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Each state summary includes the regulatory or statutory citation and category name and includes information on the following, when available:
The information for each state is based on statutes, regulations, and draft regulations. Information based on draft material is presented to indicate the potential direction of state policy. Final rules may vary from the source material. The Medicaid nursing home level-of-care criteria are included for all states to allow comparison with admission/retention criteria and highlight the functional eligibility requirements for home and community based services waivers (several states use the Medicaid state plan to pay for services in residential settings, which has different financial and functional eligibility criteria than waivers).
Assisted Living: Chapter 420-5-4,
Specialty Care Assisted Living
Facilities: Chapter 420-5-20
Sections of the regulations governing building requirements for assisted living facilities and specialty-care facilities were revised in July 2003. Revisions to incident investigations were effective in 2004. The regulations license three categories of facilities:
Specialty-care facilities must receive a separate certification from the Board of Health.
The Department of Health is evaluating whether the regulations adequately address safety related issues, e.g., if residents have recurring problems with falls, should the rules limit admission/retention or should the staffing and training requirements be changed. The Department, Board of Nursing and Legislature are considering proposals to allow unlicensed staff to administer medications either through nurse delegation or creation of medication technician category.
| Supply | ||||||
|---|---|---|---|---|---|---|
| Category | 2004 | 2002 | 2000 | |||
| Facilities | Units | Facilities | Units | Facilities | Units | |
| Assisted living facilities | 241 | 7,260 | 302 | 9,140 | 304 | 8,000 |
| Specialty-care facilities | 94 | 2,616 | 25 | 598 | NA | NA |
Assisted living facility “means an individual, individuals, corporation, partnership, limited partnership, or any other entity that provides or offers to provide residence and personal care to individuals who are in need of assistance with activities of daily living. A facility shall not be deemed to meet the definition of assisted living facility unless a residence and personal care services are provided to two or more individuals not related to the owner or administrator. To be deemed related to the owner or administrator for the purposes of this definition, an individual residing at the facility and receiving personal care must be the parent, sibling, grandparent, great-grandparent, child, grandchild, niece, nephew, aunt, uncle, first cousin, or spouse of the owner or administrator, or must stand in such relationship to the owner’s or administrator’s spouse.
Building requirements vary for congregate assisted living facilities, group assisted living facilities and family assisted living facilities.
“Specialty Care Assisted Living Facility” means a facility that meets the definition of Assisted Living Facility but which is specially licensed and staffed to permit it to care for residents with a degree of cognitive impairment that would ordinarily make them ineligible for admission or continued stay in an assisted living facility.
The regulations do not require separate living and sleeping quarters. Private bedrooms without sitting areas must provide 80 square feet, and double rooms 130 square feet. If sitting areas are included, private rooms must be 160 square feet and double rooms 200 square feet. Bathtubs or showers must be available for every eight beds; lavatories and toilets for every six beds. Lockable doors are permitted. No more than two people may share a room.
Facilities may not admit nor retain a resident who requires medical care, skilled nursing care, is severely cognitively impaired, or requires any care beyond assistance with activities of daily living unless the resident is capable of performing and does perform all tasks related to his or her own care; or is incapable of performing some or all tasks related to his or her own care due to limitations of mobility or dexterity but has sufficient cognitive ability to direct his or her own care and is able to direct others and does direct others to provide the physical assistance needed to complete such tasks, and the facility staff is capable of providing such assistance and does provide such assistance.
The statute allows residents to be served who need medical care, medication administration, or skilled nursing care due to an injury as long as the need does not exceed 90 days and arrangements are made for care from “properly licensed individuals.”
Facilities may not serve individuals with acute infectious pulmonary disease, such as influenza or active tuberculosis, or other communicable diseases, and individuals with infected draining wounds until the wound is sufficiently healed.
A physician must certify the need for continuing stay. Nursing care is required on a daily basis that as a practical matter can only be provided in a nursing facility on an in-patient basis. Residents must need two of the following services on a regular basis:
Assisted living facilities must provide personal care for bathing, oral hygiene, hair and nail care, shaving, laundry services, personal safety and assistance making and keeping appointments. Facilities may provide for general observation and health supervision and may arrange for or assist residents in obtaining medical attention or nursing services when needed. Home health may be provided by a certified agency as long as residents do not require hospital or nursing home care. A written plan of care is required at the time of admission based on the medical examination, diagnoses, and recommendations of the resident’s treating physician. It shall document the personal care and services required from the facility. Plans of care are kept current and reviewed and updated at least annually by the attending physician.
Menus must be planned and posted one week in advance. Alternate food selections must be available for residents on medically prescribed diets, including hypertension, diabetes, hyperlipdemia, and modified consistency diets. A dietician is available for residents who need special diets. Congregate assisted living facilities must be under the direction and supervision of a full- or part-time professionally qualified dietician or a consulting dietician.
Agreements must be signed prior to or at the time of admission and include: basic charges (room, board, laundry, personal care, and services); period covered; services for which there are special charges; refund policy and termination provisions; bed hold policy and process; documentation that the resident and sponsor understand that the facility is not staffed and not authorized to perform skilled nursing services nor to care for residents with severe cognitive impairment and that the resident and sponsor agree that if the resident should need skilled nursing services or care for a severe cognitive impairment as a result of a condition that is expected to last for more than ninety days, that the resident will be discharged by the facility after prior written notice; and a reminder to the resident or sponsor that the local ombudsman may be able to provide assistance if the facility and the resident or family member are unable to resolve a dispute about payment of fees or monies owed.
No facility may serve anyone with Alzheimer’s disease or dementia unless they have a specialty-care facility license. Facilities are allowed to serve residents who do not have dementia if they have readily available egress from the facility. Specialty-care facilities must have a medical director, at least one registered nurse who is responsible for staff training, resident assessment, and plans of care and medication. Minimum ratios of awake staff are specified: two staff for less than 16 residents; one staff for every eight residents for facilities with 16 or more residents from 7 a.m. to 9 p.m.; three staff from 9 p.m. to 7 a.m. for facilities with 17-24 residents; and three staff plus one for every 16 residents for facilities serving 25 or more residents. Activity programs are required. Residents must have a Physical Self Maintenance Scale score of 23 or less and may not have unmanageable behavior problems.
Continuing Education. All staff members of a specialty care assisted living facility shall have at least six hours of continuing education annually. All direct care staff, including the administrator, shall have initial training and refresher training as necessary. An RN shall identify staff refresher training needs and shall provide or arrange for needed training. Prior to providing any resident care, all staff shall complete the DETA (Dementia Education and Training Act) Brain Series Training developed by the Alabama Department of Mental Health and Mental Retardation or equivalent training approved by the State Health Officer. In addition to the training areas for staff in assisted living facilities, special care staff members must receive training on: resident fire and environmental safety; specialty care assisted living facilities Chapter 420-5-20; understanding the aging mind; basic brain function; common neuro-psychiatric disorders in the elderly; basic evaluation of the dementia patient; cognitive symptoms of dementia; psychiatric symptoms of dementia; behavioral problems associated with dementia; end of life issues in dementia; dementia other than Alzheimer’s; research and dementia; nutrition and hydration needs of the resident with dementia to include feeding techniques; safety needs of residents with dementia.
Assistance is limited to reminders, reading container labels to the resident, checking the dosage, and opening containers. Licensed nurses are allowed to administer medications for residents who are not aware of their medications.
Residents who are aware of their medications may self-administer medications. A licensed nurse may administer medication to a resident who is capable of self-administration. Facility staff may assist with the self-administration of medication. Assistance includes reminding, physically assisting by opening or helping to open a container holding oral medications, offering liquids, physically bringing a container of oral medications. Assistance does not include giving injections, administering eye drops, eardrops, nose drops (unless the resident is aware but has dexterity limitations), inhalers, suppositories, or enemas, telling or reminding a resident that it is time to take a PRN, or as needed medication, crushing or splitting medications, placing medications in a feeding tube, or mixing medications with food or liquids.
A Medicaid waiver to cover people with dementia in assisted living was approved in 2003 by CMS but has not been implemented due to budget limitations. The legislature is considering funding in 2004. The program would service SSI recipients and people who qualify under the 300 percent option. The personal needs allowance would be between $65 to $72 per month and room and board would be capped at about $500 a month. The program planned to pay providers $66 per day or $2,046 per month--total monthly reimbursement $2546. If implemented, the waiver would serve 500 people in Year 1, 650 in Year 2, and 700 in Year 3. Families would be allowed to supplement the room and board charges.
An assisted living facility shall employ sufficient staff and ensure sufficient staff are on duty to meet the care needs of all residents 24 hours a day, seven days a week. This means that an assisted living facility must not only have a sufficiently large number of staff members to meet the care needs of all residents, it must also manage and direct the activities of staff members in a manner that results in adequate care being provided. An assisted living facility shall likewise employ sufficient staff, ensure sufficient staff are on duty, and manage and direct staff activities in a manner that results in maintenance of a neat, clean, orderly, and safe environment at all times.
Administrators. Legislation passed in 2001 creates a Board of Examiners for Assisted Living Administrators. Within 18 months of passage, all administrators must be licensed which includes passing an examination and meeting education and training requirements. Existing rules require that administrators have 6 hours of continuing education annually.
Staff. Administrators and direct care staff receive initial and refresher training on state law and rules on assisted living facilities; identifying and reporting abuse, neglect and exploitation; special needs of the elderly, mentally ill, and mentally retarded; basic first aid; advance directives; protecting resident confidentiality; safety and nutritional needs of the elderly; resident fire and environmental safety; and identifying signs and symptoms of dementia.
Not specified. Facilities are required to check the nurse abuse registry before hiring staff.
Facilities are monitored through licensing review and periodic inspections by the Board of Health depending on funding for inspectors. Incidents are reported through a hotline. Written reports may be requested to determine the cause of an incident or if the facility acted appropriately. Facilities are currently inspected every 2 to 3 years. The oversight agency is seeking additional staff to permit annual inspections.
Licensure fees for assisted living facilities and specialty-care assisted living facilities rising to the level of intermediate care are $200, plus $15 per bed.
Assisted living homes: Alaska Statute §47.33.005 et seq.; 7 Alaska
Administrative Code §75.010 et seq.; 7ACC 43:1050 (g)
Medicaid
waivers: Amounts of reimbursement for HCB services General Approach and Recent
Developments
During 2003-2004, Alaska has been developing plans to consolidate state statutes for licensing. The changes are expected to be completed in 2004 and effective by the end of 2005. The Assisted Living Licensing Unit is being transferred from the Division of Senior and Disability Services to the Division of Public Health and should be completed by July 2004.
