
batteries equipped with automatic trickle charger. These units 
shall be rated at four (4) hours.
C. Patient rooms shall have a minimum general 
illumination of ten foot-candles, a night-light and a patient’s 
reading light. The general illumination fixtures and the night-
light shall be switched at the patient room door.
D. Ceiling lighting fixtures, if used, shall be of a type 
which are shaded or globed to minimize glare.
E. Each patient room shall have not less than one duplex 
receptacle on each wall in the room. The spacing of receptacles 
around the perimeter of the room shall not be greater than 
twelve (12) feet.
F. All occupied areas shall be adequately lighted as 
required by the duties performed in the space.
G. Night-lights shall be provided in corridor, stairways 
and patient rooms. Toilets adjacent to patient rooms are not 
required to have night-lights.
H. An electrically powered communication system shall 
be provided which allows staff to respond to patient calls 
regardless of patient location.
I. An electrically powered fire alarm system shall be 
provided as required by NFPA 101 (1994) The Life Safety Code. 
The fire alarm system shall have an emergency back-up source 
of electrical power and a direct connection for notifying the 
fire department or fire department dispatch service. Fire alarm 
manual pull stations shall be provided at each exit and at each 
staff workstation in the patient-care units. Smoke detectors 
shall be installed in social space rooms which open directly 
to the corridor, in the vicinity of any smoke or fire door which 
is permitted to be held open by a magnetic hold-open device, 
and in the corridors at intervals not exceeding 30 feet.
J. Portable fire extinguishers shall be provided as required 
by NFPA 101 (1994) The Life Safety Code and the local authority;
7. Mechanical systems.
A. The heating, ventilation and air-conditioning systems 
shall be capable of providing temperature ranges between 
72°F–80°F in all patient-care areas. The heating system shall be 
capable of maintaining a winter indoor temperature of not less 
than 72°F in all nonpatient areas. The air-conditioning system 
shall be capable of maintaining a summer indoor temperature 
of not more than 80°F in all nonpatient areas.
B. The heating system shall have automatic controls 
adequate to provide comfortable conditions in all portions of 
the building at all times.
C. Heating, ventilation and air-conditioning systems 
installed in inpatient hospice facilities shall be designed, 
installed and balanced in compliance with NFPA 90A (1993) 
Standard for the Installation of Air Conditioning and Ventilation 
Systems, and shall provide the pressure relationships and at 
least the minimum air change rates indicated in Table 1.
 CODE OF STATE REGULATIONS 17
John R. Ashcroft (2/28/23)
Secretary of State
19 CSR 30-35—DEPARTMENT OF HEALTH AND DIVISION 30—DIVISION OF REGULATION
 SENIOR SERVICES AND LICENSURE
TABLE 1—VENTILATION REQUIREMENTS
 Minimum Minimum
 Pressure Air Changes of Total Air All Air
 Relationship Outdoor Air Per Changes Per Exhausted Air Returned
 to Adjacent Hour Supplied Hour Supplied Directly From This
Area Designation Areas to Room to Room to Outdoors Room
Patient Room E 2 2 Optional Optional
Patient Area Corridor
 and Patient Living Room P 2 2 Optional Optional
Soiled Workroom
 and Soiled Linen Holding N Optional 6 Yes No
Clean Staff Work Area P 2 6 Optional Optional
Toilet Room N Optional 6 Yes No
Clean Linen Storage P Optional 2 Optional Optional
Designated Smoking Area N Optional 10 Yes No
Food Preparation Area E 2 6 Yes No
Warewashing N Optional 6 Yes No
Dietary and General Storage V Optional 2 Optional Optional
Linen and Trash Chute Room N Optional 6 Yes No
Medical Gas Storage and
 Manifold Rooms N Optional 6 Yes No
Administrative and
 Public Areas E 2 2 Optional Optional
P = Positive
N = Negative
V = Variable
E = Equal
18 CODE OF STATE REGULATIONS 
(2/28/23) John R. Ashcroft
Secretary of State
DIVISION 30—DIVISION OF REGULATION 19 CSR 30-35—DEPARTMENT OF HEALTH AND
 AND LICENSURE SENIOR SERVICES
D. All air-moving, heating, ventilation and air-
conditioning equipment shall be equipped with at least 
one filter located upstream of the conditioning equipment. 
