FIRST REGULAR SESSION
[CORRECTED]
[TRULY AGREED TO AND FINALLY PASSED]
SENATE SUBSTITUTE FOR
SENATE COMMITTEE SUBSTITUTE FOR
HOUSE COMMITTEE SUBSTITUTE FOR
94TH GENERAL ASSEMBLY
AN ACT
To repeal sections 198.073, 198.076, 198.079, 198.086, and 320.202, RSMo, and to enact in lieu thereof seven new sections relating to protection of vulnerable persons in long-term care facilities.
Be it enacted by the General Assembly of the state of Missouri, as follows:
Section A. Sections 198.073, 198.076, 198.079, 198.086, and 320.202, RSMo, are repealed and seven new sections enacted in lieu thereof, to be known as sections 198.073, 198.074, 198.075, 198.076, 198.079, 198.086, and 320.202, to read as follows:
198.073. 1. A residential care facility shall admit or retain only those persons who are capable mentally and physically of negotiating a normal path to safety using assistive devices or aids when necessary, and who may need assisted personal care within the limitations of such facilities, and who do not require hospitalization or skilled nursing care.
2. Notwithstanding the provisions of subsection 1 of this section, those persons previously qualified for residence who may have a temporary period of incapacity due to illness, surgery, or injury, which period does not exceed forty-five days, may be allowed to remain in a residential care facility or assisted living facility if approved by a physician.
3. Any facility licensed as a residential care facility II on August 27, 2006, shall be granted a license as an assisted living facility, as defined in section 198.006, on August 28, 2006, regardless of the laws, rules, and regulations for licensure as an assisted living facility as long as such facility continues to meet all laws, rules, and regulations that were in place on August 27, 2006, for a residential care facility II. At such time that the average total reimbursement, not including residents' cost-of-living increases in their benefits from the Social Security Administration after August 28, 2006, for the care of persons eligible for Medicaid in an assisted living facility is equal to or exceeds forty-one dollars per day, all facilities with a license as an assisted living facility shall meet all laws, rules, and regulations for licensure as an assisted living facility. Nothing in this section shall be construed to allow any facility that has not met the requirements of subsections 4 and 6 of this section to care for any individual with a physical, cognitive, or other impairment that prevents the individual from safely evacuating the facility.
4. Any facility licensed as an assisted living facility, as defined in section 198.006, except for facilities licensed under subsection 3 of this section, may admit or retain an individual for residency in an assisted living facility only if the individual does not require hospitalization or skilled nursing placement, and only if the facility:
(1) Provides for or coordinates oversight and services to meet the needs of the resident as documented in a written contract signed by the resident, or legal representative of the resident;
(2) Has twenty-four-hour staff appropriate in numbers and with appropriate skills to provide such services;
(3) Has a written plan for the protection of all residents in the event of a disaster, including keeping residents in place, evacuating residents to areas of refuge, evacuating residents from the building if necessary, or other methods of protection based on the disaster and the individual building design;
(4) Completes a pre-move-in screening with participation of the prospective resident;
(5) Completes for each resident a community-based assessment, as defined in subdivision (7) of section 198.006:
(a) Upon admission;
(b) At least semiannually; and
(c) Whenever a significant change has occurred in the resident's condition which may require a change in services;
(6) Based on the assessment in subsection 7 of this section and subdivision (5) of this subsection, develops an individualized service plan in partnership with the resident, or legal representative of the resident, that outlines the needs and preferences of the resident. The individualized service plan will be reviewed with the resident, or legal representative of the resident, at least annually, or when there is a significant change in the resident's condition which may require a change in services. The signatures of an authorized representative of the facility and the resident, or the resident's legal representative, shall be contained on the individualized service plan to acknowledge that the service plan has been reviewed and understood by the resident or legal representative;
(7) Makes available and implements self-care, productive and leisure activity programs which maximize and encourage the resident's optimal functional ability;
(8) Ensures that the residence does not accept or retain a resident who:
(a) Has exhibited behaviors that present a reasonable likelihood of serious harm to himself or herself or others;
(b) Requires physical restraint;
(c) Requires chemical restraint. As used in this paragraph, the following terms mean:
a. "Chemical restraint", a psychopharmacologic drug that is used for discipline or convenience and not required to treat medical symptoms;
b. "Convenience", any action taken by the facility to control resident behavior or maintain residents with a lesser amount of effort by the facility and not in the resident's best interest;
c. "Discipline", any action taken by the facility for the purpose of punishing or penalizing residents;
(d) Requires skilled nursing services as defined in subdivision (23) of section 198.006 for which the facility is not licensed or able to provide;
(e) Requires more than one person to simultaneously physically assist the resident with any activity of daily living, with the exception of bathing and transferring;
(f) Is bed-bound or similarly immobilized due to a debilitating or chronic condition; and
(9) Develops and implements a plan to protect the rights, privacy, and safety of all residents and to protect against the financial exploitation of all residents;
(10) Complies with the training requirements of subsection 8 of section 660.050, RSMo.
