Modifies provisions relating to long-term care facilities

SECOND REGULAR SESSION
HOUSE BILL NO. 2833
103RD GENERAL ASSEMBL Y
INTRODUCED BY REPRESENT A TIVE COLLINS.
5597H.01I JOSEPH ENGLER, Chief Clerk
AN ACT
T o repeal sections 197.315 and 198.022, RSMo, and to enact in lieu thereof three new
sections relating to long-term care facilities, with penalty provisions.
Be it enacted by the General Assembly of the state of Missouri, as follows:
Section A. Sections 197.315 and 198.022, RSMo, are repealed and three new sections
2 enacted in lieu thereof, to be known as sections 197.315, 198.022, and 198.043, to read as
3 follows:
197.315. 1. Any person who proposes to develop or offer a new institutional health
2 service within the state must obtain a certificate of need from the committee prior to the time
3 such services are of fered.
4 2. Only those new institutional health services which are found by the committee to
5 be needed shall be granted a certificate of need. Only those new institutional health services
6 which are granted certificates of need shall be of fered or developed within the state. No
7 expenditures for new institutional health services in excess of the applicable expenditure
8 minimum shall be made by any person unless a certificate of need has been granted.
9 3. After October 1, 1980, no state agency char ged by statute to license or certify
10 health care facilities shall issue a license to or certify any such facility , or distinct part of such
11 facility , that is developed without obtaining a certificate of need.
12 4. If any person proposes to develop any new institutional health care service without
13 a certificate of need as required by sections 197.300 to 197.366, the committee shall notify
14 the attorney general, and he shall apply for an injunction or other appropriate legal action in
15 any court of this state against that person.
EXPLANA TION — Matter enclosed in bold-faced brackets [thus] in the above bill is not enacted and is
intended to be omitted from the law . Matter in bold-face type in the above bill is proposed language.
16 5. After October 1, 1980, no agency of state government may appropriate or grant
17 funds to or make payment of any funds to any person or health care facility which has not first
18 obtained every certificate of need required pursuant to sections 197.300 to 197.366.
19 6. A certificate of need shall be issued only for the premises and persons named in the
20 application and is not transferable except by consent of the committee.
21 7. Project cost increases, due to changes in the project application as approved or due
22 to project change orders, exceeding the initial estimate by more than ten percent shall not be
23 incurred without consent of the committee.
24 8. Periodic reports to the committee shall be required of any applicant who has been
25 granted a certificate of need until the project has been completed. The committee may order
26 the forfeiture of the certificate of need upon failure of the applicant to file any such report.
27 9. A certificate of need shall be subject to forfeiture for failure to incur a capital
28 expenditure on any approved project within six months after the date of the order . The
29 applicant may request an extension from the committee of not more than six additional
30 months based upon substantial expenditure made.
31 10. Each application for a certificate of need must be accompanied by an application
32 fee. The time of filing commences with the receipt of the application and the application fee.
33 The application fee is one thousand dollars, or one-tenth of one percent of the total cost of the
34 proposed project, whichever is greater . All application fees shall be deposited in the state
35 treasury . Because of the loss of federal funds, the general assembly will appropriate funds to
36 the Missouri health facilities review committee.
37 1 1. In determining whether a certificate of need should be granted, no consideration
38 shall be given to the facilities or equipment of any other health care facility located more than
39 a fifteen-mile radius from the applying facility .
40 12. When a nursing facility shifts from a skilled to an intermediate level of nursing
41 care, it may return to the higher level of care if it meets the licensure requirements, without
42 obtaining a certificate of need.
43 13. In no event shall a certificate of need be denied because the applicant refuses to
44 provide abortion services or information.
45 14. A certificate of need shall not be required for the transfer of ownership of an
46 existing and operational health facility in its entirety , except for any assisted living facility ,
47 intermediate care facility , res idential care facility , or skilled nursing facility , as such
48 terms are defined in section 198.006 .
49 15. A certificate of need may be granted to a facility for an expansion, an addition of
50 services, a new institutional service, or for a new hospital facility which provides for
51 something less than that which was sought in the application.
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52 16. The provisions of this section shall not apply to facilities operated by the state,
53 and appropriation of funds to such facilities by the general assembly shall be deemed in
54 compliance with this section, and such facilities shall be deemed to have received an
55 appropriate certificate of need without payment of any fee or char ge. The provisions of this
56 subsection shall not apply to hospitals operated by the state and licensed under this chapter ,
57 except for department of mental health state-operated psychiatric hospitals.
