Missouri residential care facility license: the five-minute evacuation rule and the CON check

One license from three beds up

Missouri licenses four levels of long-term care facility, and the residential care facility is the lightest. The Section for Long-Term Care Regulation licenses 268 RCFs and 332 assisted living facilities statewide ⁠⁶. RSMo 198.006 defines it as any premises, other than an assisted living, intermediate care or skilled nursing facility, used by its owner, operator or manager “to provide twenty-four-hour care to three or more residents, who are not related within the fourth degree of consanguinity or affinity” to that owner, operator or manager, and who need shelter, board and protective oversight. Protective oversight can include storing, distributing or administering medications and caring for someone through a short illness or recovery ⁠¹.

Two parts of that definition decide whether you need a license:

• Count. The license starts at three unrelated residents. Relatives within the fourth degree (by blood or marriage) do not count toward the three ⁠¹.
• Duration. A “resident” is someone who stays in the facility for more than 24 consecutive hours ⁠¹. Daytime-only care for adults is a separate program; see the Missouri adult day care program license.

“Protective oversight” is the part that makes a house a facility. The statute defines it as 24-hour awareness of where each resident is, the ability to step in on the resident’s behalf, supervision of nutrition, medication or care, and responsibility for the resident’s welfare ⁠¹. If you rent rooms to older adults and also watch their medications and whereabouts, you are inside the definition.

Missouri has no adult family home, adult foster home or small personal care home license for older adults. A home with three residents gets the same RCF license, under the same rules, as a large building. Many of those rules do scale down for homes licensed for 12 or fewer residents, as the sections below show. Running an unlicensed facility is a class A misdemeanor, and DHSS refers unlicensed facilities to the local prosecutor or the attorney general ⁠².

RCF or assisted living: decided by evacuation, not by size

DHSS describes the levels this way ⁠⁵:

A new operator is in practice choosing between the plain RCF and an ALF. The RCF* standards in 19 CSR 30-86.043 apply only to facilities that were licensed as an RCF II on August 27, 2006 and chose to stay under those rules ⁠⁴.

The RCF rule sets the line. Every resident must be “physically and mentally capable of negotiating a normal path to safety unassisted or with the use of assistive devices within five (5) minutes” of an alarm ⁠⁴. Residents who use a wheelchair must be able to transfer in and out of it on their own and must be housed near an exit at grade, a ramp or an area of refuge. Residents who use a walker, and blind residents, must live on a floor with a grade-level exit, a ramp or no more than two steps with a handrail, unless an area of refuge is provided ⁠⁴. A resident who temporarily cannot meet the standard because of illness, injury or surgery may stay or return from the hospital for up to 45 days with a physician’s written approval ⁠⁴. Beyond that, the facility must not admit or keep residents whose needs it cannot meet ⁠⁴.

If your business plan depends on serving people with dementia who wander or cannot follow an alarm, or residents who need hands-on transfers, plan for an ALF instead, with a licensed nursing home administrator. The Missouri assisted living facility license covers that path.

Certificate of need: confirm it before you build or sign a lease

Missouri’s certificate of need law covers every facility licensed under Chapter 198, so it covers RCFs ⁠⁸. DHSS will not issue a license unless 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, has completed construction, and is in substantial compliance” ⁠³.

When a full CON is required, as published on 2026-10-12:

• New facility costing $600,000 or more. The CON rules list “the development of a new LTC facility (licensed or certified residential care facility, assisted living facility…) costing six hundred thousand dollars ($600,000) or more” as reviewable ⁠⁹. The statutory expenditure minimum for Chapter 198 beds is $600,000 in capital expenditures or $400,000 for major medical equipment ⁠⁸.
• Adding beds later. Adding beds is reviewable if it costs $600,000 or more, or if it exceeds 10 beds or 10% of existing licensed capacity, whichever is less ⁠⁹. RSMo 197.305 measures the bed increase over a two-year period ⁠⁸.
• Smaller projects. A small home under those thresholds still needs written proof that no CON is required. The CON Program handles this as a non-applicability review, “a Letter of Intent process to document that a CON is not needed for a proposal when the capital expenditure is less than the expenditure minimum” ⁠⁹. The letter of intent (Form MO 580-1860) must include a Proposed Expenditure form (MO 580-2375) “even if the project cost is ‘$0’”. If you claim costs below the minimums, attach supporting documents such as schematic drawings, equipment quotes and contractor estimates ⁠⁹.

