Title 19—Department of Health and Senior Services
Division 30—Division of Regulation and Licensure Chapter 81—Certification

19 CSR 30-81.010 General Certification Requirements

PURPOSE: This rule sets forth application procedures and general certification requirements for nursing facilities certified under the Title XIX (Medicaid) program and skilled nursing facilities under Title XVIII (Medicare), and procedures to be followed by nursing facilities when requesting a nurse staffing waiver.

PUBLISHER’S NOTE: The secretary of state has determined that the publication of the entire text of the material which 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. Definitions.
   1. Certification shall mean the determination by the Missouri Department of Health and Senior Services, or the Centers for Medicare and Medicaid Services, that a licensed skilled nursing or intermediate care facility (SNF/ICF) licensed under Chapter 198, RSMo, or an ICF for person with mental retardation (ICF/MR), is in substantial compliance with all federal requirements and is approved to participate in the Medicaid or Medicare programs.
   2. CMS shall mean the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services.
   3. Cost reporting year shall mean the facility’s twelve (12)-month fiscal reporting period covering the same twelve (12)-month period that the facility uses for its federal income tax reporting.
   4. Distinct part shall mean a portion of an institution or institutional complex that is certified to provide SNF or NF services. A distinct part must be physically distinguishable from the larger institution and must consist of all beds within the designated area. The distinct part may be a separate building, floor, wing, ward, hallway or several rooms at one end of a hall or one side of a corridor.
   5. Department shall mean the Missouri Department of Health and Senior Services.
   6. ICF/MR shall mean intermediate care facility for persons with mental retardation.
   7. Medicaid shall mean Title XIX of the federal Social Security Act.
   8. Medicare shall mean Title XVIII of the federal Social Security Act.
   9. Nursing facility (NF) shall mean an SNF or ICF licensed under Chapter 198, RSMo which has signed an agreement with the Department of Social Services to participate in the Medicaid program and which is certified by the department. As used within the contents of this rule, licensed SNFs, SNF/ICF and ICFs participating in the Medicaid program are subject to state and federal laws and regulations for participation as an NF.
   10. Section for Long Term Care (SLTC) shall mean that section of the department responsible for licensing and regulating long-term care facilities licensed under Chapter 198, RSMo.
   11. Skilled nursing facility (SNF) shall mean an SNF licensed under Chapter 198, RSMo which has a signed agreement with the CMS to participate in the Medicare program and which has been recommended for certification by the department.
   12. Title XVIII shall mean the Medicare program as provided for in the federal Social Security Act.
   13. Title XIX shall mean the Medicaid program as provided for in the federal Social Security Act.
2. An operator of an SNF or ICF licensed by the department electing to be certified as a provider of skilled nursing services under the Title XVIII (Medicare) or NF services under the Title XIX (Medicaid) program of the Social Security Act; or an operator of a facility electing to be certified as an ICF/MR facility under Title XIX shall submit application materials to the department as required by federal law and shall comply with standards set forth in the Code of Federal Regulations (CFR) of the United States Department of Health and Human Services in 42 CFR chapter IV, part 483, subpart B for nursing homes and 42 CFR chapter IV, part 483, subpart I for ICF/MR facilities, as appropriate.
   1. For Medicaid, the application shall include:
      1. Long Term Care Facility Application for Medicare and Medicaid, Form CMS-671 (12/02), incorporated by reference in this rule and available through the Centers for Medicare and Medicaid website [BROKEN LINK], or by mail at: Centers for Medicare and Medicaid Services, 7500 Security Boulevard, Baltimore, MD 21244-1850;
      2. Form DA-113, Bed Classification for Licensure and Certification by Category (8-05), incorporated by reference in this rule and available through the department’s website [NEEDS LINK], or by mail at: Department of Health and Senior Services Warehouse, Attention General Services Warehouse, PO Box 570, Jefferson City, MO 65102-0570, telephone: (573) 526-3861.
   2. For Medicare, the application shall include:
      1. Long Term Care Facility Application for Medicare and Medicaid;
      2. Expression of Intermediary Preference Form (8-05), incorporated by reference in this rule and available through the department’s website [NEEDS LINK], or by mail at: Department of Health and Senior Services Warehouse, Attention General Services Warehouse, PO Box 570, Jefferson City, MO 65102-0570, telephone: (573) 526- 3861;
      3. Form DA-113, Bed Classification for Licensure and Certification by Category;
      4. Three (3) copies of Health Insurance Benefit Agreement, Form CMS-1561 (07/01), incorporated by reference in this rule and available through the Centers for Medicare and Medicaid website [BROKEN LINK], or by mail at: Centers for Medicare and Medicaid Services, 7500 Security Boulevard, Baltimore, MD 21244-1850;
      5. Three (3) copies of Assurance of Compliance, Form HHS-690 (5/97), incorporated by reference in this rule and available through the Centers for Medicare and Medicaid website [BROKEN LINK], or by mail at the U.S. Department of Health and Human Services, 200 Independence Avenue, SW, Washington, DC 20201, telephone: (202) 619-0257; Toll Free: 1 (877) 696-6775.
      6. The forms incorporated by reference in subsections (2)(A) and (B) do not include any later amendments or additions.
   3. SNFs or NFs which are newly certified or which are undergoing a change of ownership shall submit an initial certification fee in the amount up to one thousand dollars ($1,000) as stipulated by the department in writing to the operator following receipt of the properly completed application material referenced in section (2). The amount for the initial certification fee shall be the prorated portion of one thousand dollars ($1,000) with prorating based on the month of receipt of the application in relation to the beginning of the next federal fiscal year. This initial certification fee shall be nonrefundable and a facility shall not be certified until the fee has been paid.
   4. All SNFs or NFs certified to participate in the Medicaid or Medicare program(s) shall submit to the department an annual certification fee of one thousand dollars ($1,000) prior to October 1 of each year. If the fee is not received by that date each year, a late fee of fifty dollars ($50) per month shall be payable to the department. If payment of any fees due is not received by the department by the time the facility license expires or by December 31 of that year, whichever is earlier, the department shall notify the Division of Medical Services and the CMS recommending termination of the Medicaid or Medicare agreement as denial of license will occur as provided in 19 CSR 30-82.010 and section 198.022, RSMo.
3. Application material shall be signed and dated and submitted to the department’s SLTC licensure unit at least fourteen (14) working days prior to the date the facility is ready to be surveyed for compliance with federal regulations (Initial Certification Survey). The operator or authorized representative shall notify the appropriate department regional office by letter or by phone as to the date the facility will be ready to be surveyed. There shall be at least two (2) residents in the facility before a survey can be conducted. The facility shall already be licensed or with licensure in process shall be in compliance with all state rules.
4. Any facility certified for participation as an NF in the Title XIX Medicaid program electing to participate in the Title XVIII Medicare program shall submit an application signed and dated by the operator or his or her authorized representative to the department’s SLTC central office licensure unit. The department will recommend Medicare certification to the CMS effective the date the application material is received by the department or a subsequent date if requested by the provider, provided the facility was in compliance with all federal and state regulations for SNFs at the last survey conducted by the department and provided the facility’s application is complete and has been approved by the Medicare fiscal intermediary.
5. Any facility certified for participation in the Medicare program wishing to participate in the Medicaid program shall submit a signed and dated application to the department central office. The department will certify the facility for Medicaid participation effective the date the application is received by the department or a subsequent date requested by the provider, provided the facility was in compliance with all federal regulations at the last survey conducted by the department and the application is complete.
6. For newly certified facilities, the facility will be certified for either Medicare or Medicaid participation effective the date the facility receives a license at the proper level or the date the facility achieves substantial compliance with the federal participation requirements, whichever is the later date. The application shall be completed. For certification in the Title XVIII (Medicare) program, the Medicare fiscal intermediary must approve the application and the CMS must concur with the department’s recommendation.
7. The department shall conduct federal surveys in SNFs, NFs and ICF/MR facilities, utilizing regulations and procedures contained in
   1. The State Operations Manual (SOM) (HCFA Publication 7);
   2. The Survey and Certification Regional letters received by the department from the CMS;
   3. For SNFs and NFs, federal regulation 42 CFR chapter IV, part 483, subpart B; and
   4. For ICF/MR facilities, federal regulation 42 CFR chapter IV, part 483, subpart I.
