SB 1794

                                     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:
1Section  A.  Sections  197.315  and   198.022,     RSMo,      are
2  repealed and three new sections enacted in lieu thereof, to be
3  known as sections 197.315, 198.022, and 198.043, to read as
4  follows:
1197.315.  1. Any person who proposes to develop or
2  offer a new institutional health service within the state
3  must obtain a certificate of need from the committee prior
4  to the time such services are offered.
52. Only those new institutional health services which
6  are found by the committee to be needed shall be granted a
7  certificate of need.  Only those new institutional health
8  services which are granted certificates of need shall be
9  offered or developed within the state.  No expenditures for
10  new institutional health services in excess of the
11  applicable expenditure minimum shall be made by any person
12  unless a certificate of need has been granted.
133. After October 1, 1980, no state agency charged by
14  statute to license or certify health care facilities shall
15  issue a license to or certify any such facility, or distinct
 EXPLANATION-Matter enclosed in bold-faced brackets [thus] in this bill is not enacted
 and is intended to be omitted in the law.
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16 part of such facility, that is developed without obtaining a
17 certificate of need.
184. If any person proposes to develop any new
19 institutional health care service without a certificate of
20 need as required by sections 197.300 to 197.366, the
21 committee shall notify the attorney general, and he shall
22 apply for an injunction or other appropriate legal action in
23 any court of this state against that person.
245. After October 1, 1980, no agency of state
25 government may appropriate or grant funds to or make payment
26 of any funds to any person or health care facility which has
27 not first obtained every certificate of need required
28 pursuant to sections 197.300 to 197.366.
296. A certificate of need shall be issued only for the
30 premises and persons named in the application and is not
31 transferable except by consent of the committee.
327. Project cost increases, due to changes in the
33 project application as approved or due to project change
34 orders, exceeding the initial estimate by more than ten
35 percent shall not be incurred without consent of the
36 committee.
378. Periodic reports to the committee shall be required
38 of any applicant who has been granted a certificate of need
39 until the project has been completed.   The committee may
40 order the forfeiture of the certificate of need upon failure
41 of the applicant to file any such report.
429. A certificate of need shall be subject to
43 forfeiture for failure to incur a capital expenditure on any
44 approved project within six months after the date of the
45 order. The applicant may request an extension from the
46 committee of not more than six additional months based upon
47 substantial expenditure made.
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4810. Each application for a certificate of need must be
49 accompanied by an application fee.   The time of filing
50 commences with the receipt of the application and the
51 application fee.   The application fee is one thousand
52 dollars, or one-tenth of one percent of the total cost of
53 the proposed project, whichever is greater.   All application
54 fees shall be deposited in the state treasury.   Because of
55 the loss of federal funds, the general assembly will
56 appropriate funds to the Missouri health facilities review
57 committee.
5811. In determining whether a certificate of need
59 should be granted, no consideration shall be given to the
60 facilities or equipment of any other health care facility
61 located more than a fifteen-mile radius from the applying
62 facility.
6312. When a nursing facility shifts from a skilled to
64 an intermediate level of nursing care, it may return to the
65 higher level of care if it meets the licensure requirements,
66 without obtaining a certificate of need.
6713. In no event shall a certificate of need be denied
68 because the applicant refuses to provide abortion services
69 or information.
7014. A certificate of need shall not be required for
71 the transfer of ownership of an existing and operational
72 health facility in its entirety, except for any assisted
73 living facility, intermediate care facility, residential
74 care facility, or skilled nursing facility, as such terms
75 are defined in section 198.006.
7615. A certificate of need may be granted to a facility
77 for an expansion, an addition of services, a new
78 institutional service, or for a new hospital facility which
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79  provides for something less than that which was sought in
80  the application.
8116. The provisions of this section shall not apply to
82  facilities operated by the state, and appropriation of funds
83  to such facilities by the general assembly shall be deemed
84  in compliance with this section, and such facilities shall
85  be deemed to have received an appropriate certificate of
86  need without payment of any fee or charge.   The provisions
87  of this subsection shall not apply to hospitals operated by
88  the state and licensed under this chapter, except for
89  department of mental health state-operated psychiatric
90  hospitals.
9117. Notwithstanding other provisions of this section,
92  a certificate of need may be issued after July 1, 1983, for
93  an intermediate care facility operated exclusively for the
94  intellectually disabled.