The State continues to support the expansion of assisted living homes into rural areas. Assistance with planning and technical support is provided wherever possible. One area of concern in some of the assisted homes is the language differences between administrators, staff and residents. Plans to evaluate the scope of this concern and to develop a plan of action are under way. Key informants noted there has been an increase in assisted living homes that have specialized in providing care to specific populations, such as residents with dementia, residents with physical disabilities, behavioral health residents and men-only or women-only homes.
| Supply | ||||||
|---|---|---|---|---|---|---|
| Category | 2004 | 2002 | 2000 | |||
| Facilities | Units | Facilities | Units | Facilities | Units | |
| Assisted living homes | 162 | 1,650 | 143 | 1,497 | 123 | 1,346 |
The law creates “Chapter 33. Assisted Living Homes” to emphasize that assisted living serves as the resident’s home. The statute applies to residential facilities serving three or more adults who are not related to the owner of the residence by blood or marriage; that provide housing and food service; and that provide, obtain, or offer to provide or obtain assistance with activities of daily living, personal assistance (help with IADLs, obtaining supportive services [recreational, leisure, transportation, social, legal, etc.], awareness of the resident’s whereabouts when traveling in the community, and monitoring activities), or a combination of ADL assistance and personal assistance.
The term “adult foster care” is the prior name used for what is now known, and licensed as, assisted living homes. Nothing in the regulations prohibit an assisted living home that is licensed and that serves five or fewer residents from using the term “adult foster home” or “assisted living foster home” in connection with that facility.
Single occupancy units must provide 80 square feet and double occupancy units, 140 square feet. No more than two residents may share a room. A facility must meet life safety code requirements applicable for buildings of its size. Homes for six or more people must meet applicable state and municipal standards for sanitation and environmental protection. Because of the size of the State and the geographic variation within it, the licensing standards are based on community and neighborhood standards rather than a statewide standard. This allows homes to be licensed that are consistent with prevailing local housing standards.
Residents who have exceeded the 45 consecutive day limit for receiving 24-hour skilled nursing (see below) may continue to live at the home if the home and the resident or resident’s representative have consulted with the resident’s physician and discussed the consequences and risks. In addition, a revised plan without 24-hour nursing must have been reviewed by a registered nurse. Terminally ill residents may continue to reside in the residence if a physician certifies that the person’s needs are being met.
Evacuation requirements are included in life safety code standards and facility procedures for emergency evacuation drills.
Since the regulations governing admission/retention are broad, waivers of the requirements are not needed. The rules do allow variances of any provision of the chapter that will promote aging in place and meet the goals of the rules.
Alaska implemented a new assessment tool, Consumer Assessment Tool (CAT), in May 2004 for the Medicaid waiver program. Individuals meet the level of care criteria if they:
Each resident must have an assisted living plan (developed within 30 days of move-in and approved by the resident or their representative) that identifies strengths and weaknesses performing ADLs, physical disabilities and impairments, preferences for roommates, living environment, food, recreation, religious affiliation and other factors. The plan also identifies the ADLs with which the resident needs help, how help will be provided by the home or other agencies, and health-related services and how they will be addressed. Health-related services include assistance with self-administration of medication, intermittent nursing services, 24-hour skilled nursing for 45 days, and hospice services.
The plan must promote the resident’s participation in the community and increased independence through training and support, in order to provide the resident with an environment suited to the resident’s needs and best interests.
Negotiated risk is addressed during the care planning process. The plan must recognize the responsibility and right of the resident or the resident’s representative to evaluate and choose, after discussion with all relevant parties, including the home, the risks associated with each option when making decisions pertaining to the resident’s abilities, preferences, and service needs; and recognize the right of the home to evaluate and to either consent or refuse to accept the resident’s choice of risks.
The plan must also identify the resident’s reasonable wants and how those will be addressed. If health related services are provided or arranged, the evaluation must be done quarterly. If no health related services are provided, an annual evaluation is required. Assisted living homes may provide intermittent nursing services to residents who do not require 24-hour care and supervision. Intermittent nursing tasks may be delegated to unlicensed staff for tasks designated by the board of nursing. Twenty-four hour skilled care may be provided for not more than 45 consecutive days.
Hospice services may be provided. Homes are required to have copies of living wills or advance directives for residents who have them.
An assisted living home shall offer three balanced, nutritious meals and at least one snack daily at consistent times. A home shall ensure that the meals and snacks offered include the recommended number of servings of each food type set out in the U.S. Department of Agriculture publication, The Food Guide Pyramid, as revised October 1996 and adopted by reference. The home shall offer a wide variety of food that includes fresh fruits and vegetables as often as possible. Additionally, the home shall consider each resident’s health-related or religious restrictions, cultural or ethnic preferences in food preparation, and preference for smaller portions, as reflected in the resident’s residential services contract.
A residential services contract must be signed prior to move-in that describes the services and accommodations; rates charged; rights; duties and obligations of the resident; policies and procedures for termination of the contract; amount and purpose of advance payments; and refund policy.
A person may not begin residency in an assisted living home unless a representative of the home and either the person or the person’s representative sign a residential services contract that complies with the provisions of this section. Upon signing of the contract, the home shall give the resident and the resident’s representative, if any, a copy of the contract and place a copy of the contract in the resident’s file.
The rules do not include specific provisions.
Aides (home staff persons) may provide medication reminders, read labels, open containers, observe a resident while taking medication, check self-administered dosage against the label, reassure the resident that the dosage is correct, and direct/guide the hand of a resident at the resident’s request. The authority for registered nurses to delegate tasks is contained in the nurse delegation statute and rules.
A broad HCBS waiver covers services in assisted living homes for elders and adults with disabilities. The room-and-board payment is negotiated between the home and the resident. In a limited number of cases, room and board and some services are covered by the State’s “general relief” program. The payment standard for SSI recipients is $907 and the personal needs allowance is $100 a month. Family supplementation is allowed for room and board. A new payment standard is being created for assisted living homes ($654, including a $100 personal needs allowance). Funds previously used to support a higher payment standard will be used to increase the basic Medicaid rate $8 a day.
| Medicaid Participation | |||||
|---|---|---|---|---|---|
| 2004 | 2002 | 2000 | |||
| Facilities | Participation | Facilities | Participation | Facilities | Participation |
| 174 | 632 | 126 | 492 | 108 | 363 |
Services for Medicaid waiver certified individuals in assisted living homes are funded under the State’s Choice Program, a Medicaid HCBS waiver. Rates vary by area of the State. A multiplier that ranges from 1.0 to 1.38 is applied to the rates, resulting in higher payments in rural and frontier areas (i.e., $100 service in one region may be reimbursed at $138 in another region). Providers receive a basic service rate that varies for adult foster care, adult residential I, and adult residential II. An “augmented service rate cost factor” is available for clients whose needs warrant the hiring or designating of additional staff. The “augment care” payment recognizes the added staffing needed by homes caring for residents needing incontinent care, skin care, added supervision, and help with medication. Some residents also attend adult day care (ADC). The basic service rate is lower for residents attending day care at least 3 days a week.
Contracted homes have the option of receiving payment according the tiers or cost based reimbursement. About half the contracted homes have applied for cost based reimbursement. The average cost based rate is $130 a day but is as high as $234.
| Assisted Living Reimbursement Rates, July 1, 2004 | ||||
|---|---|---|---|---|
| Anchorage Area | ADC Basic Rate |
Basic Service Rate |
Augmented Factor |
Basic and Augmented |
| Adult foster care | $32.93 | $44.52 | $17.37 | $70.54 |
| Adult residential I | $44.52 | $56.10 | $17.37 | $82.13 |
| Adult residential II | $56.10 | $67.68 | $17.37 | $93.70 |
Administrators must be 21 years of age or older and have sufficient experience, training, or education to fulfill the responsibilities of an administrator. Administrators in homes with 10 or fewer units must fulfill at least one of the following requirements: complete an approved management or administrator training course and 1 year of documented experience relevant to population to be served, or complete a certified nurse aide training program and have at least 1 year of documented experience relevant to the population to be served, or 2 years of documented care experience relevant to the population to be served.
Staff. Homes must have the type and number of staff needed to operate the home and must develop a staffing plan that is appropriate to provide services required by resident care plans. Staff must pass a criminal background check.
Regulations require that administrators receive 18 hours of training annually, direct care staff, 12 hours annually. Staff providing direct care without supervision must have sufficient language skills to meet the needs of residents. Staff must receive orientation that covers emergency procedures, fire safety, resident rights, universal precautions, resident interaction, house rules, medication management and security, physical plant layout, and reporting responsibilities.
No person may be employed who has been convicted of crimes listed in the regulations. Administrators and staff must provide a sworn statement regarding conviction of listed crimes, the results of a name check criminal background check initially and every 2 years, and a national criminal history check based on fingerprints and conducted by the Alaska Department of Public Safety initially and every 6 years.
Both the Department of Health and Social Services and the Division of Senior and Disabilities Services are responsible for screening applicants, issuing licenses, and investigating complaints. The departments may delegate responsibility for investigating and making recommendations for licensing to a state, municipal, or private agency. Homes must submit an annual self-monitoring report on forms provided by the Department of Health and Social Services. Case managers monitor Choice waiver participants monthly.
Regulations require an annual monitoring visit or self-monitoring report filed by the facility. The licensing agency may impose a range of sanctions: revoking or suspending the license, denying renewal, issuing a probationary license, restricting the type of care provided, banning or imposing conditions on admissions, or imposing a civil fine.
The State describes its oversight and monitoring process as consultative. The State acts as a licensing body first, but also sees itself as educators and teachers. If violations are found through the inspection and monitoring process, the State will hand out notices of violation, but will provide education regarding how to improve care, or address the violation.
Currently, the State has limited staff resources to provide as much education and training, as they would like. When a pattern of violations is identified, a more industry-wide, versus a one-on-one, training approach is implemented. The State still holds planned orientations for new or potentially new assisted living homes every 3 months, but training can be extended out to 6 months if there is not staff available to conduct formal orientation training.
Licensing staff currently monitor homes as well as provide consultation through education and teaching. After the consolidation of Assisted Living Licensing with Public Health this process may change at some point in the future. They envision possibly rearranging, or reassigning existing staff to perform separate functions.
Voluntary license: $25 per resident. License for 3-5 residents--$75, 6 or more residents--$150, plus $25 per resident over three residents.
Assisted living facilities. Comprehensive administrative rules and regulations §R9-10-701 et seq.
The licensing rules, established in 1998, set requirements based on the size of the facility along with supplemental requirements depending on the level of service provided. The core requirements address facilities serving 10 or fewer residents, 11 or more residents, and adult foster homes which serve one to four residents. Facilities are licensed to provide one of three levels of care (supervisory care services, personal care services, and directed care services) and must meet supplemental requirements.
The directed care level serves people with Alzheimer’s disease or dementia who cannot self-direct their care, e.g., cannot recognize danger, summon assistance, express need, or make basic decisions. Requirements for specialized training, activities, physical plant, and services will be established.