5. Exceptions to paragraphs (d) to (f) of subdivision (8) of subsection 4 of this section shall be made for residents on hospice, provided the resident, designated representative, or both, and the assisted living provider, physician, and licensed hospice provider all agree that such program of care is appropriate for the resident.
6. If an assisted living facility accepts or retains any individual with a physical, cognitive, or other impairment that prevents the individual from safely evacuating the facility with minimal assistance, the facility shall:
(1) Have sufficient staff present and awake twenty-four hours a day to assist in the evacuation;
(2) Include an individualized evacuation plan in the service plan of the resident; and
(3) [Be equipped with an automatic sprinkler system in compliance with National Fire Protection Association Code 13 or National Fire Protection Association Code 13R, and an automated fire door system and smoke alarms in compliance with 13-3.4 of the 1997 Life Safety Codes for Existing Health Care Occupancy, or for multilevel facilities, be equipped with an automatic sprinkler system in compliance with National Fire Protection Association Code 13 and each floor shall be divided into at least two smoke sections and fire alarms in compliance with 13-3.4 of the 1997 Life Safety Codes for Existing Health Care Occupancy;
(4)] Take necessary measures to provide residents with the opportunity to explore the facility and, if appropriate, its grounds; and
[(5)] (4) Use a personal electronic monitoring device for any resident whose physician recommends the use of such device.
7. An individual admitted or readmitted to the facility shall have an admission physical examination by a licensed physician. Documentation should be obtained prior to admission but shall be on file not later than ten days after admission and shall contain information regarding the individual's current medical status and any special orders or procedures that should be followed. If the individual is admitted directly from a hospital or another long-term care facility and is accompanied on admission by a report that reflects his or her current medical status, an admission physical shall not be required.
8. Facilities licensed as an assisted living facility shall disclose to a prospective resident, or legal representative of the resident, information regarding the services the facility is able to provide or coordinate, the costs of such services to the resident, and the resident conditions that will require discharge or transfer, including the provisions of subdivision (8) of subsection 4 of this section.
9. After January 1, 2008, no entity shall hold itself out as an assisted living facility or advertise itself as an assisted living facility without obtaining a license from the department to operate as an assisted living facility. Any residential care facility II licensed under this chapter that does not use the term assisted living in the name of its licensed facility on or before May 1, 2006, shall be prohibited from using such term after August 28, 2006, unless such facility meets the requirements for an assisted living facility in subsection 4 of this section. Any facility licensed as an intermediate care facility prior to August 28, 2006, that provides the services of an assisted living facility, as described in paragraphs (a), (b), and (c) of subdivision (6) of section 198.006, utilizing the social model of care, may advertise itself as an assisted living facility without obtaining a license from the department to operate as an assisted living facility.