8. A facility, in its application, shall designate the number of beds to be certified and their location in the facility. A facility can be wholly or partially certified. If partially certified, the beds shall be in a distinct part of the facility and all beds shall be contiguous.
9. If a facility certified to participate in the Title XIX (Medicaid) or Title XVIII (Medicare) program elects to change the size of its distinct part, it must submit a written request to the Licensure/Certification Unit or the ICF/MR Unit of the department, as applicable. The request shall specify the room numbers involved, the number of beds in each room and the facility cost reporting year end date. The request must include a floor diagram of the facility and a signed DA-113 form, Bed Classification for Licensure and Certification by Category. A facility is allowed two (2) changes in the size of its distinct part during the facility cost reporting year. This may be two (2) increases or one (1) increase and one (1) decrease. It may not be two (2) decreases. The first change can be done only at the beginning of the facility cost reporting year and the second change can be done effective at the beginning of a facility cost reporting quarter within that facility cost reporting year. All requests must be submitted to the Licensure/Certification Unit or the ICF/MR Unit of the department at least forty-five (45) days in advance. Any facility wishing to eliminate its distinct part to go to full certification may do so effective at the beginning of the next facility cost reporting quarter with forty-five (45) days notice. The distinct part may be reestablished only at the beginning of the next facility cost reporting year. A facility may change the location of the distinct part with thirty (30) days notice to the Licensure/Certification Unit or the ICF/MR Unit of the department.
10. If a facility certified to participate in the Title XIX (Medicaid) or Title XVIII (Medicare) program undergoes a change of operator, the new operator shall submit an application as specified in section (2) of this rule. The application shall be submitted within five (5) working days of the change of operator. For applications made for the Title XIX (Medicaid) program, the department shall provide the application to the Division of Medical Services of the Department of Social Services so that a provider agreement can be negotiated and signed. For applications made for the Title XVIII (Medicare) program, the department shall provide the application to the CMS. Certification status will be retained unless or until formally denied.
11. If it is determined by the department that a facility certified to participate in Medicaid or Medicare does not comply with federal regulations at the time of a federal survey, complaint investigation or state licensure inspection, the department shall take enforcement action using the regulations and procedures contained in the following sources:
    1. 42 CFR chapter IV, part 431, subparts D, E and F;
    2. 42 CFR chapter IV, part 442;
    3. 42 U.S.C. Section 1395i–3;
    4. 42 U.S.C. Section 1396(r);
    5. Sections 198.026 and 198.067, RSMo; and
    6. 13 CSR 70-10.015 and 13 CSR 70-10.030.
12. If a facility certified to participate in the Medicaid Title XIX program has been decertified as a result of noncompliance with the federal requirements, the facility can be readmitted to the Medicaid program by submitting an application for initial participation in the Medicaid program. After having received the application, the department shall conduct a survey at the earliest possible date to determine if the facility is in substantial compliance with all federal participation requirements. The effective date of participation will be the date the facility is found to substantially comply with all federal requirements.
13. If a change in the administrator or the director of nursing of a facility occurs, the facility shall provide written notice to the department’s SLTC central office licensure unit within ten (10) calendar days of the change. The notice shall show the effective date of the change, the identity of the new director of nursing or administrator and a copy of his or her license or the license number. Change of administrator information shall be submitted as a notarized statement by the operator in accordance with section 198.018, RSMo.
14. An NF may request a waiver of nurse staffing requirements to the extent the facility is unable to meet the requirements including the areas of twenty-four (24)-hour licensed nurse coverage, the use of a registered nurse for eight (8) consecutive hours seven (7) days per week and the use of a registered nurse as director of nursing.
    1. Requests for waivers shall be made in writing to the director of the Section for Long Term Care.
    2. Requests for waivers will be considered only from facilities licensed under Chapter 198, RSMo as ICFs which do not have a nursing pool agency that is within fifty (50) miles, within state boundaries, and which can supply the needed nursing personnel.
    3. The department shall consider each request for a waiver and shall approve or disapprove the request in writing postmarked within thirty (30) working days of receipt or, if additional information is needed, shall request from the facility the additional information or documentation within ten (10) working days of receipt of the request.
    4. Approval of a nurse waiver request shall be based on an evaluation of whether the facility has been unable, despite diligent efforts—including offering wages at the community prevailing rate for nursing facilities—to recruit the necessary personnel. Diligent effort shall mean prominently advertising for the necessary nursing personnel in a variety of local and out-of-the-area publications, including newspapers and journals within a fifty (50)-mile radius, and which are within state boundaries; contacts with nursing schools in the area; and participation in job fairs. The operator shall submit evidence of the diligent effort including:
       1. Copies of newspapers and journal advertisements, correspondence with nursing schools and vocational programs, and any other relevant material;
       2. If there is a nursing pool agency within fifty (50) miles which is within state boundaries and the agency cannot consistently supply the necessary personnel on a per diem basis to the facility, the operator shall submit a letter from the agency so stating;
       3. Copies of current staffing patterns including the number and type of nursing staff on each shift and the qualifications of licensed nurses;
       4. A current Resident Census and Condition of Residents, Form CMS-672 (10/98), incorporated by reference in this rule and available through the Centers for Medicare and Medicaid website [BROKEN LINK], or by mail at: Centers for Medicare and Medicaid Services, 7500 Security Boulevard, Baltimore, MD 21244-1850. This rule does not incorporate any subsequent amendments or additions;
       5. Evidence that the facility has a registered nurse consultant required under 19 CSR 30-85.042 and evidence that the facility has made arrangements to assure registered nurse involvement in the coordination of the assessment process as required under 42 CFR 483.20(3);
       6. Location of the nurses’ stations and any other pertinent physical feature information the facility chooses to provide;
       7. Any other information deemed important by the facility including personnel procedures, promotions, staff orientation and evaluation, scheduling practices, benefit programs, utilization of supplemental agency personnel, physician-nurse collaboration, support services to nursing personnel and the like; and
       8. For renewal requests, the information supplied shall show diligent efforts to recruit appropriate personnel throughout the prior waiver period. Updates of prior submitted information in other areas are acceptable.
    5. In order to meet the conditions specified in federal regulation 42 CFR 483.30, the following shall be considered in granting approval:
       1. There is assurance that a registered nurse or physician is available to respond immediately to telephone calls from the facility for periods of time in which licensed nursing services are not available;
       2. There is assurance that if a facility requesting a waiver has or admits after receiving a waiver any acutely ill or unstable residents requiring skilled nursing care, the skilled care shall be provided in accordance with state licensure rule 19 CSR 30-85.042; and
       3. The facility has not received a Class I notice of noncompliance in resident care within one hundred twenty (120) days of the waiver request or the department has not conducted an extended survey in the facility within one (1) year of the waiver request. Any facility which receives a Class I notice of noncompliance in resident care or an extended survey while under waiver status will not have the waiver renewed unless the problem has been corrected and steps have been taken to prevent recurrence. If a facility received more than one (1) Class I notice of noncompliance in resident care during a waiver period, the department will consider revocation of the waiver.
    6. The facility shall cooperate with the department in providing the proper documentation. For renewal requests, the request and proper documentation shall be submitted to the department at least forty-five (45) days prior to the ending date of the current waiver period. If any changes occur during a waiver period that affect the status of the waiver, a letter shall be submitted to the deputy director of institutional services within ten (10) days of the changes. The request for a waiver or renewal of a waiver shall be denied if the facility fails to abide by these previously mentioned time frames.
    7. If a waiver request is denied, the department shall notify the facility in writing and within twenty (20) days, the facility shall submit to the department a written plan for how the facility will recruit the required personnel. If appropriate personnel are not hired within two (2) months, the department shall initiate enforcement proceedings.

