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EXPLANATION-Matter enclosed in bold-faced brackets [thus] in this bill is not enacted
and is intended to be omitted in the law.
SECOND REGULAR SESSION
SENATE BILL NO. 1794
103RD GENERAL ASSEMBLY
INTRODUCED BY SENATOR WEBBER.
7211S.01I KRISTINA MARTIN, Secretary
AN ACT
To repeal sections 197.315 and 198.022, RSMo, and to enact in lieu thereof three new sections
relating to long-term care facilities.
Be it enacted by the General Assembly of the State of Missouri, as follows:
Section A. Sections 197.315 and 198.022, RSMo, are 1
repealed and three new sections enacted in lieu thereof, to be 2
known as sections 197.315, 198.022, and 198.043, to read as 3
follows:4
197.315. 1. Any person who proposes to develop or 1
offer a new institutional health service within the state 2
must obtain a certificate of need from the committee prior 3
to the time such services are offered. 4
2. Only those new institutional health services which 5
are found by the committee to be needed shall be granted a 6
certificate of need. Only those new institutional health 7
services which are granted certificates of need shall be 8
offered or developed within the state. No expenditures for 9
new institutional health services in excess of the 10
applicable expenditure minimum shall be made by any person 11
unless a certificate of need has been granted. 12
3. After October 1, 1980, no state agency charged by 13
statute to license or certify health care facilities shall 14
issue a license to or certify any such facility, or distinct 15
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part of such facility, that is developed without obtaining a 16
certificate of need. 17
4. If any person proposes to develop any new 18
institutional health care service without a certificate of 19
need as required by sections 197.300 to 197.366, the 20
committee shall notify the attorney general, and he shall 21
apply for an injunction or other appropriate legal action in 22
any court of this state against that person. 23
5. After October 1, 1980, no agency of state 24
government may appropriate or grant funds to or make payment 25
of any funds to any person or health care facility which has 26
not first obtained every certificate of need required 27
pursuant to sections 197.300 to 197.366. 28
6. A certificate of need shall be issued only for the 29
premises and persons named in the application and is not 30
transferable except by consent of the committee. 31
7. Project cost increases, due to changes in the 32
project application as approved or due to project change 33
orders, exceeding the initial estimate by more than ten 34
percent shall not be incurred without consent of the 35
committee. 36
8. Periodic reports to the committee shall be required 37
of any applicant who has been granted a certificate of need 38
until the project has been completed. The committee may 39
order the forfeiture of the certificate of need upon failure 40
of the applicant to file any such report. 41
9. A certificate of need shall be subject to 42
forfeiture for failure to incur a capital expenditure on any 43
approved project within six months after the date of the 44
order. The applicant may request an extension from the 45
committee of not more than six additional months based upon 46
substantial expenditure made. 47
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10. Each application for a certificate of need must be 48
accompanied by an application fee. The time of filing 49
commences with the receipt of the application and the 50
application fee. The application fee is one thousand 51
dollars, or one-tenth of one percent of the total cost of 52
the proposed project, whichever is greater. All application 53
fees shall be deposited in the state treasury. Because of 54
the loss of federal funds, the general assembly will 55
appropriate funds to the Missouri health facilities review 56
committee. 57
11. In determining whether a certificate of need 58
should be granted, no consideration shall be given to the 59
facilities or equipment of any other health care facility 60
located more than a fifteen-mile radius from the applying 61
facility. 62
12. When a nursing facility shifts from a skilled to 63
an intermediate level of nursing care, it may return to the 64
higher level of care if it meets the licensure requirements, 65
without obtaining a certificate of need. 66
13. In no event shall a certificate of need be denied 67
because the applicant refuses to provide abortion services 68
or information. 69
14. A certificate of need shall not be required for 70
the transfer of ownership of an existing and operational 71
health facility in its entirety, except for any assisted 72
living facility, intermediate care facility, residential 73
care facility, or skilled nursing facility, as such terms 74
are defined in section 198.006. 75
15. A certificate of need may be granted to a facility 76
for an expansion, an addition of services, a new 77
institutional service, or for a new hospital facility which 78
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provides for something less than that which was sought in 79
the application. 80
16. The provisions of this section shall not apply to 81
facilities operated by the state, and appropriation of funds 82
to such facilities by the general assembly shall be deemed 83
in compliance with this section, and such facilities shall 84
be deemed to have received an appropriate certificate of 85
need without payment of any fee or charge. The provisions 86
of this subsection shall not apply to hospitals operated by 87
the state and licensed under this chapter, except for 88
department of mental health state-operated psychiatric 89
hospitals. 90