If a pre-filter is employed, the pre-filter shall be upstream 
of the conditioning equipment and the main filter shall 
be located farther downstream. All filters shall be easily 
accessible for maintenance. Filter frames shall be durable and 
carefully dimensioned and shall provide an airtight fit with the 
enclosing ductwork. All joints between the filter segments and 
the enclosing ductwork shall be sealed to preclude air leakage.
E. Outside air intakes shall be located no less than 25 
feet from exhaust outlets of ventilation systems, combustion 
equipment stacks, clinical suction discharges and plumbing 
vent stacks or from areas which may collect vehicular exhaust 
and other noxious fumes.
F. Corridors shall not be used to supply air to or exhaust 
air from any room, except that air from corridors may be used 
to ventilate bathrooms, toilet rooms, janitor’s closets and 
small electrical or telephone closets opening directly onto 
corridors provided that ventilation can be accomplished by the 
undercutting of doors. The installation of louvers in corridor 
doors is prohibited. The space above the finished ceiling may 
be used as a plenum for return air only.
G. Exhaust hoods in meal preparation areas shall comply 
with the requirements of NFPA 96 (1994). All hoods and cooktop 
surfaces in meal preparation areas shall be equipped with 
automatic fire suppression systems, automatic fan controls and 
fuel shutoff;
8. Plumbing systems.
A. The entire plumbing system, its design, operation 
and maintenance shall comply with the requirements of all 
applicable local and state codes including the requirements 
set forth in this rule.
B. Plumbing fixtures.
(I) All plumbing fixtures shall be of nonabsorptive 
acid-resistant material.
(II) Clinical sinks shall have a bedpan-flushing device 
and shall have an integral trap in which the upper portion of a 
visible trap seal provides a water surface.
(III) Showers and tubs shall be provided with nonslip 
surfaces.
(IV) Water closets in patient areas shall be quiet 
operating types.
(V) Stools in patient toilet facilities shall be the 
elongated bowl type with nonreturn stops, backflow preventers 
and silencers. Seats shall be the split type and white in color.
(VI) Grab bars or handrails shall be provided adjacent 
to all bathtubs.
(VII) All lavatories shall be trimmed with valving 
operable without the use of hands.
C. Water supply systems.
(I) A reliable source of potable water shall be provided 
at the site to supply water in sufficient quantities to meet the 
various use demands of the hospice. The source of water shall 
have been tested and approved by the Missouri Department of 
Natural Resources.
(II) The water supply systems shall be designed to 
supply water at sufficient pressure to operate all fixtures and 
equipment during maximum demand periods.
(III) Each water service main, branch main, riser and 
branch to a group of fixtures shall be valved. Stop valves shall 
be provided at each fixture.
(IV) Reduced pressure backflow preventers shall be 
installed on water service entrance, hose bibbs, janitors’ sinks, 
bedpan-flushing attachments, and on all other fixtures to 
which hoses or tubing can be attached. The installation of 
backflow preventors shall provide safeguards against waterline 
expansion.
(V) The water supply system shall be designed to 
provide hot water at each hot water outlet at all times. The 
water-heating equipment shall have sufficient capacity to 
supply five gallons of water at 120°F per hour per bed for 
hospice fixtures and eight gallons per bed for kitchen and 
laundry. Lesser capacities may be accepted upon submission of 
the calculation for the anticipated demand of all fixtures and 
equipment in the building. Hot water at showers and bathing 
facilities shall not exceed 110°F. Hot water at handwashing 
facilities shall not exceed 120°F. Hot water circulating mains 
and risers shall be run from the hot storage tank to a point 
directly below the highest fixture at the end of each branch 
main.
D. Drainage systems.
(I) All fixtures and equipment shall be connected 
through traps to soil and waste piping and to the sewer and 
they shall all be properly vented to the outside.
(II) Courts, yards and drives which do not have natural 
drainage from the building shall have catch basins and drains 
to low ground, storm-water drainage system or dry wells.
(III) The building sanitary drain system shall be piped 
in cast iron, steel, copper or plastic.
(IV) Building sewers shall discharge into a community 
sewerage system when available. If such a system is not 
available, a facility providing sewage treatment shall conform 
to the rules of the Department of Natural Resources.