10. [For assisted living facilities built after August 28, 2006, or which have major renovations after August 27, 2006, such single-level assisted living facilities or the major renovation portion shall be equipped with an automatic sprinkler system in compliance with National Fire Protection Association Code 13 or 13R of the 1997 Life Safety Codes for Existing Health Care Occupancy, or for such multilevel assisted living facilities or the major renovation portion shall be equipped with an automatic sprinkler system in compliance with National Fire Protection Association Code 13 and each floor shall be divided into two smoke sections and fire alarms in compliance with 13-3.4 of the 1997 Life Safety Codes for Existing Health Care Occupancy. Existing facilities seeking to be licensed as assisted living facilities shall meet the fire safety standards for residential care facilities II in effect on August 28, 2006, unless such facilities seek to admit one or more individuals with physical, cognitive, or other impairments that prevent the individuals from safely evacuating the facility with minimal assistance, in which case such facilities shall comply with subsection 6 of this section.
11.] The department of health and senior services shall promulgate rules to ensure compliance with this section. Any rule or portion of a rule, as that term is defined in section 536.010, RSMo, that is created under the authority delegated in this section shall become effective only if it complies with and is subject to all of the provisions of chapter 536, RSMo, and, if applicable, section 536.028, RSMo. This section and chapter 536, RSMo, are nonseverable and if any of the powers vested with the general assembly pursuant to chapter 536, RSMo, to review, to delay the effective date, or to disapprove and annul a rule are subsequently held unconstitutional, then the grant of rulemaking authority and any rule proposed or adopted after August 28, 2006, shall be invalid and void.
198.074. 1. Effective August 28, 2007, all new facilities licensed on or after August 28, 2007, or any facilities completing a major renovation to the facility on or after August 28, 2007, as defined and approved by the department, and which are licensed under this chapter shall install and maintain an approved sprinkler system in accordance with National Fire Protection Association (NFPA) 13.
2. Facilities that were initially licensed and had an approved sprinkler system prior to August 28, 2007, shall continue to meet all laws, rules, and regulations for testing, inspection and maintenance of the sprinkler system that were in effect for such facilities on August 27, 2007.
3. Multi-level assisted living facilities 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 shall install and maintain an approved sprinkler system in accordance with NFPA 13. Single-story assisted living facilities 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 shall install and maintain an approved sprinkler system in accordance with NFPA 13R.
4. All residential care and assisted living facilities with more than twenty residents not included in subsection 3 of this section, which are initially licensed under this chapter prior to August 28, 2007, and that do not have installed an approved sprinkler system in accordance with NFPA 13R prior to August 28, 2007, shall install and maintain an approved sprinkler system in accordance with NFPA 13R by December 31, 2012, unless the facility meets the safety requirements of Chapter 33 of existing residential board and care occupancies of NFPA 101 life safety code.
5. All skilled nursing and intermediate care facilities not required prior to August 28, 2007, to install and maintain an approved sprinkler system shall install and maintain an approved sprinkler system in accordance with NFPA 13 by December 31, 2012, unless the facility receives an exemption from the department and presents evidence in writing from a certified sprinkler system representative or licensed engineer that the facility is unable to install an approved National Fire Protection Association 13 system due to the unavailability of water supply requirements associated with this system or the facility meets the safety requirements of Chapter 33 of existing residential board and care occupancies of NFPA 101 life safety code.
6. Facilities that take a substantial step, as specified in subsection 7 of this section, to install an approved NFPA 13R system prior to December 31, 2012, may apply to the department for a loan in accordance with section 198.075, to install such system. However, such loan shall not be available if by December 31, 2009, the average total reimbursement for the care of persons eligible for Medicaid public assistance in an assisted living facility and residential care facility is equal to or exceeds fifty-two dollars per day. The average total reimbursement includes room, board, and care delivered by the facility, but shall not include payments to the facility for care or services not provided by the facility. If a facility under this subsection does not have an approved sprinkler system installed by December 31, 2012, such facility shall be required to install and maintain an approved sprinkler system in accordance with NFPA 13 by December 31, 2013. Such loans received under this subsection and in accordance with section 198.075, shall be paid in full as follows:
(1) Ten years for those facilities approved for the loan and whose average total reimbursement rate for the care of persons eligible for Medicaid public assistance is equal to forty-eight and no more than forty-nine dollars per day;
(2) Eight years for those facilities approved for the loan and whose average total reimbursement rate for the care of persons eligible for Medicaid public assistance is greater than forty-nine and no more than fifty-two dollars per day; or
(3) Five years for those facilities approved for the loan and whose average total reimbursement rate for the care of persons eligible for Medicaid public assistance is greater than fifty-two dollars per day.