17. Notwithstanding other provisions of this section, 91
a certificate of need may be issued after July 1, 1983, for 92
an intermediate care facility operated exclusively for the 93
intellectually disabled. 94
18. To assure the safe, appropriate, and cost- 95
effective transfer of new medical technology throughout the 96
state, a certificate of need shall not be required for the 97
purchase and operation of: 98
(1) Research equipment that is to be used in a 99
clinical trial that has received written approval from a 100
duly constituted institutional review board of an accredited 101
school of medicine or osteopathy located in Missouri to 102
establish its safety and efficacy and does not increase the 103
bed complement of the institution in which the equipment is 104
to be located. After the clinical trial has been completed, 105
a certificate of need must be obtained for continued use in 106
such facility; or 107
(2) Equipment that is to be used by an academic health 108
center operated by the state in furtherance of its research 109
or teaching missions. 110
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198.022. 1. Upon receipt of an application for a 1
license to operate a facility, the department shall review 2
the application, investigate the applicant and the 3
statements sworn to in the application for license and 4
conduct any necessary inspections. A license shall be 5
issued if the following requirements are met: 6
(1) The application discloses all facility owners, 7
facility trustees, and companies that provide the facility 8
or operator with administrative, clinical, and financial 9
services, including real estate investment trusts; 10
(2) The statements in the application are true and 11
correct; 12
[(2)] (3) The facility and the operator are in 13
substantial compliance with the provisions of sections 14
198.003 to 198.096 and the standards established thereunder; 15
[(3)] (4) The applicant has the financial capacity to 16
operate the facility; 17
[(4)] (5) The administrator of an assisted living 18
facility, a skilled nursing facility, or an intermediate 19
care facility is currently licensed under the provisions of 20
chapter 344; 21
[(5)] (6) Neither the operator nor any principals in 22
the operation of the facility have ever been convicted of a 23
felony offense concerning the operation of a long-term 24
health care facility or other health care facility or ever 25
knowingly acted or knowingly failed to perform any duty 26
which materially and adversely affected the health, safety, 27
welfare or property of a resident, while acting in a 28
management capacity. The operator of the facility or any 29
principal in the operation of the facility shall not be 30
under exclusion from participation in the Title XVIII 31
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(Medicare) or Title XIX (Medicaid) program of any state or 32
territory; 33
[(6)] (7) Neither the operator nor any principals 34
involved in the operation of the facility have ever been 35
convicted of a felony in any state or federal court arising 36
out of conduct involving either management of a long-term 37
care facility or the provision or receipt of health care; and 38
[(7)] (8) All fees due to the state have been paid. 39
2. Upon denial of any application for a license, the 40
department shall so notify the applicant in writing, setting 41
forth therein the reasons and grounds for denial. 42
3. The department may inspect any facility and any 43
records and may make copies of records, at the facility, at 44
the department's own expense, required to be maintained by 45
sections 198.003 to 198.096 or by the rules and regulations 46
promulgated thereunder at any time if a license has been 47
issued to or an application for a license has been filed by 48
the operator of such facility. Copies of any records 49
requested by the department shall be prepared by the staff 50
of such facility within two business days or as determined 51
by the department. The department shall not remove or 52
disassemble any medical record during any inspection of the 53
facility, but may observe the photocopying or may make its 54
own copies if the facility does not have the technology to 55
make the copies. In accordance with the provisions of 56
section 198.525, the department shall make at least one 57
inspection per year, which shall be unannounced to the 58
operator. The department may make such other inspections, 59
announced or unannounced, as it deems necessary to carry out 60
the provisions of sections 198.003 to 198.136. 61
4. Whenever the department has reasonable grounds to 62
believe that a facility required to be licensed under 63
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sections 198.003 to 198.096 is operating without a license, 64
and the department is not permitted access to inspect the 65
facility, or when a licensed operator refuses to permit 66
access to the department to inspect the facility, the 67
department shall apply to the circuit court of the county in 68
which the premises is located for an order authorizing entry 69
for such inspection, and the court shall issue the order if 70
it finds reasonable grounds for inspection or if it finds 71
that a licensed operator has refused to permit the 72
department access to inspect the facility. 73
5. Whenever the department is inspecting a facility in 74
response to an application from an operator located outside 75
of Missouri not previously licensed by the department, the 76
department may request from the applicant the past five 77
years compliance history of all facilities owned by the 78
applicant located outside of this state. 79
198.043. 1. As used in this section, the following 1
terms mean: 2
(1) "Certified nursing assistant", the same meaning 3