(V) Drainage piping shall not be installed within the 
ceiling or exposed in food preparation centers, food service 
facilities, food storage areas and clean linen storage rooms; 
special precautions shall be taken to protect any of these 
areas from possible leakage or condensation from necessary 
overhead drainage piping systems. These special precautions 
include requiring noncorrosive drip troughs with a minimum 
four-inch outside diameter to be installed under the drainage 
pipe in the direction of slope to a point where the pipe leaves 
the protected space and terminates at that point—usually 
at a wall. The trough shall be supported with noncorrosive 
strap hangers and screws from the pipe above. Trough joints 
and hanging screw penetrations shall be sealed to maintain 
watertight integrity throughout.
E. Natural or liquefied petroleum (LP) gas systems.
(I) Where gas-fire equipment is used, all gas piping, 
fittings, tanks and specialties shall be provided and installed 
in compliance with NFPA 54 (1992), NFPA 58 (1992), and the 
instructions of the gas supplier, except where more strict 
requirements are stated. Where liquefied petroleum gas (LPG) 
is used, compliance with the rules of the Missouri Department 
of Agriculture is also required.
(II) Where gas piping enters the building below grade, 
it shall have an outside vent as follows: a concrete box shall be 
made 18 inches by 18 inches with three-inch thick walls, of a 
height to rest on top of the entering gas pipe, and the top of 
the box to coming within six inches of top grade. The box shall 
be filled with coarse gravel. A one-inch upright vent line shall 
be to 1/2 the depth of the box and extend 12 inches above grade 
with a screened U-vent looking down. The vent line shall be 
anchored securely to the building wall.
(III) Gas outlets and gas-fired equipment shall not be 
installed in any patients’ bedrooms.
F. Where a piped central medical gas distribution 
system is installed, the oxygen piping, outlets, manifold rooms, 
 CODE OF STATE REGULATIONS 19
John R. Ashcroft (2/28/23)
Secretary of State
19 CSR 30-35—DEPARTMENT OF HEALTH AND DIVISION 30—DIVISION OF REGULATION
 SENIOR SERVICES AND LICENSURE
and storage rooms shall be installed in accordance with the 
requirements of Chapter 4 of NFPA 99 (1993); and
9. Fire prevention and general operating requirements.
A. The hospice facility shall be maintained in a manner 
which provides a clean safe environment for the delivery of 
patient care and shall, until remodeled or renovated with 
the approval of the Department of Health, remain compliant 
with the codes and regulations under which the facility was 
constructed.
B. Exitways shall always be maintained free of 
obstructions.
C. Curtains, drapes and cubicle curtains shall be 
maintained in a manner which does not compromise their 
fire-resistant properties.
D. Smoking may be permitted in the patient’s room 
by the patient only, and designated smoking areas by others. 
Designated smoking areas shall be ventilated as required by 
Table 1 of this rule. Modification of the patient room ventilation 
system is not required to permit occasional authorized smoking 
by a patient.
E. All waste containers shall be of noncombustible 
construction.
F. Electrical systems and medical gas systems shall be 
tested according to the provisions of NFPA 99 (1993) and shall 
be modified as necessary to comply with the operational 
requirements of that standard.
(5) General Design and Construction Standards for Existing 
Inpatient Hospice Facilities.
(A) Any inpatient hospice facility existing and in continuous 
operation prior to the date of October 30, 1996, will upon 
receipt of application for licensure, be inspected by the 
Department of Health to determine compliance with this rule. 
Where existing physical conditions cause strict compliance to 
be difficult to achieve, the department may determine that the 
intent of the new construction rules has been satisfied through 
the establishment of acceptable equivalency conditions. The 
provision of fire alarm and detection systems, automatic 
extinguishment systems, building compartmentation and the 
presence of staff trained consistent with the facility’s disaster 
preparedness plan are factors which will be considered in 
determining fire safety compliance equivalency. The ability 
of the existing facility to meet the programmatic needs of 
the patients, their family, staff and public in an accessible 
and sanitary environment will be considered in determining 
functional equivalency. Existing inpatient hospice facilities 
shall provide the department evidence of compliance with 
all local regulations and codes as well as evidence that the 
existing operation is in good standing with the health facility 
licensure programs administered by Department of Social Ser-
vices/Division of Aging. Existing inpatient hospice facilities 
shall be operated and licensed exclusively under the provisions 
of section 197.250, RSMo.
