Missouri assisted living facility license: DHSS rules, CON and steps

Two assisted living licenses on one application

Missouri’s Omnibus Nursing Home Act, RSMo chapter 198, defines an assisted living facility as “any premises, other than a residential care facility, intermediate care facility, or skilled nursing facility, that is utilized by its owner, operator, or manager to provide twenty-four-hour care and services and protective oversight to three or more residents”.⁠¹ DHSS describes residents as people who get shelter and board and who may need help with eating, dressing, bathing, toileting, transferring and walking. The facility also handles medication storage, distribution or administration and health care supervision under a licensed physician, “consistent with a social model of care”.⁠⁶ Missouri has required a license for that work since January 1, 2008, and no one may “hold itself out as an assisted living facility or advertise itself as an assisted living facility” without one.⁠²

The decision you face first is which ALF license to apply for. The state application form, MO 580-2631, has separate bed counts for Assisted Living Facility and Assisted Living Facility**.⁠⁸ The double asterisk marks an ALF that “chooses to accept or retain individuals with a physical, cognitive or other condition that prevents them from safely evacuating the facility with minimal assistance”.⁠⁸ A plain ALF may not care for anyone who needs more than minimal assistance to evacuate. To do that, it must meet the extra standards of 19 CSR 30-86.045.⁠⁵

The rule defines minimal assistance precisely. The resident can prepare to leave and evacuate within five minutes of being alerted, with no more than one physical intervention and three verbal interventions from staff. Helping someone down stairs, opening a door for them or pushing their wheelchair counts as more than minimal assistance.⁠⁵ In practice, a memory care or high-acuity building will usually need the ALF** license. A building for residents who walk out on their own may not.

The heavier ALF** staffing applies only while at least one resident who needs more than minimal help with evacuation lives in the building.⁠⁵ Staff with duties under a resident’s evacuation plan must be briefed on them at least every six months and whenever the plan changes significantly. If a resident’s physician recommends a personal electronic monitoring device, the facility must use one.⁠⁵

ALF or residential care facility?

DHSS’s levels-of-licensure page lists no separate “adult family home” or “adult foster home” category for older adults; the long-term care levels are residential care, assisted living, intermediate care and skilled nursing.⁠⁶ Below the ALF sits the residential care facility (RCF), which is also licensed by DHSS under chapter 198 for three or more residents.⁠¹⁠⁶ The ALF definition excludes a facility where all residents are related within the fourth degree to the owner, operator or manager.⁠¹ The line between them is set by evacuation ability and staffing:

• RCF residents must be able to make a path to safety unassisted, and an RCF does not need a licensed nursing home administrator.⁠⁶ By statute, an RCF may admit or retain only people “capable mentally and physically of negotiating a normal path to safety using assistive devices or aids when necessary”.⁠²
• ALF residents may need minimal help to evacuate (or more, in an ALF**). An ALF must have a licensed administrator and must follow the social model of care.⁠⁵⁠⁶

If you are planning a small home for people who can still evacuate on their own, read the Missouri residential care facility guide before committing to ALF standards. Converting later costs more. Under 19 CSR 30-82.010, an RCF that changes to any other level of care must meet the construction, fire safety and physical plant rules for a new facility.⁠⁴ Day programs follow a separate set of rules, covered in the Missouri adult day care guide. An ALF may run a non-licensed adult day program for four or fewer participants inside its building. Those participants do not count toward the facility census, but they do count for staffing while they are present.⁠⁵

Unless you file a written exclusion, DHSS treats every room on the premises and every person 18 or older living there as part of the facility.⁠⁴ If you plan to live on site, or to house a relative who is not a resident, file that statement with the application.

Operating without a license is a class A misdemeanor. If abuse or neglect of a resident occurred, it is a class E felony.⁠³

Certificate of need comes before the license

This is the step that most often surprises out-of-state operators. Missouri’s certificate of need (CON) law covers “facilities licensed under chapter 198”, which includes ALFs.⁠¹⁰ Among the conditions DHSS must confirm before issuing a license is that “the applicant has received a Certificate of Need, if required, or has received a determination from the Certificate of Need Program that no certificate is required”.⁠⁴ Either way, you deal with the CON Program before DHSS licenses you.

