Questions and Answers
Are wireless call systems allowed in Assisted Living Facilities?
What are the nurse staffing requirements for a skilled nursing facility?
What are the in-service training requirements for long-term care facilities?
How does the department survey or investigate standing orders?
How often do physician order sheets have to be reviewed in a skilled nursing facility?
How many staff members are required to operate a Hoyer Lift?
Is drug testing required of employees that work in an assisted living facility?
What are the space requirements for nursing home residents?
What are the requirements to be a "social services designee" in a long-term care facility?
Is the use of side rails an appropriate intervention for protecting residents from falls in a long-term care facility?
What training is obtained by nurse aides on lifting non-ambulatory residents?
What are the minimum nursing staff requirements in a skilled nursing facility?
Can extension cords be used in a long-term care facility?
Can an electric blanket be used in a long-term care facility?
What are the requirements for transferring/discharging a resident in a long-term care facility?
What are the training requirements for staff that provide care to residents with dementia?
Yes, a "wireless pager system" that is audible in the attendant´s work area is acceptable.
Reference: 19 CSR 30-86.032 (33)
Federal regulations for Medicare and Medicaid certified facilities require that the facility must:
- Have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care.
- Provide licensed nurses and other nursing personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans.
- Designate a licensed nurse to serve as a charge nurse on each tour of duty.
- Use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week.
- Designate a registered nurse to serve as the director of nursing on a full time basis. The director of nursing may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents.
State regulations for skilled nursing facilities require:
- Each facility shall have a licensed nurse in charge that is responsible for evaluating the needs of the residents on a daily and continuous basis to ensure there is sufficient, trained staff present to meet those needs.
- The facility must employ nursing personnel in sufficient numbers and with sufficient qualifications to provide nursing and related services which enable each resident to attain or maintain the highest practicable level of physical, mental and psychosocial well-being.
- The director of nursing shall be a registered nurse.
- A registered nurse shall be on duty in the facility on the day shift.
- Either a licensed practical nurse (LPN) or a registered professional nurse (RN) shall be on duty in the facility on both the evening and night shifts.
- A registered nurse shall be on call during the time when only an LPN is on duty.
- Nursing personnel shall be on duty at all times on each resident-occupied floor.
There are state and federal training requirements for staff that work in long-term care facilities.
State requirements are located at Code of State Regulations under the
19 CSR 30-85.022 (34) (A)
19 CSR 30-85.042 (20), (22), and (23)
19 CSR 30-86.022 (6)(A)
19 CSR 30-86.042 (20)(A)
19 CSR 30-86.047 (28),(63)(A), (65)(A)
Federal requirements are located at Centers for Medicare & Medicaid Services State
Operations Manual under the following regulations:
Centers for Medicaid and Medicare Services and Department of Health and Senior Services do not recognize standing orders as different from any other order. All orders must be signed and dated by the physician in the clinical record. The order could be a verbal, telephone or fax but the physician still has to sign and date it for that individual resident. The order needs to be specific for that resident and be applicable to their individual need. Individualized plan of care for each resident.
Code of State Regulations 19 CSR 30-85.042
- 19 CSR 30-85.042 (46)
- 19 CSR 30-85.042 (48)
Centers for Medicare & Medicaid Services State Operations Manual
F386 of the SOM 483.40(b) Physician Visits
The regulations do not provide specific timeframes. Facilities are required to ensure that a supervising physician is available to assist the facility in coordinating the overall program of care offered in the facility. The facility is also required to develop policies and procedures that must include nursing practices and provide in-service training for nursing personnel to ensure staff´s continuing competency.
Facilities are required to thoroughly assess each resident's conditions and needs, and provide nursing personnel in sufficient number with sufficient qualifications to meet the residents needs. Staff members utilizing lifts are required to be trained in the proper use and the lift must be used in accordance with the manufacturer's specifications.
Regulations do not specifically require that facilities conduct drug testing; however, employees who have any contact with residents are prohibited from acting in a manner which would materially and adversely affect the health, safety, welfare or property of residents. The facility manager/administrator is ultimately responsible for the residents and must ensure that staff members are mentally and physically capable of safely providing care. How they fulfill this obligation is not specified.
If you have information that leads you to believe that facility employees are acting in a manner that could potentially adversely affect the resident's health, safety, or welfare you may call the Adult Abuse & Neglect Hotline at 1-800-392-0210.