The regulations will be revised in 2004. A small task force including state agencies and stakeholders will be convened to discuss changes. The areas likely to be discussed include oversight of the approval of training programs; address the skills and background of staff who complete the assessment; oversight and documentation of medications; content of the resident’s record; designation of representatives for people receiving directed care services. Legislation expanding the Department of Health Services’ enforcement authority for overseeing training programs is pending. HB 2024 would allow the Department to grant, deny, suspend or revoke the approval of training programs and to impose civil penalties for violations of the training requirements.
| Supply | ||||||
|---|---|---|---|---|---|---|
| Category | 2004 | 2002 | 2000 | |||
| Facilities | Units | Facilities | Units | Facilities | Units | |
| Assisted living home: < 10 | 1,509 | 24,500 | 1,077 | 8,616 | 1,241 | 22,848 |
| Assisted living centers: 11+ | 196 | 14,384 | ||||
| Adult foster care: 1-4 | 251 | 1,041 | ||||
The Arizona Health Care Cost Containment System (AHCCCS), which administers the State’s Medicaid managed care program, contains higher standards (e.g., private living units) for larger facilities serving Medicaid beneficiaries. The agency is undertaking a study of policy and practice related to serving people with dementia.
Assisted living facility means a residential care institution, including adult foster care, that provides or contracts to provide supervisory care services, personal care services, or directed care services on a continuing basis.
Supervisory care services mean general supervision, including daily awareness of resident functioning and continuing needs, the ability to intervene in a crisis, and assistance in the self-administration of prescribed medications.
Personal care services mean assistance with activities of daily living that can be performed by persons without professional skills or professional training and include the coordination or provision of intermittent nursing services and the administration of medication and treatments by a nurse who is licensed pursuant to Title 32, Chapter 15, or as otherwise provided by law.
Directed care services mean programs and services, including personal care services, provided to persons who are incapable of recognizing danger, summoning assistance, expressing need, or making basic care decisions.
Assisted living homes serve 10 or fewer residents and assisted living centers serve 11 or more residents. The Arizona Long Term Care Systems (ALTCS) Program contracts with adult foster care (four or fewer in which the provider lives in the home), assisted living homes (10 or fewer, owner is not a resident), and assisted living centers, but only centers that offer residential units (apartments).
Assisted living centers (11+ residents) may provide residential units or bedrooms. Residential units must have at least 220 square feet of floor space (excluding bathroom and closet) for one person, with an additional 100 square feet for a second person. Units must have a keyed entry, bathroom, resident controlled thermostat, and a kitchen area with sink, refrigerator, cooking appliance that may be removed or disconnected, and space for food preparation.
Assisted living centers and homes providing bedrooms must have 80 square feet in single rooms and 60 square feet per resident in double rooms. No more than two residents may share a room. Rooms occupied by residents receiving personal care services or directed care services must have a bell, intercom, or other mechanical means to contact staff. At least one toilet, sink, and shower is required for every eight residents.
Assisted living facilities (ALFs) providing supervisory care services may serve residents who need health or health related services if these services are provided by a licensed home health or hospice agency.
ALFs with a personal care service license may not accept or retain any resident who is unable to direct self-care; requires continuous nursing services unless the nursing services are provided by a licensed hospice agency or a private duty nurse; residents with a Stage III or IV pressure sore, or someone who is bed bound due to a short illness unless the primary care physician approves, the resident signs a statement, and the resident is under the care of a nurse, a licensed home health agency, or a licensed hospice agency.
ALFs licensed to provide directed care services may admit residents who are bedbound, need continuous nursing services, or have a Stage III or IV pressure sore if the requirements for facilities providing personal care services are met.
A copy of the resident agreement, resident rights, and consumer resources must be provided to residents upon move-in.
Since each facility is licensed to provide a specific level of care, waivers for admission/retention requirements are available.
Assessment information in three categories is scored: functional, emotional and cognitive, and medical. Functional areas include ADLs (bathing, dressing, grooming, eating, mobility, transferring, and toileting), communication and sensory skills, and continence. Emotional and cognitive information is obtained on orientation and behavior (wandering, self-injurious behavior, aggression, suicidal behavior, and disruptive behavior). Medical information is collected on conditions and their impact on ADLs, conditions requiring medical or nursing services and treatment, medication, special services and treatments needed, and physical measurements, history, and ventilator dependency.
Each score is weighted and totaled. The weighted functional score (ADLs and cognition) can range from 0-15 on each item, and the maximum total is 141. Applicants are grouped into two medical groups based on their conditions. Applicants in either medical group with a total score of 60 or over and those in groups 1 and 2, whose total scores are less than 60 but exceed a specified numerical threshold in each component, are eligible.
Residents must receive an assessment and a service plan within 14 days of acceptance. Plans must be reviewed every 12 months for residents receiving supervisory care services, every six months for residents receiving personal care services, and every three months for residents receiving directed care services. Services must meet scheduled and unscheduled needs. Facilities must provide general supervision; promote resident independence; autonomy; dignity; choice; self-determination; and the resident’s highest physical, cognitive, and functional capacity; help utilize community resources; encourage residents to preserve outside supports; and offer individual attention and social interaction and activities.
Facilities providing personal care services also provide skin maintenance, sufficient fluids to maintain hydration, incontinence care, and an assessment by a primary care provider for residents needing medication administration or nursing services.
Facilities providing directed care must provide cognitive stimulation and activities to maximize functioning; encouragement to eat meals and snacks; and an assessment by a primary care provider.
Hospice care may be provided by a licensed hospice agency.
An interdisciplinary team (manager, staff, RN [if nursing services are provided], resident and/or representative, and case manager, if applicable) conducts an assessment within 12 days of enrollment and every 90 days, or as needed, thereafter. A plan of care is developed with the resident or their representative that identifies the services needed, the person responsible for providing the service, the method and frequency of services, the measurable resident goals, and the person responsible for assisting the resident in an emergency.
Facilities must provide three meals a day and one snack to meet nutritional needs based on resident health and age. Menus must be based on the Food Guide Pyramid, USDA Center for Nutrition Policy and Promotion, Home and Garden Bulletin Number 252. If therapeutic diets are offered, a manual must be available for use by employees. Diets must be consistent with physicians’ orders or as prescribed by law. Provisions for the storing and preparation of food are included. Nutrition, hydration, food preparation, service, and storage are part of the orientation and training requirements.
Resident agreements that include the following must be signed upon move-in: terms of occupancy; services to be provided; amount and purpose of fees, charges, and deposit (including fees/charges for days the resident is absent); services available for additional charges; refund policy; responsibility to provide 30 days notice of any fee changes; policy and procedures for termination of residency; and the grievance procedure.
The rules contain specific provisions for facilities serving people with dementia. A minimum of four hours of training in dementia care must be provided to staff each year. Direct supervision must be available and facilities must provide cognitive stimulation and activities to maximize functioning. Facilities must have egress controls and access to secure outside areas for residents who wander. Staff ratios must be not more than six residents per staff during morning and evening hours and 12:1 at night.
Facilities must have policies and procedures governing the procurement, administration, storing, and disposal of medications. Untrained aides may supervise self-administration by opening bottle caps, reading labels, checking the dosage, and observing the resident taking the medication. Medications which cannot be self-administered must be administered by an RN or “as otherwise permitted.” The phrase as otherwise permitted was included to accommodate any future statutory changes in the state’s nurse practice act. Medication organizers can be prepared a month in advance by an RN or family member. Rules governing assistance with medications are contained in the licensing rules.
Services in assisted living facilities are covered through the Arizona Long Term Care Systems program which operates under a §1115 waiver. The program serves 32,076 elders, people with disabilities, MR/DD, and mentally ill beneficiaries. Program administrators originally used rates set for adult foster care, nursing facilities, the Oregon assisted living program, and the Arizona HCBS program as guidelines in setting the rates. Three classes of rates are negotiated based on the level of care: low, intermediate, and high skilled. The rates include room and board which is paid by the resident. The monthly room-and-board amount is the resident’s “alternative share of cost” (spend down) or 85 percent of the current SSI payment, whichever is greater. For residents who receive SSI, the payment rate is $564.00 a month of which $497.10 is paid to the residence to cover room-and-board charges and $66.90 is retained by the resident as a personal needs allowance. Rates are presented in the table below. The weighted average reflects participation among the program contractors by level.
Family members may supplement the resident’s income in order to allow the resident to have a one-bedroom rather than an efficiency unit.
| Medicaid Participation | |||||
|---|---|---|---|---|---|
| 2004 | 2002 | 2000 | |||
| Facilities | Participation | Facilities | Participation | Facilities | Participation |
| NA | 3,076 | NA | 2,300 | 670 | 1,249 |
| Arizona Rates by Program Contractor (Daily) | |||||||||
|---|---|---|---|---|---|---|---|---|---|
| Level I | Level II | Level III | |||||||
| AFC | AL Homes |
AL Centers |
AFC | AL Homes |
AL Centers |
AFC | AL Homes |
AL Centers |
|
| Program A | $49.45 | $43.09 | $55.44 | $49.45 | $50.13 | $70.83 | $49.45 | $58.36 | $84.85 |
| Program B | $41.65 | $47.60 | $57.00 | $42.75 | $49.10 | $62.95 | $51.95 | $49.10 | $80.61 |
| Program C | $42.99 | $42.59 | $54.05 | $49.30 | $49.30 | $69.00 | $57.95 | NA | $84.00 |
| Program D | $51.63 | $53.51 | $59.26 | $59.11 | $60.82 | $65.18 | $80.40 | $82.72 | $87.10 |
| Program E | $41.72 | $49.14 | $58.12 | $48.86 | $62.32 | $66.29 | NA | $76.03 | $83.18 |
| Program F | $34.67 | $43.27 | $48.46 | $41.86 | $49.75 | $55.90 | $48.21 | $54.52 | $67.62 |
| Program G | $44.00 | $56.53 | $56.20 | NA | $60.47 | $67.81 | NA | $87.27 | $83.99 |
Facilities are required to ensure that sufficient staff are available to provide: services consistent with the level of care for which the facility is licensed; services established in a care plan; services to meet resident needs for scheduled and unscheduled needs; general supervision and intervention in a crisis 24-hours a day; food services; environmental services; safe evacuations; and ongoing social and recreational services.
Managers must be 21 years old, certified, and have a minimum of 12 months of health-related experience.
Staff must complete an orientation that includes the characteristics and needs of residents; the facility’s philosophy and goals; promotion of resident dignity, independence, self-determination, privacy, choice and resident rights; the significance and location of service plans and how to read and implement a service plan; facility rules, policies, and procedures; confidentiality of resident records; infection control; food preparation, service, and storage if applicable; abuse, neglect, and exploitation; accident, incident, and injury reporting; and fire, safety, and emergency procedures.
Managers and staff must complete twelve hours of ongoing training annually covering the promotion of resident dignity; independence; self-determination; privacy; choice; resident rights; fire, safety, and emergency procedures; infection control; and abuse, neglect, and exploitation. Staff in facilities licensed to provide directed care services must also receive a minimum of four hours of training in providing services to residents.
In addition to the above topics, training may include providing services to residents; nutrition, hydration, and sanitation; behavioral health or gerontology; social, recreational, or rehabilitative services; personnel management, if applicable; common medical conditions, medication procedures, medical terminology, and personal hygiene; service plan development, implementation, or review; and other needs identified by the facility.