AUTHORITY: section 660.050 RSMo 2005.* This rule originally filed as 13 CSR 15-9.010. Emergency rule filed Sept. 18, 1990, effective Oct. 1, 1990, expired Jan. 25, 1991. Original rule filed Nov. 2, 1990, effective June 10, 1991. Amended: Filed June 3, 1993, effective Dec. 9, 1993. Amended: Filed Feb. 1, 1995, effective Sept. 30, 1995. Amended: Filed May 11, 1998, effective Nov. 30, 1998. Amended: Filed Nov. 27, 2000, effective July 30, 2001. Emergency amendment filed July 13, 2001, effective July 30, 2001, expired Feb. 28, 2002. Moved to 19 CSR 30- 81.010, effective Aug. 28, 2001. Amended: Filed July 13, 2001, effective Feb. 28, 2002. Amended: Filed Nov. 1, 2005, effective April 30, 2006.

*Original authority: 660.050, RSMo 1984, amended 1988, 1992, 1993, 1994, 1995, 2001.

19 CSR 30-81.015 Resident Assessment Instrument

(Rescinded September 30, 2012)

AUTHORITY: section 536.021, RSMo Supp. 1993. This rule originally filed as 13 CSR 15-9.015. Emergency rule filed Dec. 18, 1990, effective Dec. 31, 1990, expired April 29, 1991. Emergency rule filed May 7, 1991, effective May 17, 1991, expired Sept. 13, 1991. Original rule filed Dec. 18, 1990, effective June 10, 1991. Emergency amendment filed June 16, 1992, effective Aug. 1, 1992, expired Nov. 28, 1992. Amended: Filed June 16, 1992, effective Feb. 26, 1993. Emergency amendment filed May 14, 1993, effective June 1, 1993, expired Sept. 28, 1993. Emergency amendment filed July 14, 1993, effective July 25, 1993, expired Nov. 21, 1993. Amended: Filed May 14, 1993, effective Dec. 9, 1993. Moved to 19 CSR 30-81.015, effective Aug. 28, 2001. Rescinded: Filed March 1, 2012, effective Sept. 30, 2012.

19 CSR 30-81.020 Prelong-Term Care Screening

(Rescinded February 28, 2006)

AUTHORITY: sections 207.020 and 208.159, RSMo 1986 and 208.153, RSMo Supp. 1991.* This rule was previously filed as 13 CSR 40-81.086 and 13 CSR 15-9.020. Emergency rule filed March 14, 1984, effective April 12, 1984, expired Aug. 8, 1984. Original rule filed March 14, 1984, effective Aug. 9, 1984. Amended: Filed Aug. 3, 1992, effective May 6, 1993. Moved to 19 CSR 30-81.020, effective Aug. 28, 2001. Rescinded: Filed Aug. 12. 2005, effective Feb. 28, 2006.

19 CSR 30-81.030 Evaluation and Assessment Measures for Title XIX Recipients and Applicants

PURPOSE: This rule sets the requirements for the periodic evaluation and assessments of residents in long-term care facilities in relationship to evaluation and assessment processes, level of care needed by individuals, and appropriate placement of individuals in order to receive this care. The rule also includes the algorithm utilized for the department’s Home and Community Based Services program for its level-of-care determination. The rule includes a second level-of-care determination to be utilized from October 31, 2021, until the funding from the American Rescue Plan Act (temporary enhanced federal medical assistance percentage) has been expended.