Where a full CON application is needed, the letter of intent must reach the CON office at least 30 days before the application and stays valid for six months ⁠⁹. The volunteer Missouri Health Facilities Review Committee makes CON decisions. The program is at 920 Wildwood Drive, Jefferson City (mail: PO Box 570, Jefferson City, MO 65102), 573-751-6403, [email protected] ⁠¹⁰.

The building: plan approval, space and fixtures

The Section for Long-Term Care Regulation reviews plans for new construction, additions and major remodeling. If the facility will be licensed for more than nine residents, a Missouri-registered architect or professional engineer must prepare the plans. Construction may start only after DHSS approves the plans in writing, and you must notify DHSS when work begins. If work does not start within one year of approval and finish within three years, you must resubmit the plans under the rules then in effect ⁠⁴.

Several rules ease up for homes licensed for 12 or fewer residents. You do not need a separate attendant work area, and laundry can be outside a dedicated room as long as it is separate from the kitchen and not in a room residents use ⁠⁴. The call-system requirement (intercom, pager, buzzer or hand bells in every bedroom and toilet room) applies to RCFs licensed for more than 12 residents after December 31, 1987 ⁠⁴. A facility employing more than 15 people must meet Section 504 of the Rehabilitation Act, and any facility housing residents with disabilities must make first-floor rooms and living areas accessible to them ⁠⁴.

Only activities needed to run the facility may operate in the building unless DHSS approves them in advance in writing. One exception: you may serve up to four adult day care participants without prior approval. They do not count in your census, they count toward staffing while on site, and you must give them a private area to rest ⁠⁴.

Fire protection is the largest construction item

Under 19 CSR 30-86.022, facilities licensed on or after August 28, 2007, and any section that has undergone a major renovation since then, “shall install and maintain a complete sprinkler system in accordance with NFPA 13, 1999 edition” ⁠⁴. The rule has no small-home exception. Plan for a full NFPA 13 system if you are converting a house that was never licensed. A qualified service representative must inspect and certify the system at least annually under NFPA 25. If the system will be out of service for more than four hours in 24, you must notify DHSS immediately and post a fire watch ⁠⁴.

The other fire rules ⁠⁴:

• Fire alarm. A complete system meeting NFPA 101 section 18.3.4 (2000 edition), automatically transmitting to the fire department, a dispatcher or a central monitoring company, with audible and visual signals and pull stations at attendant stations and exits.
• Extinguishers. At least one per floor, with no point more than 75 feet from an extinguisher.
• Written emergency plan. It must cover phased relocation, floor-by-floor evacuation instructions with a floor plan, staffing assignments, alternative housing and a staff member assigned to account for every resident. Request a review from your local fire unit every year (if it declines, write to the state fire marshal) and give a copy of the plan to the local emergency management director. DHSS publishes a Fire Department Consultation form for this ⁠⁷.
• Drills. 12 a year, at least one per shift every three months, four of them unannounced, with a resident evacuation at least once a year, and written records.
• Training. Fire safety training at orientation, at least every six months, and whenever drills expose a gap.

Sprinklers also affect night staffing. In a facility licensed for 20 or fewer residents, the required night attendant may sleep if the building has a sprinkler system or a complete automatic fire detection system ⁠⁴. See the staffing section below.

Zoning

Missouri’s zoning statute requires cities to treat a home where “eight or fewer unrelated mentally or physically handicapped persons reside”, plus up to two houseparents, as a single-family dwelling. The city may still require the exterior to fit general neighborhood standards ⁠¹⁵. Whether a particular group of older residents qualifies under that wording is a local question. Confirm the use with the city or county planning office before you sign a lease, because DHSS licenses the premises named on the application and the license cannot be transferred to another address ⁠³.

Administrator, background checks and training

Administrator/manager. Every RCF must designate an administrator (the rules also call this person the manager). The administrator must either hold a Missouri nursing home administrator license, or be at least 21 years old, never convicted of an offense involving the operation of a long-term care or similar facility, and attend at least one DHSS-given or DHSS-approved continuing education workshop each calendar year. The administrator must also complete the state-approved Level I Medication Aide course unless they are a physician, pharmacist, licensed nurse or certified medication technician, or the RCF operates alongside a skilled nursing or intermediate care facility on the same premises ⁠⁴. The administrator must name, in writing, a staff member in charge during their absence ⁠⁴. A change of administrator must be reported to DHSS within 10 working days ⁠³.