Staff must also maintain current CPR certification and complete 6 hours of continuing education annually pursuant to §36-448.11(D). Nurses aides in good standing are deemed to meet the initial training requirements.
Certificate of training. Staff must obtain a certificate of training. Facilities may develop their own training and certificate program with approval from the department. Department approved training programs have requirements for instructors and the method of instruction. The competency-based approach sets standards for supervisory care services, personal care services, directed care services, and manager training.
Supervisory care services: 20 hours or the amount of time needed to verify a person demonstrates skills and knowledge in assisted living principles; communication; managing personal stress; preventing abuse, neglect, and exploitation; controlling the spread of disease and infection; documentation and record keeping; implementing service plans; nutrition, hydration, and food services; assisting with self-administration of medications; providing social, recreational, and rehabilitative activities; and fire, safety, and emergency procedures.
Personal care services: 30 hours (50 total) or the amount of time needed to verify a person demonstrates skills and knowledge in additional skills areas such as the aging process, common medical conditions associated with aging or physical disabilities, and medications; assisting with ADLs; and taking vital signs.
Directed care services: 12 hours (62 total) or the amount of time needed to verify a person demonstrates skills and knowledge of Alzheimer’s disease and related dementia; communicating with residents who are unable to direct care; providing services including problem solving, maximizing functioning, and life skills training for those unable to direct care; managing difficult behaviors; and developing and providing social, recreational, and rehabilitative activities for such persons. Four hours per year of ongoing training is required.
Managers and staff must comply with fingerprint requirements under A.R.S. 36-411.
The licensing agency conducts annual renewal inspections. Licenses may be renewed for 2 years for facilities that are free of deficiencies. Penalties for violations include civil money penalties, provisional licensing, and restricted admissions. Fines against unlicensed facilities have been increased.
Facilities are monitored by ALTCS program contractors and the Department of Health Services. Sites are recertified annually by the Department of Health Services. During the pilot phase of the waiver, program contractors monitored resident care on a quarterly basis, provided technical assistance, and conducted meetings of providers to obtain feedback on the program. With statewide expansion, participants are visited at least quarterly by their ALTCS case manager. Annual operating and financial reviews of ALTCS contractors (HMOs) are conducted annually by AHCCCS. The reviews also include case management and provider records and claims data. AHCCCS also reviews a random sample of residents, including assisted living residents, to evaluate the appropriateness and quality of care. The review found no unmet needs or quality of care problems.
There is a $50 application fee. Facilities with 1-59 beds pay an additional fee of $100 plus $10 per bed; 60-99 beds: $200 plus $10 per bed; 100-149: $300 plus $10 per bed; 150+: $500 plus $10 per bed.
Assisted living facilities; Arkansas Annotated Code
§§20-10-1701
Residential long-term care facilities; Arkansas
Annotated Code §§20-76-201 (b)(3), 20-10-203, and 20-10-224
Regulations establishing two levels of assisted living facilities were finalized in 2002 and updated in 2003 and requires that any newly-constructed Level II facility shall have to be in accordance with the requirements for I-2 Groups as specified in the International Building Code (IBC) 2000, with exceptions as listed. This regulation formally required “I-1 Groups” compliance.
Assisted living facilities in both levels provide services in a homelike setting for elderly and disabled persons. The philosophical tenets of individuality, privacy, dignity and independence, the promotion of resident self-direction and personal decision-making while protecting resident health and safety are emphasized.
While there have been no facilities who have requested special care units, the State is exploring the possibility of adopting the nursing home special care unit requirements for all assisted living facilities, particularly as it relates to staffing. Currently, the assisted living facility regulations require separate staff for special care units. In nursing facilities, special care units require sufficient staff across the entire facility to meet resident needs. The State Assisted Living Association is pushing to eliminate the residential care home regulations, and create one set of rules for assisted living facilities. There is no identified time frame for accomplishing this.
Additionally, residential care facilities would like to see changes in the assisted living regulations in the areas of programming and staffing. The State is exploring this request. There has been no timetable set to address this.
| Supply | ||||||
|---|---|---|---|---|---|---|
| Category | 2004 | 2002 | 2000 | |||
| Facilities | Units | Facilities | Units | Facilities | Units | |
| Assisted living level 1 | 1 | 54 | NA | NA | NA | NA |
| Assisted living level 2 | 5 | 221 | NA | NA | NA | NA |
| Residential care | 111 | 4,369 | 122 | 4,647 | 152 | 5,438 |
The Living Choices Assisted Living 1915 (c) Waiver Program was implemented in January 2003. Legislation revising Alzheimer’s special care standards passed (HB 1407) in 2001. Personal care services are covered under the state plan for Medicaid beneficiaries.
Residential long-term care facility (RCF) means a building or structure which is used or maintained to provide, for pay on a 24-hour basis, a place of residence and board for three or more individuals whose functional capabilities may have been impaired, but who do not require hospital or nursing home care on a daily basis but could require other assistance with activities of daily living.
An assisted living facility (ALF) is any building or buildings, section, or distinct part of a building, boarding home, home for the aged, or other residential facility whether operated for profit or not that undertakes through its ownership or management to provide assisted living services for a period exceeding 24 hours to more than three adult residents of the facility who are not relatives of the owner or administrator. ALF means facilities in which assisted living services are provided either directly or through contractual arrangements or in which contracting in the name of residents is facilitated. An ALF provides, at a minimum, services to assist residents in performing all activities of daily living on a 24-hour basis.
An Alzheimer’s special care unit (ASCU) is a separate and distinct unit within an assisted living or other long term care facility that segregates and provides a special program for residents with a diagnosis of probable Alzheimer’s disease or related dementia, and that advertises, markets, or otherwise promotes the facility as providing specialized Alzheimer’s or related dementia care services.
Residential long term care facility. A minimum of 100 square feet is required for single rooms and 80 square feet per resident in shared rooms. Rooms may be shared by two residents. A minimum of one toilet/lavatory is required for every six residents and one tub/shower for every 10 residents.
Assisted living facility. All units must be apartments of adequate size and configuration to permit residents to carry out, with or without assistance, all the functions necessary for independent living, including sleeping; sitting; dressing; personal hygiene; storing, preparing, serving, and eating food; storing clothing and other personal possessions; doing personal correspondence and paperwork; and entertaining visitors. Each apartment or unit shall be accessible to and useable by residents who use a wheelchair or other mobility aid consistent with the accessibility standards. Each apartment must have a lockable door. Separate bathroom and kitchen areas are required. Single occupancy apartments must be at least 150 square feet excluding entryway, bathroom and closets, and 230 square feet for two persons. Apartments may not be occupied by more than two persons. Each unit must provide for a small refrigerator as well as a microwave oven, except as may be otherwise provided in the regulations, and a call system monitored 24-hours a day by staff.
Residential long term care facility. Tenants must be 18 or older; independently mobile (physically and mentally capable of vacating the facility within 3 minutes); able to self-administer medications; be capable of understanding and responding to reminders and guidance from staff; do not have a feeding or intravenous tube; are not totally incontinent of bowel and bladder; do not have a communicable disease that poses a threat to the health or safety of others; do not need nursing services which exceed those that can be provided by a certified home health agency on a temporary or infrequent basis; do not have a level of mental illness, retardation, or dementia or addiction to drugs or alcohol that requires a higher level of medical, nursing, or psychiatric care or active treatment than can safely be provided in the facility; does not require religious, cultural, or dietary regimens that cannot be met without undue burden; and do not require physical restraints or have current violent behavior.
Waivers of the admission/retention policy are not available. Residents who require frequent skilled nursing services from a home health agency must be assessed by the Office of Long Term Care to determine if a nursing home placement is needed.
Level 1 assisted living facilities cannot serve nursing home eligible residents or residents who need 24-hour nursing services except as certified by a licensed home health agency for a period of 60 days with one 30-day extension; are bedridden; have transfer assistance needs that the facility cannot meet, including assistance to evacuate the building in case of an emergency; present a danger to self or others; and require medication administration performed by the facility.
Level II facilities are allowed to serve nursing home eligible residents but cannot serve residents who need 24-hour nursing services; are bedridden; have a temporary (more than 14 consecutive days) or terminal condition unless a physician or advance practice nurse certifies the resident’s needs may be safely met by a service agreement developed by the assisted living facility, the attending physician or advance practice nurse, a registered nurse, the resident or his or her responsible party if the resident is incapable of making decisions, and other appropriate health care professionals as determined by the resident’s needs; have transfer assistance needs, including but not limited to assistance to evacuate the facility in case of emergency, that the facility cannot meet with current staffing; present a danger to self or others or engage in criminal activities.
To be determined a functionally disabled individual, the individual must meet at least one of the following three criteria as determined by a licensed medical professional:
Residential long-term care facility. Facilities may provide personal care; supportive services (occasional or intermittent guidance, direction, or monitoring for ADLs); activities and socialization; assistance securing professional services; meals; housekeeping; and laundry. Residents have a choice of providers for receiving personal care services, and they may use an agency that is not the facility. RCFs may not provide medical or nursing services. Home health services may be provided by a certified home health agency when ordered by a physician.
Assisted living facilities. Level 1 facilities provide 24-hour staff supervision by awake staff; assistance in obtaining emergency care 24 hours a day (this provision may be met with an agreement with an ambulance service or hospital or emergency services through 911); assistance with social, recreational, and other activities; assistance with transportation (this does not include the provision of transportation); linen service; three meals a day; and medication assistance. Other services include attendant care, homemaker, and medication oversight. Level 1 facilities may provide occasional guidance, direction or monitoring, or assistance with ADLs and social activities and transportation.
Level II facilities offer services that directly help a resident with certain routines and activities of daily living such as assistance with mobility and transfers; hands-on assistance to resident with feeding, grooming, shaving, trimming or shaping fingernails and toenails, bathing, dressing, personal hygiene, bladder and bowel requirements, including incontinence; and assistance with medication only to the extent permitted by the state Nurse Practice Act. The assessment for residents with health needs must be completed by an RN.
Health services are available that assist in achieving and maintaining well-being (e.g., psychological, social, physical, and spiritual) and functional status. This may include nursing assessments and the monitoring and delegation of nursing tasks by registered nurses pursuant to the Nurse Practice Act, care management, records management, and the coordination of basic health care and social services in such settings.
The regulations provide for negotiation of a compliance agreement to deal with risk of an adverse outcome. In the agreement, the facility identifies the specific concern(s); provide clear, understandable information about the possible consequences of his or her choice or action; negotiates a compliance agreement with the resident or his or her responsible party that will minimize the possible risk and adverse consequences while still respecting the resident’s preferences.
The compliance agreement must address any situation or condition that is or should be known to the facility that involves risk; the probable consequences; the resident or his or her responsible party’s preference concerning how the situation will be handled and the possible consequences of action on that preference; what the facility will and will not do to meet the resident’s needs and comply with the resident’s preference to the identified course of action; alternatives offered to deal with the risk; and the agreed-upon course of action.
