Nursing Facility Quality of Care Improvement Program

19 CSR 30-82.080 Nursing Facility Quality of Care Improvement Program

PURPOSE: This rule explains the requirements for receiving funding from the Nursing Facility Quality of Care (NFQC) Fund to improve the quality of service the facility provides to its residents.

- Qualified Facility—Any facility licensed pursuant to Chapter 198, RSMo, that has received a Class I or Uncorrected Class II Notice of Noncompliance within the past twelve (12) months in one (1) of the following areas:
  1. For Residential Care Facility I (RCF I) and Residential Care Facility II (RCF II):
    1. Administrative, Personnel and Resident Care (19 CSR 30-86.042);
    2. Dietary (19 CSR 30-86.052); or
    3. Resident Rights (19 CSR 30-88.010);
  2. For Skilled Nursing Facility (SNF) and Intermediate Care Facility (ICF):
    1. Administration and Resident Care (19 CSR 30- 85.042)
    2. Dietary (19 CSR 30-85.052); or
    3. Resident Rights (19 CSR 30-88.010).

Quality Improvement Project for Missouri (QIPMO) consultation—Provides technical assistance and support to nursing facility staff throughout the state in order to improve the quality of care in nursing facilities using the Minimum Data Set (MDS) and on-site clinical

Selection of Qualified
- Qualified facilities may submit a written request to the department for funds from the Nursing Facility Quality of Care (NFQC) Fund to pay for QIPMO assistance and support. The department will provide a written response to the qualified facility’s request approving or disapproving the use of NFQC funding for QIPMO assistance. In the absence of extraordinary circumstances, a qualified facility shall receive no more than one thousand dollars ($1,000) per request. A qualified facility which wishes to receive more than one thousand dollars ($1,000) per request must separately justify reimbursement in excess of one thousand dollars ($1,000) by setting forth the extraordinary circumstances justifying reimbursement in excess of one thousand dollars ($1,000). The department may, in its sole discretion, approve reimbursement in excess of one thousand dollars ($1,000).

Qualified facilities may also submit to the department proposals describing implementation of a quality improvement program, in lieu of the QIPMO Program. Such proposals shall address areas of noncompliance that have been cited in the notice of noncompliance issued in the past twelve (12) months. Upon approval of the proposal by the department, the department may use funds in the NFQC Fund that have been collected from state civil money penalties to fund the qualified facility’s proposal. In the absence of extraordinary circumstances, a qualified facility shall receive no more than one thousand dollars ($1,000) per proposal. A qualified facility which wishes to receive more than one thousand dollars ($1,000) per proposal must separately justify reimbursement in excess of one thousand dollars ($1,000) by setting forth the extraordinary circumstances justifying reimbursement in excess of one thousand dollars ($1,000). The department may, in its sole discretion, approve reimbursement in excess of one thousand dollars ($1,000).
The department may impose upon a qualified facility a directed plan of correction, as set forth in section 198.066, RSMo, which includes QIPMO consultation. Funding for the QIPMO consultation may be taken from the NFQC Fund, not to exceed one thousand dollars ($1,000), unless the department, in its sole discretion, determines reimbursement in excess of one thousand dollars ($1,000) is justified by extraordinary

The qualified facility will submit to the department the paid invoice(s) for the QIPMO consultation or other quality improvement program. The department will reimburse the qualified facility for the amount

After installation and before the nursing home is operating, the facility shall disinfect the entire water distribution system, both hot and cold, and all connecting equipment by one (1) of the methods described in the 1987 National Plumbing Code, incorporated by reference in this rule. IIIWater softeners, if used, shall be connected to the hot water supply only or connected so that water used for cooking and drinking is not softened. IIIFacilities with plans approved on or after January 1, 1999, shall ensure that the entire electrical system and its maintenance and operation comply with the 1996 National Electrical Code, which is incorporated by reference in this rule. Facilities whose plans were approved on or before December 31, 1998, shall comply with the National Electrical Code as referenced in the 1985 Life Safety Code.

A facility with plans approved on or after January 1, 1999, shall install an air-conditioning system, or individual room air-conditioning units, that meet all the 1996 NFPA 90A requirements, incorporated by reference in this rule. The systems or units must be capable of maintaining resident-use areas at eighty-five degrees Fahrenheit (85°F) (29.4°C) at the summer design temperature. Those facilities with plans approved on or before December 31, 1998, shall comply with the NFPA 90A requirements as referenced in the 1985 Life Safety Code. II/III

Ventilation requirements given in Table I—Ventilation Requirements shall be met. II/III