Before anyone touches resident care. Before a new hire has contact with residents, you must request a criminal background check under RSMo 43.540 and check the Employee Disqualification List (EDL) at health.mo.gov/safety/edl. Staff registered with the Family Care Safety Registry can be checked through the registry instead. No one on the EDL may work or volunteer in the facility. People found guilty of specified felonies under Chapters 565, 566 or 569, or of violating 198.070.3 or 568.020, may not have resident contact unless DHSS grants a good cause waiver ⁠⁴. You must screen staff and residents for tuberculosis as 19 CSR 20-20.100 requires for long-term care facilities ⁠⁴.

Orientation. Each employee needs at least one hour of orientation on or before their first day. It must cover job duties, emergency response, infection control, confidentiality, dignity, abuse and neglect reporting to DHSS (1-800-392-0210), the EDL, residents’ rights and working with residents with mental illness. If any resident has Alzheimer’s disease or a related dementia, direct-care staff need three hours of dementia orientation and other staff need one hour ⁠⁴. A facility offering an Alzheimer’s special care unit or program must also file the Alzheimer’s Special Care Services Disclosure (MO 580-2637) with its application ⁠³.

Staffing and the nurse-hours requirement

At least one employee aged 18 or older must be on duty at all times. Staff counted toward the ratio, and anyone giving direct care, must be at least 16 ⁠⁴. The required staff person must be awake, dressed and ready to help in an emergency, with two exceptions ⁠⁴:

• In a facility licensed for 12 or fewer residents, the staff person may sleep during night hours.
• In a facility licensed for 20 or fewer residents, the staff person may sleep if there is a sprinkler system or a complete automatic fire detection system.

Running with a sleeping night attendant has a cost. Such a facility “shall not accept residents who are blind, use assistive devices, such as walkers or wheelchairs, or who need care greater than can be provided with the staffing pattern” ⁠⁴. The rule that no one may be on duty overseeing residents for more than 18 hours a day also does not apply to an RCF licensed for 12 or fewer residents ⁠⁴. That exemption is what makes a live-in operator model workable in Missouri.

Licensed nurse time. The rule requires the facility to “employ a licensed nurse eight (8) hours per week for every thirty (30) residents to monitor each resident’s condition and medication” ⁠⁴. A pharmacist or registered nurse must also review each resident’s medication regimen in the facility at least every three months and send concerns in writing to the physician and administrator ⁠⁴.

Medications and admissions

Anyone giving medications must be at least 18, trained in medication administration, and either a physician, a licensed nurse, a certified medication technician or a Level I medication aide ⁠⁴. Injections are limited to physicians and licensed nurses, with one exception: staff who have completed the state-approved insulin administration course may give insulin. A resident may self-inject insulin with written physician approval and training ⁠⁴. Controlled substances need locked storage, reconciled counts, and a pharmacist or RN review of controlled-substance records at least every three months ⁠⁴.

The rules also set admission requirements ⁠⁴:

• No residents under 16.
• Each resident needs an admission physical by a licensed physician, preferably before admission and on file no later than 10 days after.
• Residents referred by the Department of Mental Health need a DMH individual treatment or habilitation plan on file, updated yearly.
• Residents with mental illness or behavior needs must receive the services in their individual service plan.

Applying to DHSS, in order

1. Settle the level of care and capacity. Your residents’ evacuation ability determines whether you need an RCF or an ALF ⁠⁵. Capacity sets your fee tier, whether you need an architect, and which staffing exceptions you can use ⁠³⁠⁴.

2. Get the CON decision. Ask the CON Program for a CON or a non-applicability determination by letter of intent with the Proposed Expenditure form. If you need a full CON, file the letter at least 30 days before the CON application ⁠⁹⁠¹⁰.