AUTHORITY: section 197.270, RSMo 2000.* Original rule filed 
March 8, 1996, effective Oct. 30, 1996. Rescinded and readopted: 
Filed Jan. 3, 2001, effective Aug. 30, 2001. Amended: Filed Sept. 11, 
2007, effective March 30, 2008.
*Original authority: 197.270, RSMo 1992, amended 1993.
19 CSR 30-35.030 State Certification Management
PURPOSE: This rule defines the state activities related to the 
inspection, complaint investigation, and issuance of the certificate 
for state-certified hospice programs.
(1) Initial Application. When an initial application and initial fee 
of $500 for state hospice certification is received, the applicant 
shall provide the Department of Health (DOH) with sufficient 
evidence that the hospice has established appropriate policies 
and procedures for providing hospice services according to 
these rules. After review of these policies and procedures, and 
verification the hospice has the capability of providing hospice 
services by qualified persons, the DOH shall issue a temporary 
operating permit not to exceed 90 days. After the hospice has 
been in operation for 90 days, or sooner if possible, the DOH 
shall survey the hospice for compliance with these rules. The 
hospice shall have provided care to at least three patients for 
a period of at least three weeks for the purpose of the initial 
survey review. The DOH shall conduct the unannounced initial 
survey after the applicant indicates a readiness for that survey. 
The DOH may extend the temporary approved certificate if the 
hospice can show good intent to accomplish the preparations 
for initial survey.
(2) The Annual Survey Inspection. The hospice management 
shall allow representatives of the Department of Health to 
survey the hospice to determine continued eligibility for 
hospice state certification. An annual renewal application and 
annual renewal fee per sliding scale must be submitted by 
every hospice prior to the expiration of the previous certificate. 
Sliding scale annual renewal fees will be based on annual 
patient admissions and are as follows: 0–50 admissions, $250; 
51–150 admissions, $400; 151–250 admissions, $550; and 251+ 
admissions, $750.
(A) The survey may include visits to the place of residence 
of any appropriate patient or family. After completion of 
the DOH survey, a written survey deficiency report shall be 
prepared showing the findings with respect to compliance 
or noncompliance with the provisions and the standards 
established in this chapter. The list of deficiencies found shall 
be served upon the hospice within 15 business days following 
the survey process. The list of deficiencies shall specifically 
state the statute or rule which the hospice is alleged to 
have violated. The hospice shall inform the DOH of the time 
necessary for compliance not to exceed 60 days from the exit 
date of the survey and within ten business days shall file a plan 
of correction with the DOH. A follow-up by the DOH to assure 
implementation of the plan of correction shall occur within 60 
days of the hospice’s prior approved plan of correction date.
(B) Any person wishing to make a complaint against a hospice 
certified under the provisions of sections 197.250–197.280, 
RSMo, may register the complaint in writing or verbally with 
the DOH setting forth the details and facts supporting the 
complaint. The DOH shall investigate complaints received. 
Any complaint related to abuse, neglect or exploitation as 
described in section 197.266, RSMo shall be reported according 
to the requirements of that section.
(C) In addition to the survey inspection required for initial 
certification or certification renewal the DOH may make other 
survey inspections and/or complaint investigations during 
normal business hours. Each hospice shall allow the DOH or 
its authorized representatives to enter upon its premises as 
needed for the purpose of conducting a survey inspection and/
or complaint investigation.
(3) Change of Ownership. The hospice certification shall not 
be transferable or assignable. If during the period in which 
20 CODE OF STATE REGULATIONS 
(2/28/23) John R. Ashcroft
Secretary of State
DIVISION 30—DIVISION OF REGULATION 19 CSR 30-35—DEPARTMENT OF HEALTH AND
 AND LICENSURE SENIOR SERVICES
a certificate is in effect, an operator which is a partnership, 
limited partnership, or corporation undergoes any of the 
following changes, whether by one or by more than one action, 
the operator shall apply for a new approved certificate not less 
than 30 days before any change:
(A) With respect to a limited partnership, a change in the 
majority interest of general partners;
(B) With respect to a limited partnership, a change in the 
general partner or in the majority interest of limited partners; 
or
(C) With respect to a for-profit corporation, a change in the 
persons who own, hold or have the power to vote the majority 
of any class of stocks issued by the corporation.