1. For purposes of this rule only, the following definitions shall apply:
   1. Applicant—any resident or prospective resident of a certified long-term care facility who is seeking to receive inpatient Title XIX assistance;
   2. Certified long-term care facility—any long-term care facility which has been approved to participate in the inpatient pro- gram and receives Title XIX funding for eligible recipients;
   3. Initial assessment forms—the forms utilized to collect information necessary for a level-of-care determination pursuant to 19 CSR 30-81.030 and designated Forms DHSSDRL-109 (10-20), Nursing Facility Level of Care Assessment and DHSS-DRL- 110 (10-20), Level One Nursing Facility Pre- Admission Screening for Mental Illness/Intellectual Disability or Related Condition, included herein;
   4. Inpatient Title XIX assistance—Title XIX payments for intermediate or skilled nursing care in a certified long-term care facility;
   5. Level-of-care assessment—the determination of level-of-care need based on an assessed point count value for each category cited in subsection (4)(B) of this rule;
   6. Level-of-care determination—the decision whether an individual qualifies for long- term care facility care;
   7. Long-term care facility—a skilled nursing facility (SNF), an intermediate care facility (ICF), or a hospital which provides skilled nursing care or intermediate nursing care in a distinct part or swing bed under Chapter 197, RSMo;
   8. Pro re nata (PRN)—medication or treatment ordered by a physician to be administered as needed, but not regularly scheduled;
   9. Recipient—any resident in a certified long-term care facility who is receiving inpatient Title XIX assistance;
   10. Redetermination of level-of-care—the periodic assessment of the recipients’ continued eligibility and need for continuation at the previously assigned level of care. Periodic assessment includes, but is not limited to, the following:
       1. Assessment of new admissions to a long-term care facility;
       2. Assessment of a change in mental and/or physical status for a resident who is being readmitted to a long-term care facility after transfer to an acute care facility, and the previous DA-124 A/B or C forms do not reflect the resident’s current care needs; and
       3. Assessment of DA-124 forms as requested by the Department of Social Services, Family Support Division;
   11. Reevaluation of level-of-care—the periodic assessment of the recipients’ continued eligibility and need for continuation at the previously assigned level of care. Periodic assessment includes, but is not limited to, the following:
       1. Assessment of new admissions to a long-term care facility;
       2. Assessment of a change in mental and/or physical status for a resident who is being readmitted to a long-term care facility after transfer to an acute care facility, and the previous DHSS-DRL-109 (10-20), Nursing Facility Level of Care Assessment or DHSSDRL-110 (10-20), Level One Nursing Facility Pre-Admission Screening for Mental Illness/Intellectual Disability or Related Condition forms do not reflect the resident’s current care needs; and
       3. Assessment of DHSS-DRL-109 (10- 20), Nursing Facility Level of Care Assessment or DHSS-DRL-110 (10- 20), Level One Nursing Facility Pre-Admission Screening for Mental Illness/Intellectual Disability or Related Condition forms as requested by Department of Social Services, Family Support Division;
   12. Resident—a person seventeen (17) years or older who by reason of aging, illness, disease, or physical or mental infirmity receives or requires care and services furnished by a long-term care facility and who resides in, is cared for, treated, or accommodated in such long-term care facility for a period exceeding twenty-four (24) consecutive hours; and
   13. The department—Department of Health and Senior Services.
2. Initial Level-of-Care Determination Requirements.
   1. In accordance with 42 CFR sections 456.370 and 483.104, the department or its designated agents, or both, will conduct a review and assessment of the evaluations made by the attending physician for an applicant in or seeking admission to a long-term care facility. The review and assessment shall be conducted using the criteria in section (5) of this rule.
   2. The initial level-of-care determination shall be completed for the following:
      1. All applicants prior to or on admission to a long-term care facility; and
      2. When an applicant or recipient has been discharged from a long-term care facility for more than sixty (60) days.
   3. A referring individual shall fill out and submit electronically using the department’s online database system available at: https://health.mo.gov/seniors/nursinghomes/pasrr.php [NEEDS LINK]. the required documentation contained in forms DHSS-DRL-109 (10- 20), Nursing Facility Level of Care Assessment and DHSS-DRL-110 (10-20), Level One Nursing Facility Pre-Admission Screening for Mental Illness/Intellectual Disability or Related Condition.
   4. The department shall complete the assessment within ten (10) working days of receipt of all documentation required by section (5) of this rule unless further evaluation by the State Mental Health Authority is required by 42 CFR 483.100 to 483.138.
   5. The department shall provide written notice to the individual or referring entity if Level II screening is referred to the Department of Mental Health. The referring entity shall notify the applicant or recipient of the results of the screening.
3. Level-of-Care Reevaluation Requirements.
   1. The level-of-care reevaluation is applicable for recipients who are eligible for placement in a long-term care facility. The level-of-care reevaluation shall be completed for the following:
      1. When a significant change has occurred in the resident’s physical, mental, or psychosocial status for a resident diagnosed with mental illness and/or intellectual disability or related condition; or
      2. As requested by Department of Social Services, Family Support Division or the Department of Mental Health.
   2. A referring individual shall fill out and submit electronically using the department’s online database system available at: https://health.mo.gov/seniors/nursinghomes/pasrr.php [NEEDS LINK]. the required documentation contained in forms DHSS-DRL-109 (10- 20), Nursing Facility Level of Care Assessment and DHSS-DRL-110 (10-20), Level One Nursing Facility Pre-Admission Screening for Mental Illness/Intellectual Disability or Related Condition.
   3. The department shall provide written notice to the individual or referring entity if Level II screening is referred to the Department of Mental Health. The referring entity shall notify the applicant or recipient of the results of the screening.
4. Level-of-Care Criteria for Long-Term Care Facility Care—Qualified Title XIX Recipients and Applicants.
   1. Individuals will be assessed with the ultimate goal to achieve placement for these individuals in the least restrictive environment possible, yet enable them to receive all services required by their physical/mental condition.
   2. The specific areas which will be considered when determining an individual’s ability or inability to function in the least restrictive environment are—behavioral, cognition, mobility, eating, toileting, bathing, dressing and grooming, rehabilitative services, treatments, meal preparation, medication management, and safety.
   3. To qualify for intermediate or skilled nursing care, an applicant or recipient shall exhibit physical impairment, which may be complicated by mental impairment or mental impairment which may be complicated by physical impairment, severe enough to require intermediate or skilled nursing care.
5. Assessed Needs Point Designations Requirements.
   1. Applicants or recipients will be assessed for level-of-care by the assignment of a point count value for each category cited in subsection (4)(B) of this rule.
   2. Points will be assessed for the amount of assistance required, the complexity of the care, and the professional level of assistance necessary, based on the level-of-care criteria.
   3. For individuals seeking admission to a long-term care facility on or after July 15, 2021, the applicant or recipient will be determined as eligible for Title XIX-funded long-term care services if he or she is determined to need care with an assessed point level of eighteen (18) points or above, using the assessment procedure as required in this rule.
   4. For individuals seeking admission to a long-term care facility on or after July 15, 2021, an applicant with less than eighteen (18) points will be determined as ineligible for Title XIX-funded long-term care services, unless the applicant qualifies as otherwise provided in subsection (5)(E) of the rule.
   5. An applicant or recipient will be considered eligible for inpatient Title XIX assistance regardless of the total point count if the applicant or recipient is unable to meet physical/mental requirements for residential care facility (RCF) and assisted living facility (ALF) residency as specified by section 198.073, RSMo. In order to determine if an applicant or recipient is unable to meet RCF and ALF residency, the following criteria shall be applied:
      1. For RCF residency an applicant or recipient shall be physically and mentally capable of negotiating a normal path to safety. In order to meet this requirement, an applicant or recipient, without staff assistance, must be able to reach and go through a required exit door to the outside building by—
         1. Responding to verbal direction or the sound of an alarm;
         2. Being prepared to leave the facility within five (5) minutes of being alerted of the need to evacuate;
         3. If using a wheelchair, the resident shall be able to transfer into the wheelchair and propel it or reach the assistive device, and open all doors without staff assistance; and
         4. If using another assistive device, such as a walker or cane, they shall be able to reach and utilize the assistive device without staff assistance.
      2. For ALF residency, the applicant or recipient cannot be admitted or retained if they meet the following criteria:
         1. Exhibit behaviors that present a reasonable likelihood of serious harm to himself or herself or others;
         2. Require physical restraints;
         3. Require chemical restraints;
         4. Require skilled nursing services as defined in subsection 198.073.4, RSMo for which the facility is not licensed or able to provide;
         5. Require more than one (1) person to simultaneously physically assist the resident with any activity of daily living, with the exception of bathing and transferring; or
         6. Is bedbound or similarly immobilized due to a debilitating or chronic condition.
   6. Points will be assigned to each category, as required by subsection (4)(B) of this rule, in multiples of three (3) according to the following requirements:
      1. Behavioral is defined as the applicant or recipient’s repeated behavioral challenges that affect their ability to function in the community. The applicants or recipients who exhibit uncontrolled behavior that is dangerous to themselves or others must be transferred immediately to an appropriate facility. Determine if the applicant or recipient: receives monitoring for a mental condition, exhibits one (1) of the following mood or behavior symptoms: wandering, physical abuse, socially inappropriate or disruptive behavior, inappropriate public sexual behavior or public disrobing, resists care or exhibits one (1) of the following psychiatric conditions: abnormal thoughts, delusions, hallucinations. The applicant or recipient can receive up to nine (9) points in this category. The applicant or recipient will receive—
