Assisted Living in Missouri

Agency: Department of Health and Senior Services, Division of Regulation and Licensure, Section for Long Term Care Regulation
Phone: (573) 526-8524
Website: www.dhss.state.mo.us/showmelongtermcare

An assisted living facility (ALF) is any premises, other than a residential care facility, intermediate care facility, or skilled nursing facility, that is utilized by its owner, operator, or manager to provide 24-hour care and services and protective oversight to three or more residents who are provided with shelter, board, and who may need and are provided with the following: -- Assistance with any activities of daily living (ADLs) and any instrumental activities of daily living (IADLs). -- Storage, distribution, or administration of medications. -- Supervision of health care under the direction of a licensed physician provided that such services are consistent with a social model of care. ALFs do not include facilities where all of the residents are related within the fourth degree of consanguinity or affinity to the owner, operator, or manager of the facility. A residential care facility (RCF) is any premises, other than an ALF, intermediate care facility, or skilled nursing facility, which is utilized by its owner, operator, or manager to provide 24-hour care to three or more residents, who are not related within the fourth degree of consanguinity or affinity to the owner, operator, or manager of the facility and who need or are provided with shelter, board, and protective oversight, which may include storage and distribution or administration of medications and care during short-term illness or recuperation.

Facility Scope of Care:
ALFs must provide 24-hour care and protective oversight including but not limited to: assistance with ADLs and IADLs, medication management, dietary services, activities, and food sanitation. RCFs must provide 24-hour care, shelter, board, and protective oversight including but not limited to: assistance with storage, distribution, and/or administration of medications; dietary services; food sanitation, etc. The facility can provide care to residents during a short-term illness or recuperation period.

Move-In/Move-Out Requirements:
For ALFs, the following conditions would prevent admission into a facility: -- Exhibiting behaviors that present a reasonable likelihood of serious harm to self and/or others. -- Requiring a restraint (physical or chemical). -- Requiring skilled nursing care. -- Requiring more than one person to provide physical assistance (excluding bathing and transferring). -- Being bed-bound. -- Being under 16 years of age. Residents on hospice who require skilled nursing care, require more than one person to provide physical assistance, or are bedbound may be admitted or continue to reside in the facility provided the resident, his or her legally authorized representative or designee, or both, and the facility, physician, and licensed hospice provider all agree that such program of care is appropriate for the resident. Residents experiencing short periods of incapacity due to illness or injury or recuperation from surgery may be allowed to remain or be readmitted from a hospital if the period of incapacity does not exceed 45 days and written approval of a physician is obtained. The following conditions would permit a transfer/discharge from an ALF: -- The resident's needs cannot be met in the facility. -- The resident no longer needs the services provided by the facility. -- The health and/or safety of other residents in the facility is endangered. -- After appropriate notice and reasonable efforts by the facility, the resident has not paid for his/her stay. -- The facility ceases to operate. Before an ALF can transfer/discharge a resident it is required to give the resident a 30-day notice. If the health and/or safety of the resident and other residents in the facility are endangered, the resident may qualify for an emergency transfer/discharge. Facilities are required to record and document in detail the reason for a 30-day and/or emergency transfer /discharge. For RCFs, the facility shall not admit residents whose needs cannot be met or those under 16 years of age. The following conditions would permit a transfer/discharge from an RCF: -- The resident's needs cannot be met in the facility. -- The resident no longer needs the services provided by the facility. -- The health and/or safety of other residents in the facility is endangered. -- After appropriate notice and reasonable efforts the resident has not paid for his/her stay. -- The facility ceases to operate. Residents suffering from short periods of incapacity due to illness, injury, or recuperation from surgery may be allowed to remain or be readmitted from a hospital if the period of incapacity does not exceed 45 days and written approval of a physician is obtained. Before RCFs can transfer/discharge a resident they are required to give the resident a 30-day notice. If the health and/or safety of the resident and other residents in the facility are endangered, the resident may qualify for an emergency transfer/discharge. Facilities are required to record and document in detail the reason for a 30-day and/or emergency transfer/discharge

Resident Assessment:
For ALFs, prior to admission the facility must complete a premove-in screening. Within five calendar days after admission an appropriately trained and qualified individual will conduct a community-based assessment. Also, within ten days after admission the resident must have an admission physical examination. The examination must be performed by a licensed physician with documentation of the resident's current medical status and any special orders or procedures that should be followed. The community-based assessment shall be reviewed whenever there is a significant change in the resident's condition and/or at least semiannually.For RCFs, residents admitted to the facility shall have an admission physical examination no later than ten days after admission. The examination must be performed by a licensed physician with documentation of the resident's current medical status and any special orders or procedures that should be followed. The facility must perform a monthly resident review of the following: -- The resident's general medical condition and needs. -- Review of medication consumption of any resident controlling his/her own medication. -- Daily record of medication administration. -- Logging of medication regimen review process. -- Monthly weight. -- Record of each referral for services from an outside service provider. -- Record of any resident incidents including behaviors that present a reasonable likelihood of serious harm to himself or herself or others. -- Record of accidents that potentially could result in injury or did result in injuries involving the resident

Medication Management:
For ALFs, a physician, pharmacist, or registered nurse must review the medication regimen of each resident every other month. At a minimum, staff who administer medications must be a Level I Medication Aide (LIMA). Facilities are required to have a safe and effective system of medication control and use. In a level one RCF, a pharmacist or registered nurse (RN) must review the medication regimen of each resident every three months. In a level two RCF, a pharmacist or RN must review the medication regimen of each resident every other month. At a minimum, staff who administer medications must be a LIMA. Facilities are required to have a safe and effective system of medication control and use.