The trigger is cost and bed count. Under 19 CSR 60-50.400, a full CON application is required when:⁠¹¹

• a new long-term care facility, including an ALF, costs $600,000 or more;
• added ALF beds cost $600,000 or more, or exceed 10 beds or 10% of existing licensed capacity, whichever is less; or
• renovation or modernization of an existing chapter 198 facility, without new beds, costs $600,000 or more.

The statute sets the same $600,000 capital expenditure minimum for chapter 198 beds and a $400,000 minimum for major medical equipment.⁠⁹

Either path starts with a Letter of Intent (Form MO 580-1860). CON Program staff test the letter against the expenditure minimums. If your project falls below them, the committee chair may issue a Non-Applicability letter, and that review is complete.⁠¹¹ The letter is valid for six months from issuance, with one six-month extension available, and any later change in scope, cost, operator, ownership or site can void it.⁠¹¹ You must report final project costs, with third-party verification, on a Periodic Progress Report (Form MO 580-1871).⁠¹¹

If you need a full CON, the Letter of Intent must reach the CON office at least 30 days before the application, and it stays valid for six months. Full applications are filed 71 to 100 days before a meeting of the Missouri Health Facilities Review Committee.⁠¹¹ The application fee is $1,000 or one-tenth of one percent of total project cost, whichever is greater.⁠¹² The committee measures need against a formula of 25 RCF/ALF beds per 1,000 residents aged 65 and older within a 15-mile radius, minus the beds already licensed or approved there.⁠¹¹ Once approved, a CON is forfeited if no capital expenditure is made within six months of the order. The committee can extend that by no more than six months.⁠¹²

An existing RCF can sometimes move beds instead of seeking new ones. Statute allows an RCF to relocate licensed beds to another facility in the same licensure category within six miles under the same ownership.⁠²¹

Plans approval and the building

You must submit plans for new construction, additions or major remodeling to the DHSS Section for Long-Term Care. If the facility will be licensed for more than nine residents, a registered architect or professional engineer must prepare them.⁠⁵ Construction may begin only after DHSS approves the plans in writing, and you must notify DHSS when it starts. If you do not start within one year of approval and finish within three years, you must resubmit the plans under the rules then in force.⁠⁵

Source: 19 CSR 30-86.012.⁠⁵

Several other standards come from the same rule. A facility with more than 15 employees must conform with Section 504 of the Rehabilitation Act. Residents may not be housed on a level where the outside grade is more than three feet above the floor on the window side. Newly licensed facilities must have “sturdy construction with permanent foundations”.⁠⁵ Facilities licensed for 12 or fewer residents are exempt from a separate attendant’s work area. They may also skip a separate laundry room, as long as the laundry is apart from the kitchen and out of resident rooms.⁠⁵

The rule’s definition of “home-like” includes a kitchen and family-style eating area residents can use, a resident laundry area, an outdoor area, and a toilet room with toilet, lavatory and bathing unit in each resident’s room.⁠⁵ Treat it as the design target DHSS will judge your social model against.

DHSS also publishes a Certification of Electric Wiring form (MO 580-2762). On it, an inspector certifies that the installation is “essentially in compliance with the requirements of the National Electrical Code”.⁠²³

Fire safety: sprinklers, alarms and twelve drills a year

Missouri’s ALF fire rule, 19 CSR 30-86.022, incorporates fixed editions of the national codes: NFPA 101 (2000), NFPA 13 (1999), NFPA 72 (1999) and NFPA 25 (1998), among others.⁠⁵ Its main requirements:

• Sprinklers. Facilities licensed on or after August 28, 2007, or any section that has a major renovation completed after that date, must have a complete NFPA 13 (1999) system. An ALF** must use NFPA 13R if it is single-story and NFPA 13 if it is multi-level. A qualified service representative must certify the system at least annually under NFPA 25.⁠⁵
• Fire alarm. You need a complete system under NFPA 101 section 18.3.4 that automatically transmits to the fire department, a dispatching agency or a central monitoring company. Manual pull stations go at each attendant’s station and each required exit.⁠⁵
• Emergency plan. Your written plan must cover phased response, areas of refuge and staff assignments. Each year you must ask the local fire unit to review it, and you must give a copy to the local emergency management director.⁠⁵ DHSS lists a Fire Department Consultation form on its forms page.⁠⁷
• Drills. Hold at least 12 fire drills a year, with one every three months on each shift. At least four must be unannounced, and at least one a year must evacuate residents.⁠⁵
• Training. Give fire safety training at orientation and at least every six months.⁠⁵
• Fire reporting. Notify DHSS of any fire and submit a written report within seven days, “regardless of the size of the fire”.⁠⁵