         1. Zero (0) points if assessed with a stable mental condition and no mood or behavior symptoms observed and no reported psychiatric conditions;
         2. Three (3) points if assessed with a stable mental condition monitored by a physician or licensed mental health professional at least monthly or behavior symptoms exhibited in the past, but not currently present or psychiatric conditions exhibited in the past, but not recently present;
         3. Six (6) points if assessed with an unstable mental condition monitored by a physician or licensed mental health professional at least monthly, or behavior symptoms are currently exhibited, or psychiatric conditions are recently exhibited; or
         4. Nine (9) points if assessed with an unstable mental condition monitored by a physician or licensed mental health professional at least monthly and behavior symptoms are currently exhibited or psychiatric conditions are currently exhibited.
      2. Cognition is defined as the applicant or recipient’s performance in remembering, making decisions, organizing daily self-care activities, as well as understanding others and making self- understood. Determine if the applicant or recipient has an issue in one (1) or more of the following areas: cognitive skills for daily decision making, memory or recall ability (short-term, procedural, situational memory), disorganized thinking/awareness, mental function varies over the course of the day, or ability to understand others or to be understood. The applicant or recipient can receive up to eighteen (18) points in this category. The applicants or recipients with “no discernable consciousness, coma” are presumed to meet nursing facility level of care. The applicant or recipient will receive—
         1. . Zero (0) points if assessed with no issues with cognition and no issues with memory, mental function, or ability to be understood or to understand others;
         2. Three (3) points if assessed as displaying difficulty making decisions in new situations or occasionally requires supervision in decision making and has issues with memory, mental function, or ability to be understood or to understand others;
         3. Six (6) points if assessed as displaying consistent unsafe or poor decision making requiring reminders, cues, or supervision at all times to plan, organize, and conduct daily routines, and has issues with memory, mental function, or ability to be understood or understand others; or
         4. Nine (9) points if assessed as rarely or never has the capability to make decisions or displaying consistent unsafe or poor decision making or requires total supervision requiring reminders, cues, or supervision at all times to plan, organize, and conduct daily routines, and rarely or never understood by or able to understand others.
      3. Mobility is defined as the amount of assistance needed by the applicant or recipient to move from one (1) place or position to another. Determine the applicant or recipient’s primary mode of locomotion and the amount of assistance the applicant or recipient needs with: locomotion—how one moves walking or wheeling, if wheeling how much assistance is needed once in the chair, or bed mobility— transition from lying to sitting, turning, etc. The applicant or recipient can receive up to eighteen (18) points in this category. The applicants or recipients who score in the “totally dependent on others to move or those that are bedbound” are presumed to meet nursing facility level of care. The applicant or recipient will receive—
         1. Zero (0) points if assessed as independently mobile, in that the applicant or recipient requires no assistance for transfers or mobility or only has set up or supervision needed;
         2. Three (3) points if assessed as requiring limited or moderate assistance, in that the applicant or recipient performs more than fifty percent (50%) of tasks independently; or
         3. Six (6) points if assessed as requiring maximum assistance, in that the applicant or recipient needs assistance from two (2) or more individuals or more than fifty percent (50%) weight-bearing assistance or totally dependent for bed mobility.
      4. Eating is defined as the amount of assistance needed by applicant or recipient to eat and drink, including special nutritional requirements or a specialized mode of nutrition. Determine the amount of assistance the applicant or recipient needs with eating and drinking. Includes intake of nourishment by other means [e.g. tube feeding or total parenteral nutrition (TPN)]. Determine if the participant requires a physician ordered therapeutic diet. The applicant or recipient can receive up to eighteen (18) points in this category. The applicants or recipients “totally dependent on others to eat” are presumed to meet nursing facility level of care. The applicant or recipient will receive—
         1. Zero (0) points if assessed as independent in dietary needs, in that the applicant or recipient requires no assistance to eat and has no physician ordered diet;
         2. Three (3) points if assessed as requiring minimum assistance, in that the applicant or recipient requires physician ordered therapeutic diet, or set up, supervision, or limited assistance is needed with eating;
         3. Six (6) points if assessed as requiring moderate assistance with eating, in that the applicant or recipient performs more than fifty percent (50%) of tasks independently; or
         4. Nine (9) points if assessed as requiring maximum assistance with eating, in that the applicant or recipient requires an individual to perform more than fifty percent (50%) for assistance.
      5. Toileting is defined as the amount of assistance needed by the applicant or recipient to complete all tasks related to toileting including the actual use of the toilet room (or commode, bedpan, urinal), transferring on/off the toilet, cleansing self, adjusting clothes, managing catheters/ostomies, and managing incontinence episodes. The applicant or recipient can receive up to nine (9) points in this category. The applicant or recipient will receive—
         1. Zero (0) points if assessed as requiring no assistance, or requires only set up or supervision needed;
         2. Three (3) points if assessed as requiring limited or moderate assistance, in that applicant or recipient performs more than fifty percent (50%) of tasks independently;
         3. Six (6) points if assessed as requiring maximum assistance, in that applicant or recipient needs two (2) or more individuals, or more than fifty percent (50%) weightbearing assistance; or D. Nine (9) points if assessed as requiring total dependence on others.
      6. Bathing is defined as the amount of assistance needed by the applicant or recipient to complete a full body shower or bath. Determine the amount of assistance the applicant or recipient needs with bathing. Bathing includes: taking a full body bath/shower and the transferring in and out of the bath/shower. The applicant or recipient can receive up to six (6) points in this category. The applicant or recipient will receive—
         1. A. Zero (0) points if assessed as no assistance required, or requiring only set up or supervision needed;
         2. Three (3) points if assessed as requiring limited or moderate assistance, in that applicant or recipient performs more than fifty percent (50%) of tasks independently; or
         3. Six (6) points if assessed as requiring maximum assistance, in that the applicant or recipient requires two (2) or more individuals, more than fifty percent (50%) weightbearing assistance, or total dependence on others.
      7. Dressing and grooming is defined as the amount of assistance needed by the applicant or recipient to dress, undress, and complete daily grooming tasks. Dressing may also include specialized devices such as prosthetics, orthotics, etc. The applicant or recipient can receive up to six (6) points in this category. The applicant or recipient will receive—
         1. Zero (0) points if assessed as requiring no assistance, or requiring only set up or supervision needed;
         2. Three (3) points if assessed as requiring limited or moderate assistance, in that applicant or recipient performs more than fifty percent (50%) of tasks independently; or
         3. Six (6) points if assessed as requiring maximum assistance, in that applicant or recipient requires two (2) or more individuals, more than fifty percent (50%) of weightbearing assistance, or total dependence on others.
      8. Rehabilitative services is defined as the restoration of a former or normal state of health through medically-ordered therapeutic services either directly provided by or under the supervision of a licensed qualified professional. Rehabilitative services include physical therapy, occupational therapy, speech therapy, cardiac rehabilitation, and audiology. If ordered by the physician, each resident must have an individually planned and implemented program with written goals and response/progress documented. Points will be determined by intensity of required services and the applicant’s or recipient’s potential for rehabilitation as determined by the rehabilitation evaluation. The applicant or recipient will receive—
         1. Zero (0) points if assessed as requiring no ordered rehabilitative services;
         2. Three (3) points, if assessed as requiring minimal-ordered rehabilitative services of one (1) time per week;
         3. Six (6) points if assessed as requiring moderate-ordered rehabilitative services of two (2) or three (3) times per week; or
         4. Nine (9) points if assessed as requiring maximum-ordered rehabilitative services of four (4) times per week or more.
      9. Treatments are defined as a physician ordered medical care or management that requires additional hands on assistance. The scoring for treatments will be zero (0) or six (6). The applicant or recipient with the identified treatments will receive six (6) points. The applicant or recipient will receive—
         1. Zero (0) points if no treatments are ordered by the physician; or
         2. Six (6) points if assessed as requiring one (1) or more of the physician ordered treatments requiring daily attention by a licensed professional. These treatments could include: catheter/ostomy care, alternate modes of nutrition (tube feeding or TPN), suctioning, ventilator/respirator, and wound care (skin must be broken).
      10. Meal preparation is defined as the amount of assistance needed to prepare a meal based on the applicant’s or recipient’s capacity to complete the task. This includes planning, assembling ingredients, cooking, and setting out the food and utensils. The applicant or recipient can receive up to six (6) points in this category. The applicant or recipient will receive—
          1. Zero (0) points if assessed as requiring no assistance, or requiring only set up or supervision needed;
          2. Three (3) points if assessed as requiring limited or moderate assistance, in that applicant or recipient performs more than fifty percent (50%) of tasks; or
          3. Six (6) points if assessed as requiring maximum assistance in that the individual performs more than fifty percent (50%) of tasks for the applicant or recipient, or requires total dependence on others.