given to the term in section 198.082; 4
(2) "Charge nurse", a registered professional nurse 5
who oversees the operations of the nurse's specific nursing 6
unit during a set period; 7
(3) "CMS", the Centers for Medicare and Medicaid 8
Services; 9
(4) "Hours per resident day", the total number of 10
hours worked by each type of staff divided by the total 11
number of residents; 12
(5) "Registered professional nurse" or "registered 13
nurse", the same meanings given to the terms in section 14
335.016. 15
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2. Assisted living facilities shall have sufficient 16
nursing staff with the appropriate competencies and skill 17
sets to provide nursing and related services to ensure 18
resident safety and attain or maintain the highest 19
practicable physical, mental, and psychosocial well-being of 20
each resident by maintaining on a twenty-four-hour basis the 21
following types of personnel: 22
(1) Registered nurses. Each assisted living facility 23
shall comply with the following staffing requirements for 24
registered nurses: 25
(a) Each assisted living facility shall provide care 26
by registered nurses for a minimum of fifty-five hundredths 27
hours per resident day; and 28
(b) At least one registered nurse shall be on site 29
twenty-four hours a day, seven days a week; and 30
(2) Other nursing personnel. Each assisted living 31
facility shall provide care by certified nursing assistants 32
for a minimum of two and forty-four hundredths hours per 33
resident day. 34
3. Assisted living facilities shall electronically 35
submit to CMS complete and accurate direct care staffing 36
information, including information for agency and contract 37
staff, based on payroll and other verifiable and auditable 38
data in a uniform format according to specifications 39
established by CMS in accordance with 42 CFR 483.70(p). 40
4. Determinations of compliance with hours per 41
resident day specified in subsection 2 of this section shall 42
be made by the department based on the most recent available 43
quarter of Payroll-Based Journal System data maintained by 44
CMS. 45
5. The department may impose appropriate sanctions and 46
assess an administrative penalty under this section on an 47
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administrator of a facility who fails to meet the minimum 48
staffing standards two quarters in a row as determined by 49
rule. 50
6. (1) An assisted living facility may be exempted 51
from the minimum staffing requirements of subdivisions (1) 52
and (2) of subsection 2 of this section by the department if 53
a verifiable hardship exists that prohibits the facility 54
from achieving or maintaining compliance as demonstrated by 55
meeting the following criteria: 56
(a) The facility is located in an area where: 57
a. The supply of applicable health care staff, either 58
registered professional nurses or certified nursing 59
assistants or both, is not sufficient to meet area needs as 60
evidenced by a provider-population ratio for nursing 61
workforce that is medium, twenty percent below the national 62
average, or low, forty percent below the national average; 63
and 64
b. The facility is at least twenty miles from another 65
assisted living facility; 66
(b) The facility demonstrates that it has been unable, 67
despite diligent efforts, including offering at least 68
prevailing wages, to recruit and retain appropriate 69
personnel as verified by: 70
a. Job listings in commonly used recruitment forums 71
found online at American Job Centers, coordinated by the 72
U.S. Department of Labor's Employment and Training 73
Administration; MoJobs, coordinated by the department of 74
higher education and workforce development; and other forums 75
as appropriate; 76
b. Documented job vacancies, including the number and 77
duration of the vacancies and documentation of offers made, 78
including that they were made at least at prevailing wages; 79
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c. Data on the average wages in the metropolitan 80
statistical area in which the facility is located and 81
vacancies by industry as reported by the department of labor 82
and industrial relations; and 83
d. The facility's staffing plan, which shall be 84
developed and maintained to maximize recruitment and 85
retention of direct care staff; and 86
(c) The facility demonstrates through documentation 87
the amount of financial resources that the facility expends 88
on nurse staffing relative to revenue. 89
(2) A facility shall not be eligible for a hardship 90
waiver from the minimum staffing requirements if the 91
facility: 92
(a) Has been cited within the twelve months preceding 93
the survey during which the facility's noncompliance is 94
identified: 95
a. For having widespread insufficient staffing with 96
resultant resident actual harm; 97
b. For a pattern of insufficient staffing with 98
resultant resident actual harm; or 99
c. As at the immediate jeopardy level of severity with 100
respect to insufficient staffing as determined by CMS; or 101
(b) Has failed to submit data to CMS under subsection 102
3 of this section. 103
7. In order to appropriately manage required nursing 104
staff, an assisted living facility shall: 105
(1) Designate a registered professional nurse as the 106
director of nursing on a full-time basis; and 107
(2) Designate a registered professional nurse to serve 108
as a charge nurse for each nursing shift. The director of 109
nursing designated in subdivision (1) of this subsection may 110
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serve as a charge nurse only if the facility has an average 111
daily occupancy of sixty or fewer residents. 112
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