Residential long-term care facility. Facilities must provide three balanced meals a day and make snacks available, served at about the same time each day, not more than 5 hours apart between breakfast and lunch and between lunch and the evening meal, and no more than 14 hours between breakfast and the evening meal. Facilities must notify the physician if a resident does not eat meals for more than 2 consecutive days. State, county, and local health departments may have rules that deal with sanitation, safety, and health. Recommended daily allowances are established in the regulations. In large facilities (> 17), staff involved in food and dietary services cannot perform other duties on the same shift.
Assisted living facilities. Three balanced meals, snacks, and fluids are required.
Residential long-term care facility. Residents must receive a copy of the resident agreement at or prior to moving in that covers: services, materials and equipment, and food to be included in the basic charge; additional services and charges to be provided; residency rules; conditions and rules for termination; provisions for changing the charges; and refund policy.
Assisted living facilities. Covers core services (24-hour staff supervision by awake staff; assistance obtaining emergency care; assistance with social, recreational, and other activities; assistance with transportation; linen service; three meals a day; medication assistance); additional services; health care services available through home health agencies; parameters for pets; current statement of all fees and daily, weekly, or monthly charges; 30-day notice of changes in charges; identification of the party responsible for payment; refund policy; procedures for nonpayment; policy on acceptance of responsibility for personal funds and valuables; responsibility for medication; a copy of facility rules; provisions for emergency transfers; and conditions of termination of the occupancy agreement.
Residential long term care facility. The admission and retention rules limit a facility’s ability to serve anyone with dementia.
Assisted living facilities. Facilities must provide a disclosure statement that includes: the philosophy of how care and services are provided to the residents; the pre-admission screening process; the admission, discharge and transfer criteria and procedures; training topics, amount of training time spent on each topic, and the name and qualification of the individuals used to train the direct care staff; the minimum number of direct care staff assigned to the ASCU each shift; and a copy of the Residents’ Rights.
The licensing rules include program requirements that provide 24-hour care; promote social, physical, and mental well-being and protect resident rights. Nursing, direct care, and personal care staff cannot perform the duties of cooks, housekeepers, or laundry staff during their direct care shifts. An individual support plan must be prepared. Standards for the physical design of the unit are described. Policies are required for egress control and standards for locking devices are specified. Staff must have 30 hours of training on policies (1 hour); etiology, philosophy, and treatment of dementia (3 hours); stages of Alzheimer’s disease (2 hours); behavior management (4 hours); use of physical restraints, wandering, and egress control (2 hours); medication management (2 hours); communication skills (4 hours); prevention of staff burn out (2 hours); activities (4 hours); ADLs and individual centered care (3 hours); and assessment and Individual Service Plans (3 hours). Staff must receive 2 hours of ongoing training each quarter. A disclosure statement must be provided that includes the treatment philosophy; pre-admission screening process; admission, discharge, and transfer policies; assessment, care planning, and implementation; training topics and time required; minimum number of direct care staff; residents rights; assessment; individual support plan and implementation; activities; and the stages for which care is provided.
Residential long-term care facility. Residents must be familiar with their medications and the instructions for taking them. Aides may remind residents to take medications, read label instructions, and remove the cap or packaging, but the resident must remove the medication from the package or container. The State does not have provisions for nurse delegation.
Assisted living facilities. Staff of Level I facilities may assist with self-administration of, but cannot administer, medications. Staff of Level II facilities may administer medications. A pharmacy consultant is required.
The State implemented the Living Choices Assisted Living HCBS Waiver Program in January 2003. A Living Choices Assisted Living Waiver “assisted living services” provider must be licensed as a Level II Assisted Living Facility or a licensed Class A Home Health Agency who has a contract with a licensed Level II Assisted Living Facility to provide waiver “assisted living services” and provide pharmacy consultant services.
The assisted living waiver program serves clients who are age 65 and over, or who are 21 years of age or over and blind or disabled. A Division of Medical Services, Office of Long Term Care registered nurse determines level of care eligibility. A Division of Aging & Adult Services assisted living waiver registered nurse completes the comprehensive assessment and establishes the tier of need, and completes the service plan upon admission to the program, and annually or at times of significant change.
Services provided under the waiver include attendant care (assistance with ADLs); therapeutic social and recreational activities; medication oversight to the extent permitted by law; medication administration; periodic nursing evaluations; limited nursing services; and non-medical transportation as specified in the plan of care.
Personal care services are reimbursed as a state plan service under Medicaid based on a plan of care. Residential Care facilities are reimbursed on a fee-for-service basis. A maximum of 64 hours of care per month at $12.35 an hour (maximum payment of $790.40) may be covered without prior authorization. Services may exceed the cap if approved. Approximately 1,155 residents living in residential long-term care facilities receive personal care services under the Medicaid state plan. The State uses a presumptive eligibility process to expedite determinations.
| Medicaid Participation | ||||||
|---|---|---|---|---|---|---|
| Source | 2004 | 2002 | 2000 | |||
| Facilities | Participation | Facilities | Participation | Facilities | Participation | |
| State plan | NA | 1,155** | NA | 1,178** | NA | 1,143** |
| Waiver | 5 | 50 | NA | NA | NA | NA |
**Unduplicated number of residents in residential long-term care facilities.**Unduplicated number of residents in residential long-term care facilities.
Medicaid reimbursement under the Living Choices waiver is determined through the comprehensive assessment and a four-tier method of need (see table below). The daily rate pays for all direct services in the participant’s plan of care. Pharmacy consultant services are a daily rate. The waiver will pay for 3 prescription drugs beyond the Medicaid State Plan Prescription Drug Program’s monthly benefit limit. Persons receiving assisted living waiver services may not receive Medicaid State Plan Personal Care. Reimbursement is for services only and may not pay for room and board.
Based on the level of assistance, scores are assigned for ADLs (eating [2], toileting [2], ambulation [2], bathing [2], transfer [1], and body care [1]); medication assistance; sensory ability; and psycho-social/cognitive ability. Points are awarded for ADLs for people who need substantial supervision, physical assistance, or total assistance. Points for medication assistance vary with the type of assistance multiplied by the number of medications (see table).
Residential long-term care facility. Ratios for the number of direct care staff varies by the time of day (daytime, evening, and night) and the number of residents. Staffing must be sufficient to meet the needs of residents.
Assisted living facilities. Administrators must be certified as an ALF, RCF, or Nursing Home administrator. Staffing sufficient to meet the needs of residents is required according to staff ratios that vary by facility size and shift.
Level 2 facilities must designate a full-time (40 hour per week) administrator who must be on the premises during normal business hours. Sharing of administrators between assisted living facilities and other types of long-term care facilities is permitted. The facility may employ an individual to act both as administrator and as the facility’s registered nurse. At no time may the duties of administrator take precedence over, interfere with, or diminish the responsibilities and duties associated with the registered nurse position. Level 2 facilities must employ or contract with at least one RN. The assisted living Level 2 RN is responsible for the preparation, coordination, and implementation of the direct care services plan portion of the resident’s occupancy admission agreement. The Living Choices waiver plan of care developed by the Division of Aging & Adult Services assisted living waiver RN is to be filed in the resident’s occupancy admission agreement with the assisted living facility’s direct services plan of care. The assisted living facility RN, in conjunction with the physician, shall be responsible for the preparation, coordination, and implementation of the health care services plan portion of the resident’s occupancy admission agreement and shall review and oversee all LPN, CNA, and PCA staff. Level II facilities must employ a consulting pharmacist. The assisted living facility RN need not be physically present at the facility, but must be available to the facility by phone or pager.
Residential long-term care facility administrators must have a current certification as a residential care facility administrator or complete a course of instruction and training prescribed by the department.
Residential long-term care facility staff. An orientation covering, at a minimum, job duties, resident rights, abuse/neglect reporting requirements, and fire and tornado drills is required. For direct care staff, four hours of in-service training or continuing education must be provided on a quarterly basis covering residents’ rights, evacuation of a building, safe operation of fire extinguishers, incident reporting, and medication supervision.
Assisted living facilities. Staff must receive orientation on the following topics: philosophy of independent living in an assisted living residence; residents’ rights; abuse, neglect, and exploitation; safety and emergency procedures; communicable diseases; communication skills; review of the aging process; dementia/cognitive impairment; resident health and related problems; job requirements; medication supervision/management, and incident reporting. A minimum of 6 hours of ongoing training a year is required.
Written policies and procedures for monitoring quality of care are required. Remedies for violations include Civil Money Penalties, denial of admissions, directed in-service training, directed plan of correction, state monitoring, temporary administrator, temporary license, and transfer of residents.
Assisted Living Facilities: The State provides more education than consultation in their oversight and monitoring processes. This process has been very successful. With newly licensed facilities, the State will conduct mock surveys to educate the facility about the process and expectations. This has become more of a teaching/learning model regarding the interpretation of the regulations.
Education is provided on an industry-wide level versus facility-based consultation. The education is typically provided through the assisted living association. Survey nurses do not provide consultation and training. There are separate staff to perform each individual function.
Residential long-term care and assisted living administrators may not have any prior conviction pursuant to Arkansas Code Annotated §20-10-401 or relating to the operation of a long term care facility nor any conviction for abusing, neglecting, or mistreating individuals. Administrators must also successfully complete a criminal background check pursuant to Arkansas Code Ann. §20-33-201, et seq.
Criminal background checks are required for all employees. Checks include the Adult Abuse Registry.
| Assisted Living Waiver Program Tiers and Daily Rates | ||
|---|---|---|
| Tier 1 | 0-5 total ADL points and 0-39 total other points | $39.51/day |
| Tier 2 | 0-5 total ADL points and 4-60 total other points or 6-10 total ADL points and 0-39 total other points | $42.83/day |
| Tier 3 | 0-5 total ADL points and 61 or more total other points or 6-10 total ADL points and 40-69 total other points | $47.47/day |
| Tier 4 | 6-10 total ADL points and 70 or more total other points | $49.97/day |
NOTE: The Living Choices Waiver has a built-in annual rate increase of 2.9% for Year 2 based on the FY 04 market basket forecast and 3.0% for Year 3 based on the FY 05 market basket forecast. The rates shown in the above chart are the rates for Year 2.
| Tier Calculation Point Scale | |
|---|---|
| Task | Points |
| Eating | 2 points |
| Toileting | 2 points |
| Ambulation | 2 points |
| Bathing | 2 points |
| Transfer | 1 point |
| Body care | 1 point |
| Medication reminding/monitoring | 0.5 times number of medications |
| Needs RX assistance | 0.75 times number of medications |
| Dosage prep | 1 times number of medications |
| Needs administration | 2 times number of medications |
| Speech not understandable, unable to speak, unable to communicate | 10 points |
| Sight: Legally blind with corrective lenses/blind | 10 points |
| Hearing: Must be loud even with aides; unable to hear | 10 points |
| Disorientation | 12 points |
| Memory impairment | 16 points |
| Impaired judgment | 17 points |
| Wandering | 15 points |
| Disruptive behavior | 20 points |
Residential care facilities for the elderly (RCFEs) Title 22, Division 6, Chapter 87100-87730
A series of changes are being implemented following passage of several bills by the legislature. The changes replace the exceptions requirements for facilities serving people with health conditions with requirements for documentation, staff training and oversight, add requirements for special care facilities, and admissions agreements. Due to budget reductions, the licensing agency is unable to continue its technical support program that provided consultation to facilities. Staffing shortages have also changed the schedule for inspection visits. Instead of inspecting each facility annually, a sample of facilities will be visited each year.