      11. Medication management is defined as the amount of assistance needed by the applicant or recipient to safely manage their medication regimen. Assistance may be needed due to a physical or mental disability. Determine the amount of assistance the applicant or recipient needs to safely manage their medications. The applicant or recipient can receive up to six (6) points in this category. The applicant or recipient will receive—
          1. Zero (0) points if assessed as requiring no assistance;
          2. Three (3) points if assessed as requiring setup help needed or supervision needed, or requires limited or moderate assistance, in that applicant or recipient performs more than fifty percent (50%) of tasks; or
          3. Six (6) points if assessed as requiring maximum assistance, in that the individual performs more than fifty percent (50%) of tasks for the applicant or recipient, or requires total dependence on others.
      12. Safety is defined as the identification of a safety risk associated with vision impairment, falling, problems with balance, past institutionalization, and age. Determine if the applicant or recipient exhibits any of the following risk factors: vision impairment, falling, or problems with balance - balance is moving to standing position, turning to face the opposite direction, dizziness, or unsteady gait. The applicant or recipient can receive up to eighteen (18) points in this category. After determination of a preliminary score, institutionalization and age will be considered to determine the final score. Three (3) points can be added to the accumulated score if the applicant or recipient is aged seventy-five (75) years or older and/or has been institutionalized in the last five (5) years in a long-term care facility, mental health residence, psychiatric hospital, inpatient substance abuse, or settings for persons with intellectual disabilities and only to the specified points category listed. The applicants or recipients who score eighteen (18) points are presumed to meet nursing facility level of care. The applicant or recipient will receive—
          1. Zero (0) points if assessed with no difficulty or some difficulty with vision, and no falls in the last ninety (90) days, and no recent problems with balance;
          2. Three (3) points if assessed with severe difficulty with vision (sees only lights and shapes), or has fallen in the last ninety (90) days, or has current problems with balance, or has a preliminary score of zero (0) and is aged seventy-five (75) years or older or has been institutionalized;
          3. Six (6) points if assessed with no vision or has fallen in the last ninety (90) days and has current problems with balance, or assessed with a preliminary score of zero (0) and is aged seventy-five (75) years or older and has been institutionalized, or assessed with a preliminary score of three (3) points and is aged seventy-five (75) years or older or has been institutionalized;
          4. Nine (9) points if assessed with a preliminary score of six (6) points and has been institutionalized; or
          5. Eighteen (18) points if assessed with a preliminary score of six (6) points and is aged seventy-five (75) years or older or assessed with a preliminary score of three (3) points and is aged seventy-five (75) years or older and has been institutionalized.
6. Level of Care Determination for Home and Community Based Services Program. The department uses level of care determination for Home and Community Based Services (HCBS). The department utilizes the InterRAI Home Care Assessment System (HC), © InterRAI. Questions are scored within the InterRAI assessment using an algorithm, included herein. The HCBS assessment process is outlined in 19 CSR 15-7.021, 19 CSR 15-8.200, and 13 CSR 70-91.010.
7. Dual level-of-care assessments to be performed to determine level-of-care need from October 31, 2021, until the date that all of the temporary enhanced federal medical assistance percentage funds from the American Rescue Plan Act of 2021 are expended.
   1. The department is eligible to receive an additional ten percent (10%) enhanced federal medical assistance percentage for home and community based services provided from April 1, 2021, through March 31, 2022, through the American Rescue Plan Act of 2021. This funding will allow the department to determine level-of-care need under the department’s previous scoring system directly prior to the department’s level-of-care transformation which takes effect on October 31, 2021, through formal rulemaking. Therefore, if an individual does not qualify for level of care under the current level-of-care assessment as set forth in sections (5) and (6) of this rule from October 31, 2021, until the date that all of the temporary enhanced federal medical assistance percentage funds from the American Rescue Plan Act of 2021 are expended, then individuals shall also be assessed using a level-of-care assessment as set forth in section (8) of this rule. An individual may qualify for level-of-care need under either of these level of care assessments from October 31, 2021, until the date that all of the temporary enhanced federal medical assistance percentage funds from the American Rescue Plan Act of 2021 are expended.
8. Second level-of-care determination to be performed from October 31, 2021, until the date that all of the temporary enhanced federal medical assistance percentage funds from the American Rescue Plan Act of 2021 are expended. expended.
   1. Initial determination of level-of-care needs requirements.
      1. For the purpose of making a determination of level-of-care need and in accordance with 42 CFR sections 456.370 and483.104, the department or its designated agents, or both, will conduct a review and assessment of the evaluations made by the attending physician for an applicant in or seeking admission to a long-term care facility. The review and assessment shall be conducted using the criteria in subsection (8)(D) of this rule.
      2. The department shall complete the assessment within ten (10) working days of receipt of all documentation required by subsection (8)(D) in this rule unless further evaluation by the State Mental Health Authority is required by 42 CFR 483.100 to 483.138.
   2. Redetermination of level-of-care requirements.
      1. Redetermination of level-of-care of individual recipients who are eligible for placement in long-term care facilities shall be conducted by the department through a review and assessment of the DA-124A/B (10-21) Initial Assessment – Social and Medical, DA-124C (10-21) Level One Nursing Facility Pre-Admission Screening for Mental Illness/Intellectual Disability or Related Condition, and DA124C ATT (10- 21) Notice to Applicant included herein and any documentation provided by the resident’s attending physician. A referring individual shall fill out and submit the forms to the department at COMRU@health.mo.gov.
   3. Level-of-care criteria for long-term care facility care-qualified Title XIX recipients and applicants.
      1. Individuals will be assessed with the ultimate goal to achieve placement for these individuals in the least restrictive environment possible, yet enable them to receive all services required by their physical/mental condition.
      2. The specific areas which will be considered when determining an individual’s ability or inability to function in the least restrictive environment are mobility, dietary, restorative services, monitoring, medication, behavioral, treatments, personal care, and rehabilitative services.
      3. To qualify for intermediate or skilled nursing care, an applicant or recipient shall exhibit physical impairment, which may be complicated by mental impairment or mental impairment which may be complicated by physical impairment severe enough to require intermediate or skilled nursing care.
   4. Assessed needs point designations requirements.
      1. Applicants or recipients will be assessed for level-of-care by the assignment of a point count value for each category cited in paragraph (8)(C)2. of this rule.
      2. Points will be assessed for the amount of assistance required, the complexity of the care, and the professional level of assistance necessary, based on the level-of-care criteria. If the applicant’s or recipient’s records show that the applicant’s or recipient’s attending physician has ordered certain care, medication or treatments for an applicant or recipient, the department will assess points for a PRN order if the applicant or recipient has actually received or required that care, medication, or treatment within the thirty (30) days prior to review and evaluation by the department.
      3. For individuals seeking admission to a long-term care facility on or after October, 31, 2021, the applicant or recipient will be determined to be qualified for long-term care facility care if he or she is determined to need care with an assessed point level of twenty-four (24) points or above, using the assessment procedure as required in paragraph (8)(D)7. of this rule.
      4. For individuals seeking admission to a long-term care facility on or after October 31, 2021, an applicant with twenty-one (21) points or lower will be assessed as ineligible for Title XIX-funded long-term care in a long-term care facility, unless the applicant qualifies as otherwise provided in section (5), section (6), or paragraphs (8)(D)5. or 6. in this rule.
      5. Applicants or recipients may occasionally require care or services, or both, which could qualify as long-term care facility services. In these instances, a single nursing service requirement may be used as the qualifying factor, making the individual eligible for long-term care facility care regardless of the total point count. The determining factor will be the availability of professional personnel to perform or supervise the qualifying care services. Qualifying care services may include, but are not limited to:
         1. Administration of levine tube or gastrostomy tube feedings;
         2. Nasopharyngeal and tracheotomy aspiration;
         3. Insertion of medicated or sterile irrigation and replacement catheters;
         4. Administration of parenteral fluids;
         5. Inhalation therapy treatments;
         6. Administration of injectable medications other than insulin, if required other than on the day shift; and
         7. Requirement of intensive rehabilitation services by a professional therapist at least five (5) days per week.
      6. An applicant or recipient will be considered eligible for inpatient Title XIX assistance regardless of the total point count if the applicant or recipient is unable to meet physical/mental requirements for residential care facility (RCF) or assisted living facility (ALF) residency as specified by section 198.073, RSMo.
      7. Points will be assigned to each category, as required by paragraph (8)(C)2. in this rule, in multiples of three (3) according to the following requirements:
         1. Mobility is defined as the individual’s ability to move from place to place. The applicant or recipient will receive—
            1. Zero (0) points if assessed as independently mobile, in that the applicant or recipient requires no assistance for transfers or mobility. The applicant or recipient may use assistive devices (cane, walker, wheelchair) but is consistently capable of negotiating without assistance of another individual;