(4) No payments or interest shall be due until the average total reimbursement rate for the care of persons eligible for Medicaid public assistance is equal to or greater than forty-eight dollars.
7. (1) All facilities licensed under this chapter shall be equipped with a complete fire alarm system in compliance with NFPA 101, Life Safety Code for Detection, Alarm, and Communication Systems as referenced in NFPA 72, or shall maintain a system that was approved by the department when such facility was constructed so long as such system is a complete fire alarm system. A complete fire alarm system shall include, but not be limited to, interconnected smoke detectors throughout the facility, automatic transmission to the fire department, dispatching agency, or central monitoring company, manual pull stations at each required exit and attendant's station, heat detectors, and audible and visual alarm indicators.
(2) In addition, each floor accessed by residents shall be divided into at least two smoke sections by one-hour rated smoke partitions. No smoke section shall exceed one hundred fifty feet in length. If neither the length nor the width of the floor exceeds seventy-five feet, no smoke-stop partition shall be required. Facilities with a complete fire alarm system and smoke sections meeting the requirements of this subsection prior to August 28, 2007, shall continue to meet such requirements. Facilities initially licensed on or after August 28, 2007, shall comply with such requirements beginning August 28, 2007, or on the effective date of licensure.
(3) Except as otherwise provided in this subsection, the requirements for complete fire alarm systems and smoke sections shall be enforceable on December 31, 2008.
8. The requirements of this section shall be construed to supersede the provisions of section 198.058 relating to the exemption of facilities from construction standards.
9. Fire safety inspections of facilities licensed under this chapter for compliance with this section shall be conducted annually by the state fire marshal if such inspections are not available to be conducted by local fire protection districts or fire departments. The provisions of this section shall be enforced by the state fire marshal or by the local fire protection district or fire department, depending on which entity conducted the inspection.
10. By July 1, 2008, all facilities licensed under this chapter shall submit a plan for compliance with the provisions of this section to the state fire marshal.
198.075. 1. There is hereby created in the state treasury the "Fire Safety Standards Loan Fund", for implementing the provisions of subsection 3 of section 198.074. Moneys deposited in the fund shall be considered state funds under article IV, section 15 of the Missouri constitution. The state treasurer shall be custodian of the fund and may disburse moneys from the fund in accordance with sections 30.170 and 30.180, RSMo. Any moneys remaining in the fund at the end of the biennium shall revert to the credit of the general revenue fund. The state treasurer shall invest moneys in the fund in the same manner as other funds are invested. Any interest and moneys earned on such investments shall be credited to the fund.
2. Qualifying facilities shall make an application to the department of health and senior services upon forms provided by the department. Upon receipt of an application for a loan, the department shall review the application and advise the governor before state funds are allocated for a loan. For purposes of this section, a "qualifying facility" shall mean a facility licensed under this chapter that is in substantial compliance. "Substantial compliance" shall mean a facility that has no uncorrected deficiencies and is in compliance with department of health and senior services rules and regulations governing such facility.