3. Submit plans and get written approval before construction, then build to the approved plans ⁠⁴.

4. Assemble the DHSS application. Use Form MO 580-2631 (DA-150), Application for License to Operate a Long-Term Care Facility, signed by someone with authority to bind the operator ⁠³. The DHSS forms page lists the companion documents ⁠⁷:

   • Assurance of Compliance
   • Principal List
   • affiliate lists by entity type
   • Statement of Financial Condition or Financial Position, and a Forecasted Income Statement
   • Nursing Home Surety Bond or Noncancelable Escrow Agreement, if you will hold residents’ money

   The rule also requires proof of the legal right to the premises (lease or deed), any management contracts, any pledges of facility assets worth more than $500, all affiliates holding 5% or more, Social Security or employer numbers for principals, and disclosures of Medicare or Medicaid exclusions, health-care-related felonies and any Department of Mental Health license ⁠³.

5. File at least 30 days before your planned opening. Email the application to [email protected] or mail it to the Section for Long-Term Care Regulation. Mail the fee separately to Fee Receipts, PO Box 570, 920 Wildwood, Jefferson City, MO 65102. The Licensure Unit’s phone number is (573) 526-8524 ⁠³. DHSS also accepts online payment through its forms page ⁠⁷.

6. Answer DHSS requests within 10 working days. An application still incomplete 60 days after receipt is treated as withdrawn, and you must start over with a new application and fee ⁠³.

7. Licensure inspection. DHSS schedules it only after approving the application. The license is issued once DHSS finds the facility in substantial compliance and the operator financially capable, with fees paid ⁠³.

Fees as published on 2026-10-12

The fee is per level of care. If you add an ALF license on the same premises later, you request it at least 60 days in advance and pay a prorated fee ⁠³. The CON non-applicability letter of intent is a separate filing with the CON Program ⁠⁹. Sprinkler, alarm and plan-preparation costs are not set by the state and vary with the building.

Renewal, inspections and changes of ownership

A Missouri license is issued for up to two years, only for the premises and persons named on it ⁠². File the relicensure application 30 to 90 days before expiration ⁠³. DHSS must inspect each RCF at least once a year ⁠¹¹. It may accept, in whole or part, survey reports from a recognized accrediting body instead, but an accredited RCF that has a class I violation becomes subject to a full state survey ⁠¹⁸.

When an inspection finds deficiencies, the operator has five working days for a class I violation, and ten for class II or III violations, to request a conference and submit a plan of correction. Continued noncompliance leads to a notice of noncompliance that must be posted in the facility ⁠¹². Rules in 19 CSR 30-86 are tagged I, II or III to show their class ⁠⁴.

If the operator changes, including a change in business form, the new operator must apply before the change takes effect. DHSS issues a temporary operating permit while it reviews the application, and the new operator inherits any open deficiencies and plans of correction ⁠³. A partnership or corporation that has a majority ownership change during the license term must apply for a new license within ten working days ⁠²⁠³.

How RCF residents pay: state supplement and MO HealthNet personal care

Many RCF residents rely on two public payment streams:

• State cash supplement. Under RSMo 208.030, the Family Support Division makes monthly payments to eligible residents of licensed RCFs and ALFs whose income does not cover the facility’s charge. For RCFs and ALFs, the payment amount is “subject to appropriation” ⁠¹³. The Family Support Division’s Supplemental Nursing Care manual lists a maximum monthly payment of $156.00 for a residential care facility (formerly RCF I) and $292.00 for a facility that still follows the former RCF II rules, as published on 2026-10-12 ⁠¹⁹. The manual’s entries date from 2000 and 2008, so ask the Family Support Division what a resident would actually receive before you price a bed around it.
• MO HealthNet personal care. A facility that provides Medicaid personal care must hold a participation agreement with the Department of Social Services, Missouri Medicaid Audit & Compliance (MMAC). The enrollment packet includes an RCF/ALF Provider Profile Form, a Business Organizational Structure form, a Type 2 organizational NPI, a copy of the RCF/ALF license from the Section for Long-Term Care Regulation, an RCF/ALF Questionnaire and the Title XIX Participation Agreement ⁠¹⁴. The license comes first; MMAC enrollment follows.