9518. To assure the safe, appropriate, and cost-
96  effective transfer of new medical technology throughout the
97  state, a certificate of need shall not be required for the
98  purchase and operation of:
99(1) Research equipment that is to be used in a
100 clinical trial that has received written approval from a
101 duly constituted institutional review board of an accredited
102 school of medicine or osteopathy located in Missouri to
103 establish its safety and efficacy and does not increase the
104 bed complement of the institution in which the equipment is
105 to be located.   After the clinical trial has been completed,
106 a certificate of need must be obtained for continued use in
107 such facility; or
108(2) Equipment that is to be used by an academic health
109 center operated by the state in furtherance of its research
110 or teaching missions.
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1198.022.    1. Upon receipt of an application for a
2 license to operate a facility, the department shall review
3 the application, investigate the applicant and the
4 statements sworn to in the application for license and
5 conduct any necessary inspections.    A license shall be
6 issued if the following requirements are met:
7(1) The application discloses all facility owners,
8 facility trustees, and companies that provide the facility
9 or operator with administrative, clinical, and financial
10 services, including real estate investment trusts;
11(2) The statements in the application are true and
12 correct;
13[(2)] (3)   The facility and the operator are in
14 substantial compliance with the provisions of sections
15 198.003 to 198.096 and the standards established thereunder;
16[(3)] (4)   The applicant has the financial capacity to
17 operate the facility;
18[(4)] (5)   The administrator of an assisted living
19 facility, a skilled nursing facility, or an intermediate
20 care facility is currently licensed under the provisions of
21 chapter 344;
22[(5)] (6)   Neither the operator nor any principals in
23 the operation of the facility have ever been convicted of a
24 felony offense concerning the operation of a long-term
25 health care facility or other health care facility or ever
26 knowingly acted or knowingly failed to perform any duty
27 which materially and adversely affected the health, safety,
28 welfare or property of a resident, while acting in a
29 management capacity.    The operator of the facility or any
30 principal in the operation of the facility shall not be
31 under exclusion from participation in the Title XVIII
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32 (Medicare) or Title XIX (Medicaid) program of any state or
33 territory;
34[(6)] (7)   Neither the operator nor any principals
35 involved in the operation of the facility have ever been
36 convicted of a felony in any state or federal court arising
37 out of conduct involving either management of a long-term
38 care facility or the provision or receipt of health care; and
39[(7)] (8)   All fees due to the state have been paid.
402. Upon denial of any application for a license, the
41 department shall so notify the applicant in writing, setting
42 forth therein the reasons and grounds for denial.
433. The department may inspect any facility and any
44 records and may make copies of records, at the facility, at
45 the department's own expense, required to be maintained by
46 sections 198.003 to 198.096 or by the rules and regulations
47 promulgated thereunder at any time if a license has been
48 issued to or an application for a license has been filed by
49 the operator of such facility.    Copies of any records
50 requested by the department shall be prepared by the staff
51 of such facility within two business days or as determined
52 by the department.    The department shall not remove or
53 disassemble any medical record during any inspection of the
54 facility, but may observe the photocopying or may make its
55 own copies if the facility does not have the technology to
56 make the copies.    In accordance with the provisions of
57 section 198.525, the department shall make at least one
58 inspection per year, which shall be unannounced to the
59 operator. The department may make such other inspections,
60 announced or unannounced, as it deems necessary to carry out
61 the provisions of sections 198.003 to 198.136.
624. Whenever the department has reasonable grounds to
63 believe that a facility required to be licensed under
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64 sections 198.003 to 198.096 is operating without a license,
65 and the department is not permitted access to inspect the
66 facility, or when a licensed operator refuses to permit
67 access to the department to inspect the facility, the
68 department shall apply to the circuit court of the county in
69 which the premises is located for an order authorizing entry
70 for such inspection, and the court shall issue the order if
71 it finds reasonable grounds for inspection or if it finds
72 that a licensed operator has refused to permit the
73 department access to inspect the facility.
745. Whenever the department is inspecting a facility in
75 response to an application from an operator located outside
76 of Missouri not previously licensed by the department, the
77 department may request from the applicant the past five
78 years compliance history of all facilities owned by the
79 applicant located outside of this state.
1198.043.   1. As used in this section, the following
2 terms mean:
3(1)   "Certified nursing assistant", the same meaning
4 given to the term in section 198.082;
5(2)   "Charge nurse", a registered professional nurse
6 who oversees the operations of the nurse's specific nursing
7 unit during a set period;
8(3)   "CMS", the Centers for Medicare and Medicaid
9 Services;
10(4)   "Hours per resident day", the total number of
11 hours worked by each type of staff divided by the total
12 number of residents;
13(5)   "Registered professional nurse" or "registered
14 nurse", the same meanings given to the terms in section
15 335.016.