TABLE I VENTILATION REQUIREMENTS

Minimum Air

Pressure Relationship to	Changes of Outdoor Air Per Hour	Minimum Total Air Changes Per Hour	All Air Exhausted Directly to	Air Returned From
Area Designation Adjacent Areas	Supplied to Room Supplied to Room		Outdoors	This Room
Patient Area Corridor P	Optional	2	Optional	Optional
Physical Therapy N	2	4	Optional	Optional
Occupational Therapy N	2	4	Optional	Optional
Soiled Work Room or Soiled Holding N	2	10	Yes	No
*Toilet Room N	Optional	6	Yes	No
Bathroom N	Optional	6	Yes	No
Janitors’ Closet(s) N	Optional	6	Yes	No
Linen and Trash Chute Room N	Optional	6	Yes	No
Food Preparation Center E	2	6	Yes	Optional
Warewashing Room N	Optional	6	Yes	No
Dietary Day Storage V	Optional	2	Yes	No
Laundry, General V	2	6	Yes	No
Soiled Linen Sorting and Storage N	Optional	10	Yes	No
P = Positive N = Negative	E = Equal	V = Variable

*Up to 75 cubic feet per minute (cfm) of make-up air for each patient room toilet may be supplied to the corridor and need not be supplied directly to the room.

NOTE: In the interest of energy conservation, energy saving design innovations that are not in strict conformance with these requirements, which do not adversely affect direct patient care, will be acceptable if approved in writing by the Division of Aging.

The entire plumbing system and its maintenance and operation shall comply with the requirements of all applicable local and state codes including the requirements set forth in this rule and with the requirements of the 1987 National Plumbing Code, which is incorporated by reference in this rule. II/III

Plumbing fixtures that require hot water and are resident-accessible shall be supplied with water thermostatically controlled to provide a water temperature of between one hundred twenty degrees Fahrenheit (120°F) (49°C) and one hundred five degrees Fahrenheit (105°F) (41°C) at the fixture or faucet. I/II

The hot water heating equipment shall have sufficient capacity to supply five (5) gallons (19 l) of water at one hundred twenty degrees Fahrenheit (120°F) (49°C) per hour per bed for nursing home fixtures or faucets, and eight

(8) gallons (30 l) of water at one hundred sixty degrees Fahrenheit (160°F) (71.1°C) per hour per bed for kitchen and laundry. The division may accept lesser capacities following submission of the calculation for the anticipated demand of all fixtures and equipment in the building. II

Pipes shall be sized to supply water to all fixtures with a minimum pressure of fifteen pounds per square inch (15 psi) (1.02 atmospheres) at the top floor fixture during maximum demand periods. All plumbing fixtures except water closets, urinals and drinking fountains shall have both hot and cold water supplies. III

Facilities shall protect every supply outlet or connection to a fixture or appliance against back flow as provided by the 1987 National Plumbing Code, incorporated by reference in this rule. All faucets to which hoses can be attached, all spray fittings and all other fittings that could deliver water to points below overflow lines, shall be equipped with vacuum breakers. II/III

Wherever the usage of fixtures or appliances will permit, water supplied to all fixtures, open tanks and equipment shall be introduced through a suitable air gap between the water supply and the flood level of the fixture. II

Hot water circulating mains and risers shall be run from the hot storage tank to a point directly below the highest fixture at the end of each branch main. III

Where the building is higher than three (3) stories, each riser shall be circulated. III

Water pipe sizes shall be equal to or greater than those prescribed by the 1987 National Plumbing Code, incorporated by reference in this rule. III

All fixtures and equipment shall be connected through traps to soil and waste piping and to the sewer and they shall all be properly trapped and vented to the outside. II

Courts, yards and drives which do not have natural drainage from the building shall have catch basins and drains to low ground, storm-water system or dry wells. III

107) Facilities where gas-fired equipment is to be installed for use on or after January 1, 1999, shall provide and install all gas piping, fittings, tanks and specialties in compliance with the 1996 NFPA 54, Installation of Gas Appliances and Gas Piping, the 1995 NFPA 58, Storage and Handling of Liquefied Petroleum Gases, incorporated by reference in this rule, and the instructions of the gas supplier, except where more strict requirements are stated. Facilities which installed gas-fired equipment on or before December 31, 1998, shall ensure that the installation was in compliance with the instructions and requirements outlined in the NFPA 54 and NFPA 58 as referenced in the 1985 Life Safety Code. Where liquefied petroleum gas (LPG) is used, the Missouri Department of Agriculture also requires compliance with its rules. II

Where gas piping enters the building below grade, it shall have an outside vent as follows: A concrete box, eighteen inches by eighteen inches (18‖ × 18‖) with three- inch (3‖) thick walls, of a height to rest on top of the entering gas pipe, and top of the box to come within six inches (6‖) of top The box shall be filled with coarse gravel. A one-inch (1‖) upright vent line shall be to one- half (1/2) the depth of the box and extend twelve inches (12‖) above top grade with a screened U-vent looking down. The vent line is to be anchored securely to the building wall. II