58 17. Notwithstanding other provisions of this section, a certificate of need may be
59 issued after July 1, 1983, for an intermediate care facility operated exclusively for the
60 intellectually disabled.
61 18. T o assure the safe, appropriate, and cost-eff ective transfer of new medical
62 technology throughout the state, a certificate of need shall not be required for the purchase
63 and operation of:
64 (1) Research equipment that is to be used in a clinical trial that has received written
65 approval from a duly constituted institutional review board of an accredited school of
66 medicine or osteopathy located in Missouri to establish its safety and ef ficacy and does not
67 increase the bed complement of the institution in which the equipment is to be located. After
68 the clinical trial has been completed, a certificate of need must be obtained for continued use
69 in such facility; or
70 (2) Equipment that is to be used by an academic health center operated by the state in
71 furtherance of its research or teaching missions.
198.022. 1. Upon receipt of an application for a license to operate a facility , the
2 department shall review the application, investigate the applicant and the statements sworn to
3 in the application for license and conduct any necessary inspections. A license shall be issued
4 if the following requirements are met:
5 (1) The application discloses all facility owners, facility trustees, and companies
6 that pr ovide the facility or operator with administrative, clinical, and financial services,
7 including real estate investment trusts;
8 (2) The statements in the application are true and correct;
9 [ (2) ] (3) The facility and the operator are in substantial compliance with the
10 provisions of sections 198.003 to 198.096 and the standards established thereunder;
11 [ (3) ] (4) The applicant has the financial capacity to operate the facility;
12 [ (4) ] (5) The administrator of an assisted living facility , a skilled nursing facility , or
13 an intermediate care facility is currently licensed under the provisions of chapter 344;
14 [ (5) ] (6) Neither the operator nor any principals in the operation of the facility have
15 ever been convicted of a felony of fense concerning the operation of a long-term health care
16 facility or other health care facility or ever knowingly acted or knowingly failed to perform
17 any duty which materially and adversely affected the health, safety , welfare or property of a
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18 resident, while acting in a management capacity . The operator of the facility or any principal
19 in the operation of the facility shall not be under exclusion from participation in the T itle
20 XVIII (Medicare) or T itle XIX (Medicaid) program of any state or territory;
21 [ (6) ] (7) Neither the operator nor any principals involved in the operation of the
22 facility have ever been convicted of a felony in any state or federal court arising out of
23 conduct involving either management of a long-term care facility or the provision or receipt
24 of health care; and
25 [ (7) ] (8) All fees due to the state have been paid.
26 2. Upon denial of any application for a license, the department shall so notify the
27 applicant in writing, setting forth therein the reasons and grounds for denial.
28 3. The department may inspect any facility and any records and may make copies of
29 records, at the facility , at the department's own expense, required to be maintained by sections
30 198.003 to 198.096 or by the rules and regulations promulgated thereunder at any time if a
31 license has been issued to or an application for a license has been filed by the operator of such
32 facility . Copies of any records requested by the department shall be prepared by the staf f of
33 such facility within two business days or as determined by the department. The department
34 shall not remove or disassemble any medical record during any inspection of the facility , but
35 may observe the photocopying or may make its own copies if the facility does not have the
36 technology to make the copies. In accordance with the provisions of section 198.525, the
37 department shall make at least one inspection per year , which shall be unannounced to the
38 operator . The department may make such other inspections, announced or unannounced, as it
39 deems necessary to carry out the provisions of sections 198.003 to 198.136.
40 4. Whenever the department has reasonable grounds to believe that a facility required
41 to be licensed under sections 198.003 to 198.096 is operating without a license, and the
42 department is not permitted access to inspect the facility , or when a licensed operator refuses
43 to permit access to the department to inspect the facility , the department shall apply to the
44 circuit court of the county in which the premises is located for an order authorizing entry for
45 such inspection, and the court shall issue the order if it finds reasonable grounds for
46 inspection or if it finds that a licensed operator has refused to permit the department access to
47 inspect the facility .
48 5. Whenever the department is inspecting a facility in response to an application from
49 an operator located outside of Missouri not previously licensed by the department, the
50 department may request from the applicant the past five years of compliance history of all
51 facilities owned by the applicant located outside of this state.
198.043. 1. As used in this section, the following terms mean:
2 (1) "Certified nursing assistant", the same meaning given to the term in section
3 198.082;
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4 (2) "Charge nurse", a regi stered profession al nurse who oversees the operations
5 of the nurse's specific nursing unit during a set period;
6 (3) "CMS", the Centers for Medicar e and Medicaid Services;
7 (4) "Hours per r esident day", the total number of hours worked by each type of
8 staff divided by the total number of res idents;
9 (5) "Registere d pro fessional nurse" or "r egistere d nurse", the same meanings
10 given to the terms in section 335.016.