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162.    Assisted living facilities shall have sufficient
17 nursing staff with the appropriate competencies and skill
18 sets to provide nursing and related services to ensure
19 resident safety and attain or maintain the highest
20 practicable physical, mental, and psychosocial well-being of
21 each resident by maintaining on a twenty-four-hour basis the
22 following types of personnel:
23(1)    Registered nurses.   Each assisted living facility
24 shall comply with the following staffing requirements for
25 registered nurses:
26(a)    Each assisted living facility shall provide care
27 by registered nurses for a minimum of fifty-five hundredths
28 hours per resident day; and
29(b)    At least one registered nurse shall be on site
30 twenty-four hours a day, seven days a week; and
31(2)    Other nursing personnel.   Each assisted living
32 facility shall provide care by certified nursing assistants
33 for a minimum of two and forty-four hundredths hours per
34 resident day.
353.    Assisted living facilities shall electronically
36 submit to CMS complete and accurate direct care staffing
37 information, including information for agency and contract
38 staff, based on payroll and other verifiable and auditable
39 data in a uniform format according to specifications
40 established by CMS in accordance with 42 CFR 483.70(p).
414.    Determinations of compliance with hours per
42 resident day specified in subsection 2 of this section shall
43 be made by the department based on the most recent available
44 quarter of Payroll-Based Journal System data maintained by
45 CMS.
465.    The department may impose appropriate sanctions and
47 assess an administrative penalty under this section on an
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48 administrator of a facility who fails to meet the minimum
49 staffing standards two quarters in a row as determined by
50 rule.
516.    (1) An assisted living facility may be exempted
52 from the minimum staffing requirements of subdivisions (1)
53 and (2) of subsection 2 of this section by the department if
54 a verifiable hardship exists that prohibits the facility
55 from achieving or maintaining compliance as demonstrated by
56 meeting the following criteria:
57(a)    The facility is located in an area where:
58a.    The supply of applicable health care staff, either
59 registered professional nurses or certified nursing
60 assistants or both, is not sufficient to meet area needs as
61 evidenced by a provider-population ratio for nursing
62 workforce that is medium, twenty percent below the national
63 average, or low, forty percent below the national average;
64 and
65b.    The facility is at least twenty miles from another
66 assisted living facility;
67(b)    The facility demonstrates that it has been unable,
68 despite diligent efforts, including offering at least
69 prevailing wages, to recruit and retain appropriate
70 personnel as verified by:
71a.    Job listings in commonly used recruitment forums
72 found online at American Job Centers, coordinated by the
73 U.S. Department of Labor's Employment and Training
74 Administration; MoJobs, coordinated by the department of
75 higher education and workforce development; and other forums
76 as appropriate;
77b.    Documented job vacancies, including the number and
78 duration of the vacancies and documentation of offers made,
79 including that they were made at least at prevailing wages;
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80c.    Data on the average wages in the metropolitan
81  statistical area in which the facility is located and
82  vacancies by industry as reported by the department of labor
83  and industrial relations; and
84d.    The facility's staffing plan, which shall be
85  developed and maintained to maximize recruitment and
86  retention of direct care staff; and
87(c)    The facility demonstrates through documentation
88  the amount of financial resources that the facility expends
89  on nurse staffing relative to revenue.
90(2)    A facility shall not be eligible for a hardship
91  waiver from the minimum staffing requirements if the
92  facility:
93(a)    Has been cited within the twelve months preceding
94  the survey during which the facility's noncompliance is
95  identified:
96a.    For having widespread insufficient staffing with
97  resultant resident actual harm;
98b.    For a pattern of insufficient staffing with
99  resultant resident actual harm; or
100c.    As at the immediate jeopardy level of severity with
101 respect to insufficient staffing as determined by CMS; or
102(b)    Has failed to submit data to CMS under subsection
103 3 of this section.
1047.    In order to appropriately manage required nursing
105 staff, an assisted living facility shall:
106(1)    Designate a registered professional nurse as the
107 director of nursing on a full-time basis; and
108(2)    Designate a registered professional nurse to serve
109 as a charge nurse for each nursing shift.     The director of
110 nursing designated in subdivision (1) of this subsection may
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111 serve as a charge nurse only if the facility has an average
112 daily occupancy of sixty or fewer residents.
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