If you plan a secured dementia area, the rule requires at least 40 square feet of common space per resident inside the secured area. Locks on exit doors must be delayed-egress magnetic locks that release when the fire alarm activates, when power fails, and within 30 seconds after the release is pushed for three seconds.⁠⁵ DHSS also requires a separate disclosure form for an Alzheimer’s special care unit or program (covered below).

The administrator needs a nursing home administrator license

An ALF operator “shall designate an individual for administrator who is currently licensed as an administrator by the Missouri Board of Nursing Home Administrators”.⁠⁵ Under RSMo 344.020, the board may issue a separate license for administrators of assisted living facilities. That license does not authorize the holder to run an intermediate care or skilled nursing facility.⁠¹³ The board’s rule for that license, 19 CSR 73-2.022, requires the applicant to be at least 21, hold a high school diploma or equivalent, be of good moral character, and have no conviction involving fraud, dishonesty, moral turpitude or the operation of a health care facility. Experience can be two years of health care or aging-related work that included managing and supervising two staff, an associate degree plus one year (with six months of management), or a bachelor’s degree plus six months of that work. The applicant then becomes eligible for the board’s examinations.⁠²² The board’s fee rule, 19 CSR 73-2.015 (Code of State Regulations dated 10/31/23), lists a $150 application review fee and renewal fees of $50 for a one-year or $100 for a two-year license, with a separate fee for each examination set by the board.⁠²²⁠¹⁴ Applicants who already hold an administrator license from another state may apply by reciprocity under 19 CSR 73-2.025.⁠²² The full nursing home administrator license under RSMo 344.030 has different experience rules, so confirm with the board which license you need.⁠¹⁴

One administrator may serve up to five facilities within a 30-mile radius, with no more than 100 residents in total, if each facility has a designated daily manager. An administrator may also run several licensed facilities on the same premises.⁠⁵ The administrator must name a person in charge during an absence. If the administrator is away for more than 30 consecutive days without being reachable by phone, or is absent from the facility for more than 60 working days in a calendar year, that person in charge must be a licensed administrator.⁠⁵

Staffing floors and nurse hours

The plain-ALF minimum in 19 CSR 30-86.047 is one staff person per 15 residents (or major fraction of 15) on the day shift, one per 20 on the evening shift and one per 25 at night.⁠⁵ Every facility, however small, needs at least one person on each shift. Required staff must be “in the facility awake, dressed and prepared to assist residents in case of emergency”. The administrator counts toward staffing only when physically present. If you set your own shift hours, they must appear on the work schedule, and no shift may be shorter than six hours.⁠⁵ The rule states that meeting these minimums “may not meet the needs of residents” as set out in their assessments and service plans.⁠⁵

Other staffing rules in 19 CSR 30-86.047:⁠⁵

• A licensed nurse must work at the facility at least 8 hours a week for every 30 residents, or additional major fraction of 30. The nurse reviews charts, medications and diets and observes each resident’s condition.
• Staff counted in the ratio, and anyone giving direct care, must be at least 16. At least one employee aged 18 or older must be on duty at all times.
• No one may be on duty with responsibility for resident oversight for more than 18 hours a day.
• Only a physician or licensed nurse, or a certified medication technician or level I medication aide, may administer medication. Insulin injections may also be given by a medication technician or level I aide who has completed the state-approved insulin course.
• A physician, pharmacist or registered nurse must review each resident’s medication regimen in the facility at least every other month.
• One staff member must be designated to coordinate leisure activities and promote the social model.