Facilities shall not install gas-fired equipment in any resident bedroom except that through-wall gas heating units may be used if vented directly to the outside, take combustion air directly from the outside and provide a complete separation of the combustion system from the atmosphere of the occupied area. II

In facilities where oxygen systems are installed on or after January 1, 1999, the facilities shall install the oxygen piping, outlets, manifolds, manifold rooms and storage rooms in accordance with the requirements of the 1993 NFPA 99, incorporated by reference in this rule. In facilities where oxygen systems were installed on or before December 31, 1998, facilities shall ensure that the installation was in compliance with NFPA 99 as required and referenced in the 1985 Life Safety Code. I/II

The building sanitary drain system may be cast iron, steel, copper or plastic if installed in compliance with the National Plumbing Code, current edition. III

Each main, branch main, riser and branch to a group of fixtures of the water system shall be valved. III

To prevent condensation, facilities shall cover cold water mains in occupied spaces with approved vapor-proof insulation. III

To prevent freezing, facilities shall insulate all pipes in outside walls. III

Facilities shall test soil, waste, vent and drain lines according to the requirements of the 1987 National Plumbing Code, incorporated by reference in this rule. The facility shall make certification of these tests available to the division. III

II/III

Facilities shall adequately light all occupied areas as required by the duties performed in that space. II/III

Residents’ bedrooms shall have a minimum general illumination of ten (10) footcandles, a night-light and a resident’s reading light. The outlets for general illumination and night-lights shall be switched at the door. III

Each single-bed resident room shall have at least two

(2) duplex receptacles. All multi-bed resident rooms shall have at least one (1) duplex receptacle at the head of each bed plus one (1) additional duplex receptacle. Facilities shall not place duplex receptacles in a manner to cause an electrical shock hazard. III

Facilities shall furnish lighting fixtures of a type suitable for the space for all lighting outlets. III

If ceiling lights are used in residents’ rooms, they shall be of a type which are shaded or globed to minimize glare. III

Facilities shall provide an electrically-powered nurses’ call system with indicator lights at the corridor entrance of each bedroom. Audible signals and indicating panels shall be located in each nurses’ station and utility room. Facilities shall provide signal buttons at the head of each resident bed, in each toilet room and in each bathroom. III

Facilities shall provide night-lights in hallways, individual toilet rooms, stairways and resident rooms or adjacent toilet rooms. II

A qualified electrician shall test and certify the entire electrical system as being in compliance with the 1996 National Electrical Code, incorporated by reference in this rule. In facilities whose plans were approved on or before December 31, 1998, the electrician shall test the system according to the standards of the National Electrical Code as referenced in the 1985 Life Safety Code. Facilities shall make this test certification available to the division. III

Facilities shall provide a complete, electrically- operated door alarm system that is audible in the nurses’ station for all resident-accessible exterior doors. III

A facility shall have emergency lighting for exits, stairs, corridors and nurses’ stations. Facilities may provide this emergency lighting using an emergency generator or battery-operated lights rated at least one and one-half (1 1/2) hours. In facilities with plans approved on or after January 1, 1999, an emergency generator shall supply emergency power to life support systems as required by the 1993 NFPA 99, Health Care Facilities, incorporated by reference in this rule. In facilities where plans were approved on or before December 31, 1998, the electrical system shall comply to the standards of the National Electrical Code as referenced in the 1985 Life Safety Code. III

The elevator installations shall comply with all local and state codes, American Standards Association Specification A17.1, 1993 Safety Code for Elevators and Escalators, the 1996 National Electrical Code, incorporated by reference in this rule, and the minimum general standards as set forth in this rule. In facilities whose plans were approved on or before December 31, 1998, the elevators shall comply with applicable local and state codes and the requirements set forth in the ASAS A17.1, Safety Code for Elevators and Escalators, and the National Electrical Code as referenced in the 1985 Life Safety Code. II

Any facility with residents on one (1) or more floors above the first floor shall have at least one (1) hydraulic or electric motor driven elevator. Facilities with a bed capacity from sixty-one to two hundred (61–200) above the first floor shall not have less than two (2) elevators. II

Facilities with a bed capacity of from two hundred to three hundred fifty (200—350) above the first floor shall have not less than three (3) elevators—two (2) passenger and one (1) service. II

Inside cab dimensions of elevators shall be not less than five feet four inches by eight feet (5’ 4‖ × 8’) with a capacity of three thousand five hundred pounds (3,500 lbs.). Cab and shaft doors shall have no less than three feet ten inches (3’ 10‖) clear opening. Elevators for which operators will not be employed shall have automatic push- button controls, signal controls or dual controls for use with or without the operator. Where two (2) push-button elevators are located together and where one (1) elevator serves more than three (3) floors and basement, they shall have collective or signal control. II