(4) Multiple Offices/Counties. When the hospice consistently 
manages and supervises multiple offices, serving contiguous 
geographic areas as evidenced by indicators such as consistent 
meetings, chart review and other methods, and evidences 
the provision of patient-care services on a consistent basis 
throughout its geographic area of services, only one certificate 
shall be required. A $200 fee per each multiple office will be 
added to the annual renewal fee, not to exceed a total of $750. 
When the hospice has multiple offices or county areas and 
it is evident that consistent management and supervision or 
consistent provision of patient-care services throughout its 
service area is lacking, a separate certificate shall be required 
for one or more of the multiple offices or through the new 
development of a separate certified office as determined by 
the DOH. Statewide certification will not be granted. Inpatient 
facilities shall be located within boundaries of the state of 
Missouri.
(5) Satellite Offices and Reciprocal Agreements with Bordering 
States. All agencies providing hospice services in Missouri shall 
have a valid Missouri Hospice Certification and shall pay the 
annual fee. The satellite office shall make available all records 
required for the survey which shall be conducted by the DOH.
(6) Certificate Not Issued. A certificate shall not be issued 
or renewed if the operator, owner or any principal in the 
operation of the hospice has ever been convicted of any offense 
concerning the operation of hospice or of any offense which 
is reasonably related to the qualification, functions, or duties 
of a hospice. Notwithstanding any other provisions of law, 
the DOH shall have access to records involving an owner or 
manager of a hospice applying for or renewing a certificate 
as provided in this chapter, where the applicant has been 
adjudicated and found guilty or entered a plea of guilty or 
nolo contendere in a prosecution under the laws of any state 
or of the United States for any offense reasonably related 
to the qualification, functions or duties of any person who 
manages or owns a hospice certified under sections 197.250–
197.280, RSMo. The DOH may deny, suspend, or revoke the 
certificate of any company whose owners or managers have 
been convicted of such an offense.
(7) Revocation. The DOH may refuse to issue, may suspend or 
may revoke or refuse to renew the certificate of any hospice 
for failure to comply with any provision of sections 197.250–
197.280, RSMo, or with any of these rules or standards adopted 
under the provisions of sections 197.250–197.280, RSMo, or for 
obtaining a certificate by means of fraud, misrepresentation or 
concealment of any material facts. Any hospice which has been 
refused a certificate or which has had its certificate revoked or 
suspended by the DOH may seek a review of the Department 
of Health’s action by the Administrative Hearing Commission. 
There shall be a six-month waiting period for reapplication 
from final Department of Health action.
(8) Intermediate Sanctions. If the department determines 
on the basis of an inspection, or otherwise, that a state-
certified hospice program is no longer in compliance with the 
requirements specified in these rules, and determines that the 
deficiencies jeopardize the health and safety of the patients of 
the hospice, the department shall take action to remedy the 
specific deficiencies through intermediate sanctions or the 
termination of the certification. Any action taken under this 
section shall be immediately effective not-withstanding any 
provisions of law to the contrary. Intermediate sanctions may 
include:
(A) Suspension of all or part of the services provided by the 
hospice;
(B) Restrictions on the admission of new patients to the 
hospice’s program;
(C) DOH approval of the appointment of temporary 
management at hospice expense to oversee the operation of 
the hospice to protect and assure the health and safety of the 
individuals under the care of the hospice while improvements 
are made in order to bring the hospice into compliance with 
the requirements of these rules; and
(D) These intermediate sanctions shall be designed so as 
to minimize the time between identification of deficiencies 
and imposition of these sanctions, and shall provide for the 
imposition of incrementally more severe sanctions for repeated 
or uncorrected deficiencies.
AUTHORITY: section 197.270, RSMo 2000.* Original rule filed 
March 8, 1996, effective Oct. 3, 1996. Rescinded and readopted: 
Filed Jan. 3, 2001, effective Aug. 30, 2001.
*Original authority: 197.270, RSMo 1992, amended 1993.