3. The fund shall be a loan of which the interest rate shall not exceed two and one half percent.
4. The fund shall be administered by the department of health and senior services.
198.076. The department shall promulgate reasonable standards and regulations for all residential care facilities and all assisted living facilities. The standards and regulations shall take into account the level of care provided and the number and type of residents served by the facility to insure maximum flexibility. These standards and regulations shall relate to:
(1) The number and qualifications of employed and contract personnel having responsibility for any of the services provided for residents;
(2) The equipment, facilities, services and supplies essential to the health and welfare of the residents;
(3) Fire safety [and] , including resident smoking in designated areas only, unannounced fire drills, fire safety training, and notification to the department of fires and fire watches;
(4) Sanitation in the facility;
[(4)] (5) Diet, which shall be based on good nutritional practice;
[(5)] (6) Personal funds and property of residents;
[(6)] (7) Resident rights and resident grievance procedures appropriate to the levels of care, size and type of facility;
[(7)] (8) Record keeping appropriate to the levels of care, size and type of facility;
[(8)] (9) Construction of the facility;
[(9)] (10) Care of residents.
198.079. The department shall promulgate reasonable standards and regulations for all intermediate care facilities and all skilled nursing facilities. The standards and regulations shall take into account the level of care provided and the type of residents served by the facility. These standards and regulations shall relate to:
(1) The number and qualifications of employed and contract personnel having responsibility for any of the services provided for residents;
(2) The equipment, facilities, services and supplies essential to the health and welfare of the residents;
(3) Fire safety [and] , including resident smoking in designated areas only, unannounced fire drills, fire safety training, and notification to the department of fires and fire watches;
(4) Sanitation in the facility;
[(4)] (5) Diet, which shall be related to the needs of each resident and based on good nutritional practice and on recommendations which may be made by the physician attending the resident;
[(5)] (6) Personal funds and property of residents;
[(6)] (7) Resident rights and resident grievance procedures;
[(7)] (8) Record keeping, including clinical and personnel records;
[(8)] (9) The construction of the facility, including plumbing, heating, ventilation and other housing conditions which shall insure the health, safety and comfort of residents and protection from fire hazards;
[(9)] (10) Care of residents;
[(10)] (11) Social and rehabilitative service;
[(11)] (12) Staff training and continuing education.
198.086. 1. The department of health and senior services shall develop and implement a demonstration project designed to establish a licensure category for health care facilities that wish to provide treatment to persons with Alzheimer's disease or Alzheimer's-related dementia. The division shall also:
(1) Inform potential providers of the demonstration project and seek letters of intent;
(2) Review letters of intent and select provider organizations to participate in the demonstration project. Ten such organizations may develop such projects using an existing license and additional organizations shall be newly licensed facilities with no more than thirty beds per project. One demonstration project shall be at a stand-alone facility of no more than one hundred twenty beds designed and operated exclusively for the care of residents with Alzheimer's disease or dementia within a county of the first classification with a charter form of government with a population over nine hundred thousand. A total of not more than three hundred beds may be newly licensed through the demonstration projects. All projects shall maintain their pilot status until a complete evaluation is completed by the division of aging, in conjunction with a qualified Missouri school or university, and a written determination is made from such evaluation that the pilot project is successful;
(3) Monitor the participants' compliance with the criteria established in this section;
(4) Recommend legislation regarding the licensure of dementia-specific residential care based on the results of the demonstration project; and
(5) Submit a report regarding the division's activities and recommendations for administrative or legislative action on or before November fifteenth of each year to the governor, the president pro tem of the senate and the speaker of the house of representatives.
2. The director of the division [of aging] shall:
(1) Develop a reimbursement methodology to reasonably and adequately compensate the pilot projects for the costs of operation of the project, and require the filing of annual cost reports by each participating facility which shall include, but not be limited to, the cost equivalent of unpaid volunteer or donated labor;
(2) Process the license applications of project participants;
(3) Monitor each participant to assure its compliance with the requirements and that the life, health and safety of residents are assured;
(4) Require each participating facility to complete a minimum data set form for each resident occupying a pilot bed;
(5) Require the division of aging to assign a single team of the same surveyors to inspect and survey all participating facilities at least twice a year for the entire period of the project; and
(6) Submit to the president pro tem of the senate and speaker of the house of representatives copies of any statements of deficiencies, plans of correction and complaint investigation reports applying to project participants.