            2. Three (3) points if assessed as requiring minimum assistance, in that the applicant or recipient is independently mobile once the applicant or recipient receives assistance with transfers, braces, or prosthesis application or other assistive devices, or a combination of these (example, independent use of wheelchair after assistance with transfer). This category includes individuals who are not consistently independent and need assistance periodically;
            3. Six (6) points if assessed as requiring moderate assistance, in that the applicant or recipient is mobile only with direct staff assistance. The applicant or recipient must be assisted even when using canes, walker, or other assistive devices; and (IV) Nine (9) points if assessed as requiring maximum assistance, in that the applicant or recipient is totally dependent upon staff for mobility. The applicant or recipient is unable to ambulate or participate in the ambulation process, requires positioning, supportive device, application, prevention of contractures or pressure sores, and active or passive range of motion exercises;
         2. Dietary is defined as the applicant’s or recipient’s nutritional requirements and need for assistance or supervision with meals. The applicant or recipient will receive—
            1. Zero (0) points if assessed as independent in dietary needs, in that the applicant or recipient requires no assistance to eat. The applicant or recipient has physician’s orders for a regular diet, mechanically altered diet, or requires only minor modifications (example, limited desserts, no salt or sugar on tray);
            2. Three (3) points if assessed as requiring minimum assistance, in that the applicant or recipient requires meal supervision or minimal help, such as cutting food or verbal encouragement. Calculated diets for stabilized conditions shall be included;
            3. Six (6) points if assessed as requiring moderate assistance, in that the applicant or recipient requires help, including constant supervision during meals, or actual feeding. Calculated diets for unstable conditions are included; and
            4. Nine (9) points if assessed as requiring maximum assistance, in that the applicant or recipient requires extensive assistance for special dietary needs or with eating, which could include enteral feedings or parenteral fluids;
         3. Restorative services are defined as specialized services provided by trained and supervised individuals to help applicants or recipients obtain and/or maintain their optimal highest practicable functioning potential. Each applicant or recipient must have an individual overall plan of care developed by the provider with written goals and response/progress documented. Restorative services may include, but are not limited to, applicant or recipient teaching program (self-transfer, self-administration of medications, self-care), range of motion, bowel and bladder program, remotivational therapy, validation therapy, patient/family program, and individualized activity program. The applicant or recipient will receive—
            1. Zero (0) points if restorative services are not required;
            2. Three (3) points if assessed as requiring minimum services in order to maintain level of functioning;
            3. Six (6) points if assessed as requiring moderate services in order to restore the individual to a higher level of functioning; and
            4. Nine (9) points if assessed as requiring maximum services in order to restore to a higher level of functioning. These are intensive services, usually requiring professional supervision or direct services;
         4. Monitoring is defined as observation and assessment of the applicant’s or recipient’s physical and/or mental condition. This monitoring could include assessment of routine laboratory work, including, but not limited to, evaluating digoxin and coumadin levels, measurement and evaluation of blood glucose levels, measurement and evaluation of intake and output of fluids the individual has received and/or excreted, weights and other routine monitoring procedures. The applicant or recipient will receive—
            1. Zero (0) points if assessed as requiring only routine monitoring, such as monthly weights, temperatures, blood pressures, and other routine vital signs and routine supervision;
            2. Three (3) points if assessed as requiring minimal monitoring, in that the applicant or recipient requires periodic assessment due to mental impairment, monitoring of mild confusion, or both, or periodic assessment of routine procedures when the recipient’s condition is stable;
            3. Six (6) points if assessed as requiring moderate monitoring, in that the applicant or recipient requires recurring assessment of routine procedures due to the applicant’s or recipient’s unstable physical or mental condition; and (IV) Nine (9) points if assessed as requiring maximum monitoring, which is intensive monitoring usually by professional personnel due to applicant’s or recipient’s unstable physical or mental condition;
         5. Medication is defined as the drug regimen of all physician-ordered legend medications, and any physician-ordered non-legend medication for which the physician has ordered monitoring due to the complexity of the medication or the condition of the applicant or recipient. The applicant or recipient will receive—
            1. Zero (0) points if assessed as requiring no medication, or has not required PRN medication within the thirty (30) days prior to review and evaluation by the department;
            2. Three (3) points if assessed as requiring any regularly scheduled medication and the applicant or recipient exhibits a stable condition;
            3. Six (6) points if assessed as requiring moderate supervision of regularly scheduled medications, requiring daily monitoring by licensed personnel; and
            4. Nine (9) points if assessed as requiring maximum supervision of regularly scheduled medications, a complex medication regimen, unstable physical or mental status, or use of medications requiring professional observation and assessment, or a combination of these;
         6. Behavioral is defined as an individual’s social or mental activities. The applicant or recipient will receive—
            1. Zero (0) points if assessed as requiring little or no behavioral assistance. Applicant or recipient is oriented and memory intact;
            2. Three (3) points if assessed as requiring minimal behavioral assistance in the form of supervision or guidance on a periodic basis. Applicant or recipient may display some memory lapses or occasional forgetfulness due to mental or developmental disabilities, or both. Applicant or recipient generally relates well with others (positive or neutral) but needs occasional emotional support;
            3. Six (6) points if assessed as requiring moderate behavioral assistance in the form of supervision due to disorientation, mental or developmental disabilities, or uncooperative behavior; and
            4. Nine (9) points if assessed as requiring maximum behavioral assistance in the form of extensive supervision due to psychological, developmental disabilities, or traumatic brain injuries with resultant confusion, incompetency, hyperactivity, hostility, severe depression, or other behavioral characteristics. This category includes residents who frequently exhibit bizarre behavior, are verbally or physically abusive, or both, or are incapable of self-direction. Applicants or recipients who exhibit uncontrolled behavior that is dangerous to themselves or others must be transferred immediately to an appropriate facility;
         7. Treatments are defined as a systematized course of nursing procedures ordered by the attending physician. The applicant or recipient will receive—
            1. Zero (0) points if no treatments are ordered by the physician;
            2. Three (3) points if assessed as requiring minimal type-ordered treatments, including nonroutine and preventative treatments, such as whirlpool baths and other services;
            3. Six (6) points if assessed as requiring moderate type-ordered treatments requiring daily attention by licensed personnel. These treatments could include daily dressings, PRN oxygen, oral suctioning, catheter maintenance care, treatment of stasis or pressure sore ulcers, wet/moist packs, maximist, and other such services; and
            4. Nine (9) points if assessed as requiring maximum type-ordered treatments of an extensive nature requiring provision, direct supervision, or both, by professional personnel. These treatments could include intratrachial suctioning, insertion or maintenance of suprapubic catheter, continuous oxygen, new or unregulated ostomy care, dressings of deep draining lesions more than once daily, care of extensive skin disorders such as advanced pressure sore or necrotic lesions, infrared heat, and other services;
         8. Personal care is defined as activities of daily living, including hygiene; personal grooming, such as dressing, bathing, oral and personal hygiene, hair and nail care, shaving; and bowel and bladder functions. Points will be determined based on the amount of assistance required and degree of assistance involved in the activity. The applicant or recipient will receive—
            1. Zero (0) points if assessed as requiring no assistance with personal care, in that the applicant or recipient is an independent, self-care individual. No assistance is required with personal grooming; the applicant or recipient has complete bowel and bladder control;
            2. Three (3) points if assessed as requiring minimal assistance with personal care, in that the applicant or recipient requires assistance with personal grooming, and/or exhibits infrequent incontinency (once a week or less);
            3. Six (6) points if assessed as requiring moderate assistance with personal care, in that the applicant or recipient requires assistance with personal grooming, requiring close supervision or exhibits frequent incontinency (incontinent of bladder daily but has some control or incontinent of bowel two (2) or three (3) times per week), or a combination of these; and
            4. Nine (9) points if assessed as requiring maximum assistance with personal care, in that the applicant or recipient requires total personal care to be performed by another individual, and/or exhibits continuous incontinency all or most of the time; and
         9. Rehabilitation is defined as the restoration of a former or normal state of health through medically ordered therapeutic services either directly provided by or under the supervision of a qualified professional. Rehabilitation services include, but are not limited to, physical therapy, occupational therapy, speech therapy, and audiology. If ordered by the physician, each resident must have an individually planned and implemented program with written goals and response/progress documented. Points will be determined by intensity of required services and the applicant’s or recipient’s potential for rehabilitation as determined by the rehabilitation evaluation. The applicant or recipient will receive—
            1. Zero (0) points if assessed as requiring no ordered rehabilitation services;
            2. Three (3) points, if assessed as requiring minimal-ordered rehabilitation services of one (1) time per week;
            3. Six (6) points if assessed as requiring moderate-ordered rehabilitative services of two (2) or three (3) times per week; or
            4. Nine (9) points if assessed as requiring maximum-ordered rehabilitative services of four (4) times per week or more.