19 CSR 30-85.032 (3) In an existing facility licensed prior to July 1, 1965, the number of persons in any room or area used as sleeping quarters shall not exceed the proportion of one (1) adult for each sixty (60) square feet. In facilities licensed on or after July 1, 1965, adult resident rooms shall be a minimum of eighty (80) square feet per bed in multi-bed resident rooms and one hundred (100) square feet for private rooms. This square footage can include all useable floor spaces such as closets, entryways, and areas with moveable items or furniture that do not impact the safety or welfare of the resident, used for residents' belongings or if related to their care. Only the area of a room with a ceiling height of at least seven feet (7') can be included when calculating the square footage. II/III
(41) A minimum of three feet (3') shall be available between parallel beds. III
The regulations pertaining to social services designees vary by the type of facility. For residential care facilities (RCF) and assisted living facilities (ALF) there are no state regulations pertaining to social services designees.
For intermediate care facilities (ICF) and skilled nursing facilities (SNF), the following state regulation applies:
- 19 CSR 30-85.042 (92): The facility shall designate a staff member to be responsible for the facility's social services program. The designated staff person shall be capable of identifying social and emotional needs, knowledgeable of methods or resources, or a combination of these, to use to meet them and services shall be provided to residents as needed. II/III
If the ICF or SNF is a federally certified (accepts Medicare and/or Medicaid) facility, then the following Federal regulation also apply:
- A facility with more than 120 beds must employ a qualified social worker on a full-time basis.
- Qualifications of a social worker. A qualified social worker is an individual with- (i) A bachelor's degree in social work or a bachelor's degree in a human services field including but not limited to sociology, special education, rehabilitation counseling, and psychology; and (ii) One year of supervised social work experience in a health care setting working directly with individuals.
Is the use of side rails an appropriate intervention for protecting residents from falls in a long-term care facility?
The decision to use or not use a side rail requires a thorough assessment of the individual resident's condition and circumstances. Side rails can be an assistive device for one resident and a restraint for another. Side rails create an increased risk of injury or death for residents who attempt to exit a bed through, between, over or around them. Residents can become entrapped and suffocate or suffer a more serious fall than from a bed without side rails.
The following state regulations might be helpful in making decisions regarding side rails:
- 19 CSR 30-85.042 Administration and Resident Care Requirements for New and Existing Intermediate Care and Skilled Nursing Facilities.
- 19 CSR 30-88.010 Resident Rights
Guidance in the Centers for Medicare and Medicaid Services (CMS) State Operations Manual (SOM) at F221 and F323 might also be beneficial.
A Device Decision Guide: Restraint, Enabler, and Safety Hazard is also available.
Another resource that might be of assistance is the Missouri Long-Term Care Ombudsman. The Ombudsman office provides advocacy for long-term care residents and their family members.
Nurse aides are required to be trained and certified. The required curriculum for Missouri nurse aide training programs is Nurse Assistant in a Long-Term Care Facility produced by the Instructional Materials Laboratory, University of Missouri-Columbia. The manual has extensive lessons concerning proper lifting. It is available through the University (catalog number 50-5061-s). The manual may also be available through a local library.
Additionally, if assistive devices are used, manufacturer's recommendations should be followed.
There are minimum requirements outlined in regulation related to fire safety and protective oversight. The regulations are as follows:
19 CSR 30-85.022 (41)(A)
(41) Minimum staffing for safety and protective oversight to residents shall be-
(A) In a fire-resistant or sprinklered building-
7 a.m. to 3 p.m.
3 p.m. to 11 p.m.
11 p.m. to 7 a.m.
(B) In a non fire-resistant, non sprinklered building—
7 a.m. to 3 p.m.
3 p.m. to 11 p.m.
11 p.m. to 7 a.m.
*One (1) additional staff person for every fraction after that.
19 CSR 30-85.042 (37)
All facilities are required to employ nursing personnel in sufficient numbers and with sufficient qualifications to provide nursing and related services which enable each resident to attain or maintain the highest practice level of physical, mental, and psychological well-being. Each facility shall have a licensed nurse in charge who is responsible for evaluating the needs of the residents on a daily and continuous basis to ensure there are sufficient, trained staff present to meet those needs.
Additionally, facilities certified to provide Medicare/Medicaid services are required to employ sufficient nursing staff to provide nursing and related
services to attain or maintain the highest practicable, physical, mental and psychological well-being of each resident, in accordance with
F309 and F353.
Extension cords may be used in accordance with the following regulatory requirements:
19 CSR 30-85.032 (37) If extension cords are used, they must be Underwriters Laboratories (UL)-approved or shall comply with other recognized electrical appliance approval standards and sized to carry the current required for the appliance used. Only one (1) appliance shall be connected to one (1) extension cord. Only two (2) appliances may be served by one (1) duplex receptacle. Extension cords shall not be placed under rugs, through doorways, or located where they are subject to physical damage.