The Department of Health Services (DHS) was directed by the legislature to develop a pilot program to test two models for covering assisted living services under a Medicaid HCBS waiver. One model will cover services in licensed residential care facilities for the elderly and the second will deliver services in elderly housing settings.
The Community Care Licensing Division plans to revise and post technical guides on their Web site. The Web site includes a manual that interprets regulations and gives guidance to facilities about how to apply the rules.
| Supply | ||||||
|---|---|---|---|---|---|---|
| Category | 2004 | 2002 | 2000 | |||
| Facilities | Units | Facilities | Units | Facilities | Units | |
| Residential care facilities for the elderly | 6,543 | 154,830 | 6,207 | 147,580 | 6,152 | 136,719 |
A residential care facility for the elderly is defined as a housing arrangement chosen voluntarily by the resident--or the resident’s guardian, conservator, or other responsible person--where 75 percent of the residents are 60 years of age or older, or, if younger, have needs compatible with other residents, and where varying levels of care and supervision are provided, as agreed to at time of admission or as determined necessary at subsequent times of reappraisal.
Occupancy is limited to two residents per bedroom, which must be large enough to accommodate easy passage between beds, required furniture, and assistant devices such as wheelchairs or walkers. One toilet and sink is required for every six residents and a bathtub or shower for every 10 residents.
Facilities may admit or retain residents who are capable of administering their own medications; receive medical care and treatment outside the facility or from a visiting nurse; residents who need to be reminded to take medications; and people with mild dementia or mild temporary emotional disturbance resulting from personal loss or change in living arrangement. Facilities may not admit or retain anyone with a communicable disease; anyone who requires 24-hour skilled nursing or intermediate care. The regulations allow residents with health conditions requiring incidental medical services which are specified in the rules (e.g., administration of oxygen, catheter care, colostomy/ileostomy care, contractures, diabetes, enemas, suppositories, and/or fecal impaction removal, incontinence of bowel and/or bladder, injections, intermittent positive pressure breathing machine, and Stage 1 and 2 dermal ulcers) to be admitted and retained if the resident can perform the care or a licensed professional provides care. Facilities may not serve people who require care for Stage 3 and 4 dermal ulcers, gastrostomy care, naso-gastric tubes, tracheostomies, staph infection or other serious infection, and/or who depend on others to perform all activities of daily living.
Residents who will be bedridden more than 14 days may be retained if the facility notifies the Department of Social Services that the condition is temporary.
Beneficiaries must have a medical condition that requires an out-of-home protective living arrangement with 24-hour supervision and skilled nursing care or observation on an ongoing intermittent basis to abate health deterioration.
Services are divided into (1) basic services and (2) care and supervision. Basic services include safe and healthful living accommodations; personal assistance and care; observation and supervision; planned activities; food service; and arrangements for obtaining incidental medical and dental care. Care and supervision covers assistance with activities of daily living and assumption of varying degrees of responsibility for the safety and well being of residents. Tasks include assistance with dressing, grooming, bathing, and other personal hygiene; assistance with self-administered medications; and central storing and distribution of medications.
Legislation enacted a few years ago requires that RCFEs inform residents that they have the right to have an advance directive. A brochure explaining advance directives was developed for care providers to give residents.
Legislation enacted in 1994 allows hospice care provided the resident contracts individually with a hospice agency. Facilities must request a waiver to allow hospice care and be able to meet the resident’s needs when the hospice agency is not present. If the resident shares a room, the other party needs to agree to allow hospice care in the shared living space.
The total daily diet must meet the recommended dietary allowances of the Food and Nutrition Board of the National Research Council. At least three meals and snacks must be provided in facilities that have responsibility for all food arrangements. Meals must include an appropriate variety of foods, planned in consideration of cultural and religious backgrounds and resident preferences. Modified diets prescribed by physicians are provided. Facilities with 16 to 49 residents must designate one person with appropriate training to be responsible for food planning, service, and preparation. Staff must have training or related experience on the assigned job tasks.
Admission agreements must be signed within 7 days of admission and include provisions for: the basic services available; optional services; payment provisions (basic rate, optional service rate, payer, due date, funding source); process for changing the requirements and a 60-day notice; and refunds.
Legislation passed in 2003 (SB 211, Chapter 211, Statutes of 2003), adds Health and Safety (H&S) Code Sections 1569.880 through 1569.888 to ensure that RCFE admission agreements do not violate residents’ rights and to provide residents with the information necessary to make informed choices. Many requirements overlap existing statutes or regulations in Title 22 California Code of Regulations (CCR) chapter 6. The applicability of some requirements will depend on the type of services provided by the facility. The law specifies that the admission agreement includes the following: a comprehensive description of any items and services provided under a single fee; a comprehensive description of, and the fee schedule for, all items and services not included in a single fee; the resident shall receive a monthly statement itemizing all separate charges incurred by the resident and authorized by the admission agreement; a statement acknowledging the acceptance or refusal to purchase the additional services shall be signed and dated by the resident or the resident’s representative and attached to the admission agreement; an explanation of the use of third-party services within the facility that are related to the resident’s service plan, including, but not limited to, ancillary, health, and medical services, how they may be arranged, accessed, and monitored, any restrictions on third-party services, and who is financially responsible for the third-party services; a comprehensive description of billing and payment policies and procedures; the conditions under which rates may be increased; the facility’s policy concerning family visits and other communication with residents; refund policy; conditions under which the agreement may be terminated; and an explanation of the resident’s right to notice prior to an involuntary transfer, discharge, or eviction, the process by which the resident may appeal the decision and a description of the relocation assistance offered by the facility.
During 1995, legislation (Chapter 550 of the Acts of 1995) was passed that allows RCFEs that serve people with dementia to develop secure perimeters. Based on the results of a pilot project, the law allows facilities that meet specific additional requirements to secure exterior doors or perimeter fences, or to install delayed egress devices on exterior doors and perimeter fence gates. Resident supervision devices--wrist bracelets that activate a visual or auditory alarm when a resident leaves the facility--may also be used. Facilities must provide interior and exterior space for residents to wander freely, must receive approval from the local fire marshal, and must conduct quarterly fire drills. Facilities with delayed egress devices must be sprinklered and contain smoke detectors, and the delayed egress devices must deactivate when the sprinkler system or smoke detectors activate. The devices must also be able to be deactivated from a central location and deactivate when a force of 15 pounds is applied for more than two seconds to the panic bar. In addition, facilities shall permit residents to leave, who continue to indicate such a desire, and staff must ensure continued safety. Reports must be submitted when residents wander away from the facility without staff. Delayed egress devices may not substitute for staff.
Facilities may admit and retain people with dementia who are not able to respond to verbal instructions to leave a building without assistance provided they have:
Facility staff may assist with self-administration of medications and, if authorized by law, administer injections. Medications may also be administered by licensed home health agency personnel.
The California legislature (HB 499, 2000) directed the Department of Health Services to develop an Assisted Living Waiver Pilot Project (ALWPP) in three counties: Sacramento, San Joaquin and Los Angeles, and will serve 1,000 people over 3 years in two different settings--licensed RCFEs and conventional elderly housing sites. About 100 sites are expected to participate in the pilot. An HCBS waiver will be submitted to CMS to implement the pilot. The pilot defines assisted living based on the work of the Assisted Living Work group:
“Assisted living is a state regulated and monitored residential long-term care option. Assisted living provides or coordinates oversight and services to meet the residents’ individualized scheduled needs, based on the residents’ assessments and service plans and their unscheduled needs as they arise.”
The pilot will require private occupancy, with shared occupancy only by residents’ choice. Units will have a kitchen area equipped with a refrigerator, a cooking appliance (microwave is acceptable), and storage space for utensils and supplies.
The project developed a four-tiered payment methodology based on the tiers used in Arkansas. The bundled rate will include payment for the following services: 24-hour awake staff to provide oversight and meet the scheduled and unscheduled needs; provision and oversight personnel and supportive services (assistance with activities of daily living and instrumental activities of daily living); health related services (e.g., medication management services); social services; recreational activities; meals; housekeeping and laundry; and transportation
As of January 1, 2004 the SSI/State Supplement in licensed facilities is $853 a month with a personal needs allowance of $111. The remainder of $742 pays for Room and Board.
Administrators of facilities with 16 to 49 beds must have 15 college credits and in facilities with 50 or more units, 2 years of college or 3 years of experience or equivalent education and experience. Administrators who do not have a license must complete a certification program and 12 hours of classroom training.
Sufficient staff must be employed to deliver services required by residents. On-the-job training or experience is required in the principles of nutrition, food storage and preparation, housekeeping, and sanitation standards; skill and knowledge to provide necessary care and supervision; assistance with medications; knowledge to recognize early signs of illness; and knowledge of community resources.
Requirements for awake staff vary by the size of the facility. For 16 or fewer, staff must be available in the facility; 16 to 100, at least one awake staff; 101 to 200, one on call and one awake, with an additional awake staff for each additional 100 residents.
Administrators. Individuals shall complete an approved certification program prior to being employed as an administrator. The program must include 40 hours of classroom training which covers laws, rights, regulations, and policies (12 hours); business operations (3 hours); management and supervision (3 hours); psycho-social needs of the elderly (5 hours); physical needs of the elderly (5 hours); community and support services (2 hours); use, misuse, and interaction of drugs (5 hours); and admission, retention, and assessment procedures (5 hours). All administrators shall be required to complete at least 20 clock hours of continuing education per year in areas related to aging and/or administration.
Staff. Personnel must be given on-the-job training or have related experience in: the principles of good nutrition, good food preparation and storage and menu planning; housekeeping and sanitation procedures; skill and knowledge required to provide necessary resident care and supervision including the ability to communicate with residents; knowledge required to safely assist with prescribed medications which are self-administered; knowledge necessary in order to recognize early signs of illness and the need for professional help; and knowledge of community services and resources.
Facilities licensed for 16 or more must have a planned on-the-job training program in the above areas including orientation, skill training, and continuing education.
The licensing agency conducts a criminal background check of officers of the organization, staff responsible for administration and direct supervision, persons providing direct care, and employees having frequent contact with residents and others and may approve or deny a license or employment based on its findings. A fingerprint clearance shall be received by the licensing agency on all persons subject to criminal record review prior to issuing a license. All facility staff must be fingerprint cleared prior to their physical presence in the facility.