Training before and after the first shift

Every new employee needs at least two hours of orientation on or before the first day of work. It must cover job duties, emergency response, infection control, confidentiality, abuse and neglect reporting to the DHSS hotline (1-800-392-0210), the Employee Disqualification List, residents’ rights, working with residents with mental illness, and person-centered care under the social model.⁠⁵ Facilities serving anyone with Alzheimer’s disease or a related dementia add dementia orientation: at least three hours for direct-care staff and one hour for other staff with daily contact. Dementia content must also be part of ongoing in-service training.⁠⁵

Staff who transfer residents need at least two classroom hours of initial training plus on-the-job training. The trainer must be a licensed nurse, physical therapist, physical therapy assistant, occupational therapist or certified occupational therapy assistant, who also checks competency. After that, staff need one hour of transfer training a year from a licensed nurse.⁠⁵

Before any new hire has contact with residents, the facility must request a criminal background check under RSMo 192.2495 and check the Employee Disqualification List.⁠⁵ Anyone found guilty of a class A or B felony under chapters 565, 566 or 569, or of certain other offenses, may not have resident contact unless DHSS grants a good cause waiver.⁠⁵ Separately, a person with a controlled-substance offense may not have access to controlled substances unless DHSS grants a written waiver for that employee.⁠⁵

Who you can admit and keep

Before admission, an ALF must complete a pre-move-in screening with the prospective resident. Within five calendar days of admission, an “appropriately trained and qualified individual” must complete a community-based assessment, repeated at least every six months and after any significant change. The standard form is MO 580-2835.⁠⁵ That individual must hold a health care license or a degree in a health care, social services or human services field, or an administrator license. They also need facility orientation, dementia training and 24 more hours of DHSS-approved training in ADL assessment, cognitive assessment, service planning and interviewing.⁠⁵ You must then write an individualized service plan with the resident, signed by both sides and reviewed at least annually.⁠⁵

Residents also need an admission physical by a licensed physician, on file no later than ten days after admission. No one under 16 may be admitted.⁠⁵ Before move-in, you must tell prospective residents what services you can provide or coordinate, what they cost, and what conditions will require discharge.⁠²⁠⁵

An ALF may not admit or keep a resident who:⁠⁵

• has shown behaviors that present a reasonable likelihood of serious harm to self or others;
• needs physical or chemical restraint;
• needs skilled nursing services the facility is not licensed or able to provide;
• needs more than one person at a time to physically help with any activity of daily living other than bathing and transferring; or
• is bed-bound or similarly immobilized by a debilitating or chronic condition.

The last three limits do not apply to a resident on hospice, if the resident or representative, the facility, the physician and the hospice all agree the arrangement is appropriate.⁠⁵ Statute also lets a previously qualified resident stay through a temporary incapacity of up to 45 days if a physician approves.⁠²

What goes into the application packet

The application is form MO 580-2631, which you can send to the Licensure Unit by mail or email it to [email protected]. The fee travels separately by mail to DHSS Fee Receipts, PO Box 570, Jefferson City.⁠⁴ The operator’s legal name must match its Missouri Secretary of State filing.⁠⁸ Under 19 CSR 30-82.010 and the form instructions, a new facility attaches:⁠⁴⁠⁸

1. Financial capacity

   A recent statement of financial position, a forecasted income statement for the first 12 months, and a statement of how expenses will be met during the license period. DHSS forms MO 580-2635/2632 and 580-2636 may be used.

2. Ownership

   A list of principals with Social Security or employer numbers (MO 580-2925). Also list affiliates: partners, 5% owners, officers and directors, and LLC managers and 5% members, with an affiliate list for any affiliate that is itself an entity.

3. Premises and contracts

   The lease or deed and other contracts conveying the right to the premises; any management contract; and any security agreement pledging assets worth more than $500.

4. Other facilities

   All long-term care facilities the applicant or owner operates in any state. Out-of-state operators may be asked for five years of compliance history.⁠²⁰

5. Disclosures

   Any Medicare or Medicaid exclusion, any health-care-related felony, and whether the facility holds a Department of Mental Health license.

6. Resident funds

   A nursing home surety bond (MO 580-2624) or noncancelable escrow agreement (MO 580-2628) if you will hold any resident’s personal funds, “regardless of the amount of funds held or the length of time held”.

7. Civil rights

   The Assurance of Compliance (MO 580-2622).

8. Dementia programs

   If you run an Alzheimer’s special care unit or program, the Alzheimer’s Special Care Services Disclosure (MO 580-2637) and your program brochure.