3. Project participants shall:
(1) Be licensed by the division [of aging];
(2) Provide care only to persons who have been diagnosed with Alzheimer's disease or Alzheimer's-related dementia;
(3) Have buildings and furnishings that are designed to provide for the resident's safety. Facilities shall have indoor and outdoor activity areas, and electronically controlled exits from the buildings and grounds to allow residents the ability to explore while preventing them from exiting the facility's grounds unattended;
(4) Be staffed twenty-four hours a day by the appropriate number and type of personnel necessary for the proper care of residents and upkeep of the facility;
(5) Conduct special staff training relating to the needs, care and safety of persons with Alzheimer's disease or Alzheimer's-related dementia within the first thirty days of employment;
(6) Utilize personal electronic monitoring devices for any resident whose physician recommends use of such device;
(7) Permit the resident's physician, in consultation with the family members or health care advocates of the resident, to determine whether the facility meets the needs of the resident; and
(8) [Be equipped with an automatic sprinkler system, in compliance with the National Fire Protection Association Code 13 or National Fire Protection Association Code 13R, and an automated fire alarm system and smoke barriers in compliance with the 1997 Life Safety Codes for Existing Health Care Occupancy; and
(9)] Implement a social model for the residential environment rather than an institutional medical model.
4. For purposes of this section, "health care facilities for persons with Alzheimer's disease or Alzheimer's-related dementia" means facilities that are specifically designed and operated to provide elderly individuals who have chronic confusion or dementia illness, or both, with a safe, structured but flexible environment that encourages physical activity through a well-developed recreational and aging-in-place and activity program. Such program shall continually strive to promote the highest practicable physical and mental abilities and functioning of each resident.
5. Nothing in this section shall be construed to prohibit project participants from accommodating a family member or other caregiver from residing with the resident in accordance with all life, health, and safety standards of the facility.
320.202. 1. There is hereby established within the department of public safety a "Division of Fire Safety", which shall have as its chief executive officer the fire marshal appointed under section 320.205. The fire marshal and the division shall be responsible for:
(1) The voluntary training of firefighters, investigators, inspectors, and public or private employees or volunteers in the field of emergency response, rescue, fire prevention or preparedness;
(2) Establishing and maintaining a statewide reporting system, which shall, as a minimum, include the records required by section 320.235 and a record of all fires occurring in Missouri showing:
(a) The name of all owners of personal and real property affected by the fire;
(b) The name of each occupant of each building in which a fire occurred;
(c) The total amount of insurance carried by, the total amount of insurance collected by, and the total amount of loss to each owner of property affected by the fire; and
(d) All the facts, statistics and circumstances, including, but not limited to, the origin of the fire, which are or may be determined by any investigation conducted by the division or any local firefighting agency under the laws of this state. All records maintained under this subdivision shall be open to public inspections during all normal business hours of the division;
(3) Conducting all investigations of fires mandated by sections 320.200 to 320.270;
(4) Conducting all fire inspections required of any private premises in order for any license relating to such private premises to be issued under any licensing law of this state, except those organizations and institutions licensed pursuant to [chapters 197 and 198] chapter 197, RSMo;
(5) Establishing and maintaining a voluntary training and certification program based upon nationally recognized standards. A certification testing fee and recertification fee shall be established by promulgated rules and regulations by the state fire marshal under the provisions of section 536.024, RSMo. Fees collected shall be deposited into the general revenue fund.
2. The state fire marshal shall exercise and perform all powers and duties necessary to carry out the responsibilities imposed by subsection 1 of this section, including, but not limited to, the power to contract with any person, firm, corporation, state agency, or political subdivision for services necessary to accomplish any of the responsibilities imposed by subsection 1 of this section.
3. The state fire marshal shall have the authority to promulgate rules and regulations under the provisions of section 536.024, RSMo, to carry out the provisions of this section.
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