Facilities certified to provide Medicare/Medicaid services are also required to comply with the following regulatory guidance:
K147 - Facilities are required to comply with the National Electric Code Section 400-8:
Uses Not Permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
- As a substitute for fixed wiring of a structure
- Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
- Where run through doorways, windows, or similar openings
- Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
- Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
- Where installed in raceways, except as otherwise permitted in this Code
F323 - Extension cords should not be used to take the place of adequate wiring in a facility. If extension cords are used, the cords should be properly secured and not be placed overhead, under carpets or rugs, or anywhere that the cord can cause trips, falls, or overheat. Extension cords should be connected to only one device to prevent overloading of the circuit. The cord itself should be of a size and type for the expected electrical load and made of material that will not fray or cut easily. Electrical cords including extension cords should have proper grounding if required and should not have any grounding devices removed or not used if required.
Power strips may not be used as a substitute for adequate electrical outlets in a facility. Power strips may be used for a computer, monitor, and printer. Power strips are not designed to be used with medical devices in patient care areas. Precautions needed if power strips are used include: installing internal ground fault and over-current protection devices; preventing cords from becoming tripping hazards; and using power strips that are adequate for the number and types of devices used. Overload on any circuit can potentially cause overheating and fire. The use of ground fault circuit interruption (GFCIs) may be required in locations near water sources to prevent electrocution of staff or residents.
Guidance to Surveyors for Long Term Care Facilities is available at the Centers for Medicare & Medicaid Services (CMS)
State Operations Manual Appendix PP.
State regulations do not prohibit the use of electric blankets. The Division of Regulation and Licensure, Engineering and Consultation Unit has provided the following guidance concerning the use of electric blankets:
- Must be UL labeled and maintained according to manufacturer's recommendations.
- Resident must not be incontinent.
- If the resident is confused, the controls must be modified so the resident cannot increase the temperature setting.
- Staff must maintain close observation to assure comfort and safety.
Medicare/Medicaid certified facilities are required to comply with federal guidance at F323, which specifically addresses this issue.
The facility must ensure that -
(1) The resident environment remains as free from accident hazards as is possible; and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents
The proper use of electric blankets and heating pads is essential to avoid thermal injuries. These items should not be tucked in or squeezed. Constriction can cause the internal wires to break. A resident should not go to sleep with an electric blanket or heating pad turned on. Manufacturer's instructions for use should be followed closely. Injuries and deaths have been related to burns and fires related to the use of heating pads. Most deaths are attributable to heating pads that generated fires, but most injuries are burns from prolonged use or inappropriate temperature setting. Prolonged use on one area of the body can cause a severe burn, even when the heating pad is at a low temperature setting.
State regulations at 19 CSR 30-82.050 set out the requirements that a facility must meet in order to discharge or transfer a resident. Below is a brief summary of the basic requirements:
In most circumstances, the facility must allow the resident to remain in the facility. There are limited circumstances in which a facility may discharge or transfer a resident, including:
- The transfer or discharge is appropriate because the resident's welfare and the resident's needs cannot be met by the facility;
- Because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility;
- The safety of individuals in the facility is endangered;
- The health of individuals in the facility would otherwise be endangered;
- The resident has failed, after reasonable and appropriate notice, to pay for (or have paid under Medicare or Medicaid) a stay at the facility; or
- The facility ceases to operate.
Before a facility transfers or discharges a resident, the facility must:
- Send written notice to the resident, any legal representative of the resident, and at least one family member. If no family member is known to the facility, they must send the notice to the State Long-Term Care Ombudsman.
- The written notice must include:
- The reason for the transfer or discharge;
- The effective date of transfer or discharge;
- The resident's right to appeal the transfer or discharge notice to the director of the Department of Health and Senior Services or his/her designated hearing official;
- The address to which the request for a hearing should be sent;
- That filing an appeal will allow a resident to remain in the facility until the hearing is held unless a hearing official finds otherwise;
- The location to which the resident is being transferred or discharged; and
- The name, address and telephone number of the designated regional long-term care ombudsman office.
- For Medicare and Medicaid certified residents with developmental disabilities, the mailing address and telephone number of the Missouri Protection and Advocacy Agency.
The notice of transfer or discharge described above must be made by the facility no less than 30 days before the resident is to be transferred or discharged. In the case of an emergency discharge, the notice must be made as soon as practicable before the discharge.
The discharge of the resident will be stayed at the time the request for a hearing was filed unless the facility can show good cause why the resident should not remain in the facility until a written hearing decision has been issued.
Facilities certified to provide Medicare/Medicaid services are also required to comply with similar federal regulations found at F177.
The training requirements vary depending on the type of facility, however all facilities are required to have dementia-specific training as part of new employee orientation and ongoing in-service training for all employees who provide care for residents with dementia. It is best to review regulations that are specific to the facility type. To view the requirements, please click on the links below.
- F497 483.75 (e)(8) Regular In-Service Education
- F498 483.75 (f) Proficiency of Nurse Aides
- 86.042 (20)
- 86.047 (4)
- 86.047 (63)
- 660.050 8 RSMO