When DHSS asks for corrections or more information, you have ten working days to respond, by letter or on form MO 580-2623.⁠⁴

Fees as published

Sources: 19 CSR 30-82.010 and RSMo 197.315.⁠⁴⁠¹²

Each level of care is licensed separately and needs its own fee. If you put ALF beds and RCF beds on the same premises, you pay twice and receive two licenses with one expiration date.⁠⁴ The license fee is nonrefundable unless you withdraw within ten days of DHSS receiving the application. Licenses run for no more than two years, and the fee is prorated for shorter terms.⁠⁴ You can pay by money order, bank draft or check payable to the Department of Health and Senior Services, and DHSS also offers online payment.⁠⁷⁠⁸

The order that works

1. Choose ALF or ALF**,

   based on the residents you intend to serve. The choice drives sprinkler type, staffing and nurse hours.⁠⁵

2. File a Letter of Intent with the CON Program

   and get either a Non-Applicability letter or a full certificate of need.⁠¹¹

3. Submit plans to DHSS

   for new construction, additions or major remodeling, and build only after written approval.⁠⁵

4. Line up a licensed administrator

   and a licensed nurse for the required weekly hours.⁠⁵

5. File MO 580-2631 at least 30 days before opening,

   with the full packet. DHSS must approve the application before it schedules the licensure inspection. If the application is still incomplete 60 days after receipt, DHSS treats it as withdrawn.⁠⁴

6. Pass the licensure inspection

   DHSS issues the license only after finding the facility and operator in substantial compliance with chapter 198 and the rules, and the CON requirement satisfied.⁠⁴

Missouri does not publish a processing time for an original license. The rules give only the 30-day minimum lead time and the 60-day cutoff for incomplete applications.⁠⁴

Inspections, renewal and changes

DHSS must inspect every ALF at least once a year.⁠¹⁵ After an inspection, you have five working days to submit a plan of correction for class I violations and ten working days for class II or III.⁠¹⁶ File for relicensure 30 to 90 days before the license expires.⁠⁴ Within ten working days, report any change that makes your application inaccurate, including a new administrator.⁠⁴ To add a new level of care, request it at least 60 days before you start.⁠⁴

Licenses cannot be transferred. A new operator, including a change in business form, must apply before the change takes effect and receives a temporary operating permit while DHSS reviews the application.⁠⁴ A change in majority control of a partnership or corporation also requires a new application within ten working days.⁠³

How Missouri ALF residents pay with public funds

Under DHSS policy, the facility’s basic shelter, food and 24-hour protective oversight are meant to be covered by the resident’s own income, such as SSI or Social Security, plus a supplemental cash grant from the Department of Social Services.⁠¹⁷ When a Medicaid-eligible resident’s needs go beyond what the license requires, Medicaid State Plan RCF/ALF Personal Care can pay for basic personal care, advanced personal care and authorized nurse visits.⁠¹⁷

To qualify, the resident must be 18 or older, in active Medicaid status, and meet nursing facility level of care. Referrals go to the DHSS Division of Senior and Disability Services. With a valid physician prescription, DSDS authorizes at least one hour of personal care a day.⁠¹⁷ If a newly admitted resident needs personal care, notify the Person-Centered Care Planning team within two weeks of admission so the authorization dates back to the admission date.⁠¹⁷ The policy manual does not state the supplemental cash grant amount or the steps for an ALF to enroll as a personal care provider, so ask DSS for the current grant amount and DHSS DSDS how to become an authorized provider before you plan revenue around either.⁠¹⁷

Rule changes in 2026

DHSS amended 19 CSR 30-86.047, the main ALF rule. The amendment was proposed in the December 1, 2025 Missouri Register, published in the Code of State Regulations on April 30, 2026, and took effect May 30, 2026.⁠¹⁸ The current text cites RSMo 192.2495 for background checks and directs facilities to the department’s online Employee Disqualification List and CNA registry pages.⁠⁵ Two related rules also changed: 19 CSR 30-82.060, the good cause waiver rule for disqualified hires, took effect April 30, 2026.⁠⁴ An amendment to 19 CSR 30-86.042, the rule for residential care facilities, took effect July 30, 2026.⁠⁵ The CON Letter of Intent rule, 19 CSR 60-50.400, was amended effective April 30, 2026.⁠¹¹

DHSS’s licensing page, checked 2026-10-12, counts 332 assisted living facilities and 268 residential care facilities statewide.⁠¹⁹ For the other Missouri care licenses, see the Missouri state page, the home health agency guide and the national assisted living overview.