Physical Plant Requirements:
For both ALFs and RCFs, resident units must provide a minimum of 70 square feet per resident.

Residents Allowed Per Room:
For both ALFs and RCFs, the maximum number of beds/residents allowed is four per unit.

Life Safety:
ALFs and RCFs with more than 20 residents that do not have an approved sprinkler system, and single-story and multi-level ALFs that accept or retain any individual with a physical, cognitive, or other impairment that prevents the individual from safely evacuating the facility with minimal assistance, will be required to have an approved sprinkler system by December 31, 2012. Facilities that have an approved sprinkler system shall continue to meet all laws, rules, and regulations for testing, inspection, and maintenance of the sprinkler system. All ALFs and RCFs are required to have a complete fire alarm system.

Alzheimer's Unit Requirements:
Any facility with an Alzheimer's special care unit is required to provide a document with information on selecting an Alzheimer's special care unit to any person seeking information about or placement in such a unit. For both ALFs and RCFs, during the admission disclosure, a facility must explain how care in the Alzheimer's special care unit or program is different from the rest of the facility and if the services are appropriate. The disclosure must include the following: -- A written statement of its overall philosophy and mission reflecting the needs of residents afflicted with dementia; -- The process and criteria for placement in, and transfer or discharge from, the unit or program; -- The process used for assessment and establishment of the plan of care and its implementation, including the method by which the plan of care evolves and is responsive to changes in condition; -- Staff training and continuing education practices; -- The physical environment and design features appropriate to support the functioning of cognitively impaired adult residents; -- The types and frequency of resident activities; -- The involvement of families and the availability of family support programs; -- The costs of care and any additional fees; and -- Safety and security measures.

Staff Training for Alzheimer's Care:
For both ALFs and RCFs, staff who provide direct care to any resident having Alzheimer's disease or related dementias must have at least three hours of dementia-specific orientation training. One hour of dementia-specific orientation training is required for staff who do not provide direct care but may have daily contact with residents. All dementia-specific training must be incorporated into each facility's new employee orientation and ongoing in-service training.

Staffing Requirements:
ALFs are required to have an adequate number and type of personnel for the proper care of residents, the residents' social well being, protective oversight of residents, and upkeep of the facility. At a minimum, the staffing pattern for fire safety and care of residents shall be one staff person for every 15 residents or major fraction of 15 during the day shift, one person for every 20 residents or major fraction of 20 during the evening shift, and one person for every 25 residents or major fraction of 25 during the night shift. ALFs which provide services to residents with a physical, cognitive, or other impairment that prevents the individual from safely evacuating the facility with minimal assistance are required to have an adequate number and type of personnel for the proper care of residents and upkeep of the facility. At a minimum, the staffing pattern for fire safety and care of residents shall be one staff person for every 15 residents or major fraction of 15 during the day shift, one person for every 15 residents or major fraction of 15 during the evening shift, and one person for every 20 residents or major fraction of 20 during the night shift. RCFs are required to provide an adequate number and type of personnel on duty at all times for the proper care of residents and upkeep of the facility. In a level one RCF, at a minimum, one employee shall be on duty for every 40 residents to provide protective oversight to residents and for fire safety. In a level two RCF, at a minimum, the staffing pattern for fire safety and care of residents shall be one staff person for every 15 residents or major fraction of 15 during the day shift, one person for every 20 residents or major fraction of 20 during the evening shift, and one person for every 25 residents or major fraction of 25 during the night shift.

Staff Education Training:
For ALFs, prior to or on the first day that a new employee works in a facility, he/she shall receive orientation of at least two hours appropriate to job function and responsibilities. The orientation shall include but not be limited to: job responsibilities, emergency response procedures, infection control, confidentiality of resident information, preservation of resident dignity, information regarding what constitutes abuse/neglect and how to report abuse/neglect, information regarding the Employee Disqualification List, instruction regarding the rights of residents and protection of property, instruction regarding working with residents with mental illness, instruction regarding personcentered care and the concept of a social model of care, and techniques that are effective in enhancing resident choice and control over his/her own environment. Also, staff are required to have a minimum of two hours of initial training on the appropriate ways to transfer a resident care within the facility (e.g., wheelchair to bed, bed to dining room chair). For RCFs, prior to or on the first day that a new employee works in a facility, he/she shall receive orientation of at least one hour appropriate to job function. The orientation shall include but not be limited to: job responsibilities, emergency response procedures, infection control, confidentiality of resident information, preservation of resident dignity, information regarding what constitutes abuse/neglect and how to report abuse/neglect, information regarding the Employee Disqualification List, instruction regarding the rights of residents and protection of property, and instruction regarding working with residents with mental illness. ALFs and RCFs are required to ensure that specified fire safety training is provided to all employees.

Medicaid Policy and Reimbursements:
The Medicaid state plan covers personal care and advanced personal care services.