Facilities are inspected on a rotating basis. Facilities are inspected on a random sample basis, but at least once every 5 years. Facilities that require “targeted visits” will be visited on an annual basis. These consist of facilities that need closer attention because of their compliance histories. Three levels of penalties are allowed for violations with an (A) immediate, (B) potential, and (C) technical impact. Fifty dollars per day civil penalties are allowed for A and B violations increasing to $100 per day if the same violation is repeated three times in a 12-month period. Consultation is provided for Type C violations. The licensing agency is mandated to conduct an investigation within 10 days on any complaint received against a facility.
Licensing fees required at initial licensure and annually thereafter are adjusted by facility size: 1 to 6--$375, 7 to 15--$563, 16 to 49--$750, and 50+--$938 (effective August 4, 2003). A proposal to increase the licensing fees due to declines in state revenues is pending.
Assisted living residences; Chapter VII, §1.1 et seq.
Revisions to rules based on legislation that passed in 2002 were approved by the Board of Public Health in March 2004. HB 02-1323 changed the licensing category to assisted living residences and added intermediate sanctions. Supply has remained fairly stable with new construction replacing smaller independently-owned homes. The Department anticipates that once the regulations are approved, work might begin on some issues that are not addressed in the pending regulations such as administrator requirements and staffing.
The Department of Public Health web site has links to interpretive guidelines, the survey protocol, and a consumer comparison checklist that covers provider agreements, license/certification, Medicaid participation, space, safety, care plans, personal services, staff, meals, socialization, communication, and facility tour/observations. It also posts the 10 most commonly cited deficiencies for each quarter.
| Supply | ||||||
|---|---|---|---|---|---|---|
| Category | 2004 | 2002 | 2000 | |||
| Facilities | Units | Facilities | Units | Facilities | Units | |
| Assisted living residences | 525 | 13,779 | 538 | 14,291 | 551 | 13,868 |
The new law defines “assisted living residence” or “residence” as a residential facility that makes available to three or more adults not related to the owner of such facility, either directly or indirectly through a resident agreement with the resident, room and board and at least the following services: personal services; protective oversight; social care due to impaired capacity to live independently; and regular supervision that shall be available on a 24-hour basis, but not to the extent that regular 24-hour medical or nursing care is required. The term “assisted living residence” does not include any facility licensed in this State as a residential care facility for individuals with developmental disabilities, or any individual residential support services that are excluded from licensure requirements pursuant to rules adopted by the department.
The rules allow no more than two people to share a room for facilities built after July 1, 1986. Single occupancy rooms must have at least 100 square feet and double occupancy rooms at least 60 square feet per person. One full bathroom is required for every six residents. Cooking is not allowed in bedrooms, and facilities provide access to a food preparation area for heating or reheating food or making hot beverages subject to “house rules.” Cooking may be allowed in facilities that provide apartments rather than bedrooms. Facilities that are Medicaid certified are prohibited from cooking. However, microwaves can be used if the facility has assessed the resident for his or her ability to safely use the appliance.
Assisted living residences may not admit or retain residents who are:
A facility may keep a resident who becomes bedridden if a physician describes the services needed to meet the health needs of the residents, there is an ongoing assessment and monitoring by a licensed home health agency or hospice service that ensures that the resident’s physical, mental and psychological needs are met, and there is adequate staff trained in the needs of bedridden residents.
Additional criteria are applied to facilities contracting with Medicaid as alternative care facilities (ACFs). ACFs may not admit or retain anyone needing more than intermittent skilled services; who has an acute illness that cannot be managed through medications or therapy; is unable or unwilling to meet his or her own personal hygiene needs under supervision; has ambulation limitations, unless compensated by assistive devices or staff; is consistently disoriented to the extent that he or she poses a danger to themselves or others; requires tray food service on a continuous basis; or is consistently unwilling to take prescribed medication.
Each facility develops admission criteria based on the capacity of the facility. A review of Medicaid pre-admission screening assessment forms showed that Medicaid waiver participants in ACFs had fewer skilled needs than nursing home residents.
Residents may be allowed to receive hospice care if they are long-term residents (i.e., the facility has been their home), the facility can continue to meet the needs of the other residents, and staff are trained and are not doing things outside their scope of practice. Residents requiring hospice care upon admission would not be accepted.
Medical eligibility is determined by local Utilization Review Contractors according to guidelines based on a functional needs assessment of the following areas: confusion or contact with reality; behavior; communication; mobility; bathing; dressing; eating/feeding; bowel continence; bladder continence; skin care; vision; hearing; need for supervision and observation; and living skills (i.e., cooking, shopping, laundry, etc.). Residents must need skilled or maintenance services at least 5 days a week. Skilled and maintenance services are performed in the following areas: skin care; medication; nutrition; activities of daily living; therapies; elimination; and observation and monitoring. (Note: The determinations were formerly made by the statewide Peer Review Organization.)
The scores in each of the functional areas are based on a set of criteria and weights developed by the PRO and approved by the State which measures the degree of impairment in each of the functional areas. When the combined score in each of the functional areas exceeds 19 points, the nurse reviewer may certify that the person being reviewed is eligible for placement in a nursing facility. If the score is less than 20 points, the PRO physician advisor may use professional judgment to determine the individual’s need for the level of services provided in a nursing facility.
Facilities must provide a physically safe and sanitary environment, room and board, personal services (transportation, assistance with activities of daily living and instrumental activities of daily living, individualized social supervision), social and recreational services, protective oversight, and social care. Written care plans, which must be reviewed at least annually, are required for each resident and include a comprehensive assessment of physical, health, behavioral and social needs and capacity for self-care, a list of current prescribed medications (dosage, time and route of administration, whether self-administered or assisted), dietary restrictions, allergies, and any physical or mental limitations or activity restrictions. Nursing and therapies may be received if provided by a home health agency.
Three nutritionally balanced meals using a variety of foods from the basic food groups and snacks of nourishing quality are required. Therapeutic diets prescribed by a physician are provided, and the recipes are available for review. Meals cannot be routinely provided in resident rooms unless indicated on the care plan. Staff must receive on-the-job training or have experience in the tasks assigned to them.
A copy of the resident agreement must be provided upon move-in. The agreement must include: charges, refunds and deposit policies; services included in the rates and charges, including optional services for which there will be an additional, specified charge; types of services provided by the facility, those services which are not provided, and those which the facility will assist the resident in obtaining; bed hold fees; transportation services; therapeutic diets; and whether the facility will be responsible for providing bed and linens, furnishing and supplies. There must also be written evidence that the facility has disclosed the policies and procedures (admissions; discharges; emergency plan and fire escape procedures; illness, injury or death; resident rights; smoking; management of residents’ funds; internal grievance process; investigation of abuse and neglect allegations; and restrictive egress devices); method of determining staffing levels and the extent to which certified or licensed health professionals are available on-site; whether the facility has an automatic sprinkler system; if the facility uses restrictive egress alert devices and the types of behavior exhibited by persons needing such devices.
Facilities must disclose that they operate a secure environment, information about the type of diagnosis or behaviors served and for which staff are trained. Facilities serving people whose right to move outside the environment is limited must have a secured environment. For a facility to serve a resident in a secured environment, legal authority must be established by guardianship, court order, health care proxy, or durable power of attorney. Assessments that evaluate (by a qualified professional) the need for a secured environment must be completed. Reassessments must be completed within ten days of a significant change to determine whether placement is appropriate. Staff and the owner/operator must have appropriate training. Facilities with secured environments must establish a forum that meets at least quarterly for family members to make suggestions, and express concerns and grievances. Families meet with the administrator and a staff representative. Suggestions must be responded to in writing.
In addition to the interior common areas required by this regulation, the facility shall provide a safe and secure outdoor area for the use of residents year round. Fencing or other encloses may be installed around secure areas. Residents must be able to access the secure areas in facilities establishing a secured environment after June 1, 2004.
Most larger facilities have hired LPNs to administer or manage medications and ensure that physicians’ orders have been received and recorded. Staff who have completed a medication training course given by a licensed nurse, physician, physician’s assistant, or pharmacist and who have passed a competency test may assist with and administer medications (except injections).
Services in alternative care facilities have been covered since 1984 under a 1915(c) waiver for elders, people with disabilities, MR/DD, and people with mental illness. Medicaid rules limit room-and-board charges for Medicaid recipients to $518 a month. The Medicaid rate for services is $36.03 a day. The rate covers oversight, personal care, homemaker, chore, and laundry services. A pilot program tested the impact of an enhanced rate to create incentives to retain people as their needs increased and to accept residents with greater needs from nursing homes and hospitals. An additional $400 per month was available for residents who have enhanced needs in three of four areas: personal care, mobility, incontinence, and behavior/confusion. There is continuing interest in developing a tiered rate methodology.
The SSI payment is $564 and the PNA is $46 a month.
| Monthly Rates 2004 | |
|---|---|
| Room and board | $518.00 |
| Service | $1,094.31 |
| Total | $1,612.31 |
| Medicaid Participation | |||||
|---|---|---|---|---|---|
| 2004 | 2002 | 2000 | |||
| Facilities | Participation | Facilities | Participation | Facilities | Participation |
| 273 | 3,804 | 266 | 3,773 | 243 | 2,654 |
Family members are allowed to supplement resident income for items that are not covered in the Medicaid rate. Most supplementation allows residents to move from a semiprivate to private unit. Medicaid allows residents up to 42 days “leave” per year for nonmedical purposes. Facilities receive the Medicaid payment during this period.
Facilities must employ sufficient staff to ensure provision of services necessary to meet resident needs including services provided under the care plan and services provided under the resident agreement. Facilities contracting with Medicaid must maintain a 1:10 staff ratio during the day and a 1:15 ratio from 7 p.m. to 6 a.m., unless a lower ratio that does not jeopardize the health and safety of residents can be documented. Facilities that are Medicaid certified and provide a secure environment must have a 1:6 ratio and awake staff at all times.
Administrators must meet the minimum education, training, and experience requirements by successfully completing a program approved by the department. Acceptable programs may be conducted by an accredited college; university or vocational school; or a program, seminar, or in-service training program sponsored by an organization, association, corporation, group, or agency with specific expertise in that area. The curriculum includes at least 30 actual clock hours of which at least 15 consist of a discussion of each of the following topics: resident rights; environment and fire safety, including emergency procedures and first aid; assessment skills; identifying and dealing with difficult behaviors; and nutrition.
The remaining 15 hours shall provide emphasis on meeting the personal, social, and emotional care needs of the resident population served.
Administrators of facilities contracting with Medicaid must complete training on rules and regulations for ACFs.
Staff. All staff, including volunteers, must be given on-the-job training or have related experience in the job assigned to them and shall be supervised until they have completed on-the-job training appropriate to their duties and responsibilities or have had previous related experience evaluated. Training and orientation in emergency procedures shall be provided to each new staff member, including volunteers, within three days of employment.
Staff members not serving as an operator of the facility who have direct responsibility for the provision of personal care, i.e. hygiene, of residents or for the supervision or training of residents in the residents’ own personal care, shall provide documentation of either successful completion of course work in the provision of personal care or previous and related job experience in providing personal care to residents.