11 2. Assisted living facilities shall have sufficient nursing staff with the appr opriate
12 competencies and skill sets to pr ovide nursing and rela ted services to ensur e res ident
13 safety and attain or maintain the highest practicable physical, mental, and psychosocial
14 well-being of each resi dent by maintaining on a twenty-four -hour basis the following
15 types of personnel:
16 (1) Register ed nurses. Each assisted living facility shall comply with the
17 following staffing r equir ements for register ed nurses:
18 (a) Each assisted living facility shall pr ovide care by r egistered nurses for a
19 minimum of fifty-five hundred ths of one hour per res ident day; and
20 (b) At least one registe red nurse shall be on site twenty-four hours a day , seven
21 days a week; and
22 (2) Other nursing personnel. Each assisted living facility shall pr ovide care by
23 certified nursing assistants for a minimum of two and forty-four hundred ths hours per
24 r esident day .
25 3. Assisted living facilities shall electr onically submit to CMS complete and
26 accurate dir ect care staffing information, including information for agency and contract
27 staff, based on payro ll and other verifiable and auditable data in a uniform format
28 according to specifications established by CMS in accordance with 42 CFR 483.70(p).
29 4. Determinations of compliance with hours per r esident day specified in
30 subsection 2 of this section shall be made by the department based on the most recent
31 available quarter of Payroll -Based Journal System data maintained by CMS.
32 5. The department may impose appr opriate sanctions and assess an
3 3 administrative penalty under this section on an administrator of a facility who fails to
34 meet the minimum staffing standards two quarters in a ro w as determined by rule.
35 6. (1) An assisted living facility may be exempted fr om the minimum staffing
36 r equir ements of subdivisions (1) and (2) of subsection 2 of this section by the department
37 if a verifiable hardship exists that pr ohibits the facility fr om achieving or maintaining
38 compliance as demonstrated by meeting the following criteria:
39 (a) The facility is located in an area where :
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40 a. The supply of applicable health car e staff, either registe red pr ofessional
41 nurses or certified nursing assistants or both, is not sufficient to meet ar ea needs as
42 evidenced by a pr ovider -population ratio for nursing workfor ce that is medium, twenty
43 per cent below the national average, or low , forty per cent below the national average;
44 and
45 b. The facility is at least twenty miles fro m another assisted living facility;
46 (b) The facility demonstrates that it has been unable, despite diligent efforts,
47 including offering at least pr evailing wages, to rec ruit and ret ain appr opriate personnel
48 as verified by:
49 a. Job listings in commonly used recrui tment forums found online at American
50 Job Centers, coordinated by the United States Department of Labor's Employment and
51 T raining Administration; MoJobs, coordinated by the department of higher education
52 and workforce development; and other forums as appr opriate;
53 b. Documented job vacancies, including the number and duration of the
54 vacancies and documentation of offers made, including that they were made at least at
55 pr evailing wages;
56 c. Data on the average wages in the metr opolitan statistical area in which the
57 facility is located and vacancies by industry as reported by the department of labor and
58 industrial relat ions; and
59 d. The facility's staffing plan, which shall be developed and maintained to
60 maximize rec ruitment and ret ention of direct car e staff; and
61 (c) The facility demonstrates thr ough documentation the amount of financial
62 r esources that the facility expends on nurse staffing r elative to revenu e.
63 (2) A facility shall not be eligible for a hardship waiver fr om the minimum
64 staffing req uirements if the facility:
65 (a) Has been cited within the twelve months pr eceding the survey during which
66 the facility's noncompliance is identified:
67 a. For having widespr ead insufficient staffing with re sultant re sident actual
68 harm;
69 b. For a pattern of insufficient staffing with res ultant re sident actual harm; or
70 c. As at the immediate jeopardy level of severity with r espect to insufficient
71 staffing as determined by CMS; or
72 (b) Has failed to submit data to CMS under subsection 3 of this section.
73 7. In order to appr opriately manage requ ired nursing staff, an assisted living
74 facility shall:
75 (1) Designate a register ed pro fessional nurse as the dir ector of nursing on a full-
76 time basis; and
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77 (2) Designate a regi stered pro fessional nurse to serve as a charge nurse for each
78 nursing shift. The direc tor of nursing designated in subdivision (1) of this subsection
79 may serve as a charge nurse only if the facility has an average daily occupancy of sixty
80 or fewer r esidents.
✔
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