AUTHORITY: sections 192.006, 192.2000, and 198.079, RSMo 2016.* This rule was previously filed as 13 CSR 40- 81.084 and 13 CSR 15-9.030. Original rule filed Aug. 9, 1982, effective Nov. 11, 1982. Emergency rescission filed Nov. 24, 1982, effective Dec. 4, 1982, expired March 10, 1983. Rescinded: Filed Nov. 24, 1982, effective March 11, 1983. Readopted: Filed Dec. 15, 1982, effective March 11, 1983. Emergency amendment filed Dec. 21, 1983, effective Jan. 1, 1984, expired April 11, 1984. Emergency amendment filed March 14, 1984, effective April 12, 1984, expired June 10, 1984. Amended: Filed March 14, 1984, effective June 11, 1984. Moved to 19 CSR 30-81.030, effective Aug. 28, 2001. Emergency amendment filed June 20, 2005, effective July 1, 2005, expired Dec. 27, 2005. Amended: Filed June 20, 2005, effective Dec. 30, 2005. Emergency amendment filed July 5, 2017, effective July 15, 2017, expired Feb. 22, 2018. Amended: Filed July 5, 2017, effective Feb. 28, 2018. Amended: Filed Jan. 12, 2021, effective Oct. 31, 2021. Emergency amendment filed Oct. 15, 2021, effective Oct. 29, 2021, expired April 26, 2022. Amended: Filed Oct. 15, 2021, effective April 30, 2022.

* Original authority: 192.006, RSMo 1993, amended 1995; 192.2000, RSMo 1984, amended 1988, 1992, 1993, 1994, 1995, 2001, 2014; and 198.079, RSMo 1979, amended 2007.