Sources

1. 1
   Missouri Revisor of Statutes, RSMo 198.006 (Definitions, Omnibus Nursing Home Act) Checked 12 Oct 2026 · Back to text ↑
2. 2
   Missouri Revisor of Statutes, RSMo 198.073 (Residential care and assisted living facilities: admission and requirements) Checked 12 Oct 2026 · Back to text ↑
3. 3
   Missouri Revisor of Statutes, RSMo 198.015 (License required, duration, change of ownership, penalty) Checked 12 Oct 2026 · Back to text ↑
4. 4
   Missouri Secretary of State, 19 CSR 30-82 (General Licensure Requirements) Checked 12 Oct 2026 · Back to text ↑
5. 5
   Missouri Secretary of State, 19 CSR 30-86 (Residential Care Facilities and Assisted Living Facilities) Checked 12 Oct 2026 · Back to text ↑
6. 6
   Missouri Department of Health and Senior Services, Levels of Licensure for Long-Term Care Facilities Checked 12 Oct 2026 · Back to text ↑
7. 7
   Missouri Department of Health and Senior Services, LTC Applications and Forms Checked 12 Oct 2026 · Back to text ↑
8. 8
   Missouri Department of Health and Senior Services, Application for License to Operate a Long-Term Care Facility (MO 580-2631) Checked 12 Oct 2026 · Back to text ↑
9. 9
   Missouri Revisor of Statutes, RSMo 197.305 (Certificate of need definitions) Checked 12 Oct 2026 · Back to text ↑
10. 10
    Missouri Revisor of Statutes, RSMo 197.366 (Health care facilities defined) Checked 12 Oct 2026 · Back to text ↑
11. 11
    Missouri Secretary of State, 19 CSR 60-50 (Certificate of Need Program) Checked 12 Oct 2026 · Back to text ↑
12. 12
    Missouri Revisor of Statutes, RSMo 197.315 (Certificate of need required, fee, forfeiture) Checked 12 Oct 2026 · Back to text ↑
13. 13
    Missouri Revisor of Statutes, RSMo 344.020 (Nursing home administrator license required) Checked 12 Oct 2026 · Back to text ↑
14. 14
    Missouri Revisor of Statutes, RSMo 344.030 (Administrator license qualifications) Checked 12 Oct 2026 · Back to text ↑
15. 15
    Missouri Revisor of Statutes, RSMo 198.525 (Inspection of long-term care facilities) Checked 12 Oct 2026 · Back to text ↑
16. 16
    Missouri Revisor of Statutes, RSMo 198.026 (Noncompliance, plans of correction, probationary license) Checked 12 Oct 2026 · Back to text ↑
17. 17
    Missouri Department of Health and Senior Services, HCBS Policy Manual 3.20: RCF/ALF Personal Care, State Plan (Agency Model) Checked 12 Oct 2026 · Back to text ↑
18. 18
    Missouri Department of Health and Senior Services, Regulation Update Notice: 19 CSR 30-86.047 (May 1, 2026) Checked 12 Oct 2026 · Back to text ↑
19. 19
    Missouri Department of Health and Senior Services, Licensing and Certification Checked 12 Oct 2026 · Back to text ↑
20. 20
    Missouri Revisor of Statutes, RSMo 198.022 (Licensure applications, inspections) Checked 12 Oct 2026 · Back to text ↑
21. 21
    Missouri Revisor of Statutes, RSMo 197.318 (Long-term care bed expansion and relocation) Checked 12 Oct 2026 · Back to text ↑
22. 22
    Missouri Secretary of State, 19 CSR 73-2 (Missouri Board of Nursing Home Administrators: General Rules) Checked 12 Oct 2026 · Back to text ↑
23. 23
    Missouri Department of Health and Senior Services, Certification of Electric Wiring (MO 580-2762) Checked 12 Oct 2026 · Back to text ↑

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