Recent rule changes

• 19 CSR 30-86.042, effective July 30, 2026. DHSS amended the RCF administrative, personnel and resident care rule ⁠¹⁶. The amendment, proposed in the March 2, 2026 Missouri Register, removed the requirement to keep a physician’s written statement that each employee can work in a long-term care facility. It also changed the background-check wording from “convicted of, pled guilty or nolo contendere” to “found guilty”, updated statute citations for the EDL and background checks (RSMo 192.2490 and 192.2495), and dropped the obsolete “RCF I and II” labels from the rule’s purpose statement ⁠¹⁷. Staff with a diagnosed communicable disease still need written physician approval to start or return to work ⁠⁴.
• Assisted living rule. The companion ALF rule, 19 CSR 30-86.047, was amended effective May 30, 2026 ⁠⁴. Read it if you are weighing an ALF license instead.

If you plan to open more than one level of care, or to add day participants, read 19 CSR 30-82.010 and 86.032 together: each level needs its own license and fee, and other businesses in the building need prior written DHSS approval ⁠³⁠⁴.

Sources

1. 1
   Missouri Revisor of Statutes, Section 198.006 RSMo: Definitions (residential care facility, protective oversight, resident) Checked 12 Oct 2026 · Back to text ↑
2. 2
   Missouri Revisor of Statutes, Section 198.015 RSMo: License, when required, duration, change of operator Checked 12 Oct 2026 · Back to text ↑
3. 3
   Missouri Secretary of State, Code of State Regulations, 19 CSR 30-82: General Licensure Requirements (19 CSR 30-82.010) Checked 12 Oct 2026 · Back to text ↑
4. 4
   Missouri Secretary of State, Code of State Regulations, 19 CSR 30-86: Residential Care Facilities and Assisted Living Facilities (86.012, 86.022, 86.032, 86.042, 86.043) Checked 12 Oct 2026 · Back to text ↑
5. 5
   Missouri Department of Health and Senior Services, Level of Licensure for Long-Term Care Facilities Checked 12 Oct 2026 · Back to text ↑
6. 6
   Missouri Department of Health and Senior Services, Licensing and Certification (Section for Long-Term Care Regulation) Checked 12 Oct 2026 · Back to text ↑
7. 7
   Missouri Department of Health and Senior Services, LTC Applications & Forms Checked 12 Oct 2026 · Back to text ↑
8. 8
   Missouri Revisor of Statutes, Section 197.305 RSMo: Certificate of need definitions (expenditure minimum, new institutional health service) Checked 12 Oct 2026 · Back to text ↑
9. 9
   Missouri Secretary of State, Code of State Regulations, 19 CSR 60-50: Certificate of Need Program rules (Letter of Intent process and package) Checked 12 Oct 2026 · Back to text ↑
10. 10
    Missouri Department of Health and Senior Services, Certificate of Need Program Checked 12 Oct 2026 · Back to text ↑
11. 11
    Missouri Revisor of Statutes, Section 198.525 RSMo: Inspection of long-term care facilities Checked 12 Oct 2026 · Back to text ↑
12. 12
    Missouri Revisor of Statutes, Section 198.026 RSMo: Noncompliance, correction, reinspection, probationary license Checked 12 Oct 2026 · Back to text ↑
13. 13
    Missouri Revisor of Statutes, Section 208.030 RSMo: State payments for residents of licensed facilities Checked 12 Oct 2026 · Back to text ↑
14. 14
    Missouri Medicaid Audit & Compliance, Department of Social Services, Residential Care Facility or Assisted Living Facility Enrollment Packet Checked 12 Oct 2026 · Back to text ↑
15. 15
    Missouri Revisor of Statutes, Section 89.020 RSMo: Municipal zoning powers, group homes Checked 12 Oct 2026 · Back to text ↑
16. 16
    Missouri Department of Health and Senior Services, Section for Long-Term Care Regulation, Regulation Update Notice: 19 CSR 30-86.042 Checked 12 Oct 2026 · Back to text ↑
17. 17
    Missouri Secretary of State, Missouri Register, Vol. 51, No. 5 (March 2, 2026), proposed amendment to 19 CSR 30-86.042 Checked 12 Oct 2026 · Back to text ↑
18. 18
    Missouri Revisor of Statutes, Section 198.022 RSMo: Licensure applications, inspections, accreditation reports Checked 12 Oct 2026 · Back to text ↑
19. 19
    Missouri Department of Social Services, Family Support Division, Supplemental Nursing Care Manual, 0615.005.00 Maximum Grants Checked 12 Oct 2026 · Back to text ↑

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