Before providing direct care, staff must receive training specific to the needs of the population served, resident rights, environment and fire safety, first aid and injury response, the care and services of current residents, and the facility’s medication administration program.
The facility shall provide adequate training and supervision for staff comprising a discussion of each of the following topics: resident rights, environment and fire safety, including emergency procedures and first aid; assessment skills; and identifying and dealing with difficult situations and behaviors.
ACF staff must be trained in the needs of the population served.
The owner or licensee may have access to and shall obtain any criminal history record information from a criminal agency for all persons responsible for the care and welfare of residents. Owners and administrators must undergo a finger print check. Owners are responsible for obtaining a criminal background check of administrators to determine whether they have been convicted of a felony and misdemeanor that could pose a risk to the health, safety and welfare of residents.
The regulations require that facilities provide the ombudsman program with access to the facility and residents at reasonable times. New remedies were incorporated in HB 02-1323 and include requiring written plans to correct violations found as a result of inspections; retaining a consultant to address corrective measures; monitoring by the department for a specific period; providing additional training to employees, owners, or operators of the residence; complying with a directed written plan to correct the violation; or paying a civil fine not to exceed $2,000 in a calendar year.
Civil fines are used for expenses related to continuing monitoring; education to avoid restrictions or conditions or to facilitate the application process or the change of ownership process; education for residents and their families about resolving problems with a residence, rights of residents, and responsibilities of residences; providing technical assistance to any residence for the purpose of complying with changes in rules or state or federal law; relocating residents to other facilities or residences; maintaining the operation of a residence pending correction of violations; closing a residence; or reimbursing residents for personal funds lost.
HB 02-1323 sets fee of $150, plus $23 per bed. Fees for facilities with a high percentage of Medicaid beneficiaries pay $15 per bed. Fees for new construction are $5,000. Facilities pay a fee of $2,500 to reissue a license due to a change in ownership. Facilities with secure environments are assessed a fee of $1,500.
The new rules establish fees for reviewing construction plans: new construction or remodeling of 2,000 square feet or less, $500; and $.25 per additional square foot over 2,000. Remodeling limited to installation or renovation of fire suppression systems: 3-16 beds, $500; 17-40 beds, $750; 41-60 beds, $1,000; and 61 or more beds, $1,250. Fees cannot exceed $2,000.
Assisted living services agency; Connecticut General Statutes
§19a-490
Connecticut Department of Public Health, Public Health Code
§19-13-D105
Residential care homes (homes for the aged, rest homes)
§19-13-D-6
Assisted living regulations issued by the Health Department were last revised in June 2001. The regulations take a unique approach by allowing “managed residential communities” (MRCs) to offer assisted living services through assisted living services agencies (ALSAs). MRCs may obtain a license to also serve as an ALSA. Rules governing medication administration in residential care homes were revised in March 2002. Medicaid waiver and state funds are being used to cover services provided by Assisted Living Service Agencies.
The State is currently focusing on level of care concerns in managed residential communities providing assisted living services. Since the regulations went into effect, residents have aged in place, and the State wants to ensure that residents are receiving the right amount of services. The State encourages aging in place, but as the regulatory body, needs to ensure that services are available to meet resident needs.
| Supply | ||||||||
|---|---|---|---|---|---|---|---|---|
| Category | 2004 | 2002 | 2000 | 1998 | ||||
| Facilities | Units | Facilities | Units | Facilities | Units | Facilities | Units | |
| Assisted living services agencies | 65 | NA | 63 | NA | 48 | NA | 22 | NA |
| Managed residential communities | 104 | NA | NR | NR | NR | NR | NR | NR |
| Residential care homes | 101 | 2,753 | 109 | 2,949 | 113 | NR | 113 | NR |
The ALSA regulations focus on the licensing of agencies to provide services rather than the licensing of building and services as an entity. MRCs have to notify the health department of their intention to provide assisted living services and present specified information and assurances to the department. The ALSA, either the MRC or another agency, must be licensed by the Department of Public Health to provide services. The MRC is not licensed by the Department of Public Health. MRCs must show evidence of compliance with local zoning ordinances and building codes.
A pilot program to build 300 units to serve low-income residents has been implemented jointly by the Department of Social Services, Department of Economic Development, Department of Public Health, Office of Policy and Management and the Connecticut Housing Finance Authority.
An assisted living services agency means an institution that provides, among other things, nursing services and assistance with activities of daily living to a population whose conditions are chronic and stable.
Assisted living services means nursing services and assistance with ADLs provided to clients living within a managed group-living environment having supportive services that encourage clients primarily age 55 or older to maintain a maximum level of independence. Routine household services may be provided as assisted living services or by the managed residential community. These services provide an option for elderly persons who require some help or aid with ADLs and/or nursing services.
A managed residential community means a facility consisting of private residential units that provides a managed group living environment, including housing and services primarily for persons age 55 or older.
Residential care home means an institution having facilities and all necessary personnel to furnish food, shelter and laundry for two or more persons unrelated to the proprietor and in addition, providing services of a personal nature which do not require the training or skills of a licensed nurse. Additional services of a personal nature may include assistance with bathing, help with dressing, preparation of special diets and supervision over medications which are self-administered.
Managed residential communities. To qualify as a managed residential community and a setting in which assisted living services may be provided, units are defined as a living environment belonging to a tenant(s) that includes a full bathroom within the unit including water closet, lavatory, tub or shower bathing unit, and access to facilities and equipment for the preparation and storage of food. Managed residential communities may not require tenants to share units. Sharing of a unit shall be permitted solely upon the request and mutual consent of tenants.
Residential care homes. Single rooms must have a minimum of 150 square feet, excluding closets, toilet rooms, lockers or wardrobes and vestibule. Multiple bed rooms must have a minimum of 125 square feet per bed. A resident unit shall be 25 beds. No resident room shall be designed to permit more than two (2) beds. Baths must have one separate shower or bathtub for every eight residents. There must be one separate shower and one separate bathtub per resident unit. One toilet may serve two resident rooms, but no more than four residents.
Assisted Living Service Agencies. Each ALSA agency will develop its own admission and discharge criteria but the regulations do not allow the ALSAs to impose unreasonable restrictions and screen out people whose needs may be met by the ALSA. Assisted living services may be provided to residents with chronic and stable health, mental health, and cognitive conditions as determined by a physician or health care practitioner.
Discharge policies must include categories for the discharge of clients, which include but are not limited to change in resident’s condition; routine discharge; emergency discharge; financial discharge; and premature discharge.
The State requires that residents have uncontrolled and/or unstable and/or chronic conditions requiring continuous skilled nursing services and/or nursing supervision or have chronic conditions requiring substantial assistance with personal care on a daily basis.
Assisted Living Service Agencies. Core services provided by managed residential communities include three meals a day; laundry; scheduled transportation; housekeeping; maintenance services including chore services for routine domestic tasks that the tenant is unable to perform; and social and recreational services. In addition, 24-hour a day security and emergency call systems in each unit are required. Communities must have a service coordinator who assists tenants and acts as a liaison with the ALSA. Service coordinators ensure that all core services are provided to or are made available to residents, assist residents in making arrangements to meet their personal needs, establish collaborative relations with provider agencies, support services and community resources, establish a resident council, and ensure that a resident information system is in place.
The managed residential community, through its service coordinator or any other representative, may not provide health services, including but not limited to the provision of rehabilitative therapy, administration or supervision of the self-administration of medications, nursing care or medical treatment, unless it has been licensed as an assisted living services agency. It may contract with one or more assisted living services agencies, home health care agencies, or other appropriately licensed health care providers to make available health services for tenants provided by such licensed persons or entities.
Trained aides may provide assistance with ADLs; assistance with exercise, ambulation, transfer, and self-administration of medications; and routine household tasks.
Nursing services may only be provided by licensed ASLAs or other appropriately licensed agencies or individuals. Nursing services include client teaching, wellness counseling, health promotion and disease prevention, medication administration and delegation of supervision of self-administered medications, and provision of care and services to clients whose conditions are chronic and stable.
Registered nurses may also perform quarterly assessments, coordination, orientation, training, and supervision of aides.
Residential care homes. Services provided include recreational activities, laundry, housekeeping, and maintenance services.
Assisted Living Service Agencies. Managed residential communities must offer three meals a day. Other aspects of food service are not specified in the Assisted Living Service Agency regulations.
Residential care homes. Menus shall be prepared, posted and filed and shall meet state department of health requirements for basic nutritional needs.
Assisted Living Service Agencies. A “bill of rights” must be developed and signed for each resident upon move-in. The agreement includes: services available, charges and billing mechanisms; 15-day notice of changes; criteria for admission to service; rights to participate in service planning; client responsibilities; information about the complaint process; circumstances for discharge; description of Medicare-covered services and billing and payment for such services and other rights.
Residential care homes. Agreements are not required for residential care homes.
Not specified.
Assisted Living Service Agencies. The regulations allow for administration of medications by licensed staff. Assisted living aides may supervise the self-administration of medications which includes reminding, verifying, and opening the package. All medications must be stored in the resident’s unit.
Residential care homes. Residents of licensed residential care homes may self administer medications, and may request assistance from staff with opening containers or packages and replacing lids. Unlicensed personnel who administer medications must be certified.
Prior to the administration of any medication by program staff members, the program staff members who are responsible for administering the medications shall first be trained by a registered pharmacist, physician, physician assistant, advanced practice registered nurse or registered nurse in the methods of administration of medications and shall have successfully completed a written examination and practicum administered by the Connecticut League For Nursing or other department-approved certifying organization.
The State provides assisted living services through ALSAs to elders in sixteen state funded congregate housing projects and three HUD facilities that have been approved as MRCs. State general revenue and Medicaid waiver funds were made available January 1, 2003, for a pilot program that serves 75 people in private assisted living facilities. State funds are available to residents who do not meet Medicaid financial or functional criteria.
| Medicaid Participation | |||||
|---|---|---|---|---|---|
| 2004 | 2002 | 2000 | |||
| Facilities | Participation | Facilities | Participation | Facilities | Participation |
| 34 | 65 | NA | NA | NA | NA |
A nursing home transition grant is being implemented to assist residents to relocate to community settings. The grant includes funding for transitional expenses. The grant is going to be coming to a close in 2004. However, the Governor’s budget for FY 2005 includes a recommendation for the State to fund 100 percent of the grant for an additional 3 years.
An RFP was issued in 1999 by the Connecticut Housing Finance Authority “to test the extent to which subsidized assisted living communities are a viable and cost effective response for frail seniors facing inappropriate nursing facility admission.” Four projects have been approved for development. Two of the projects are under construction with the first to open this summer and the other in late 2004/early 2005. Two hundred nineteen subsidized units have been selected thus far. At least 40 percent of the units must be occupied by residents with less than 50 percent of the median income. Services for eligible low-income residents (less than $1,692 per month income or 300 percent of the federal SSI benefit) are covered by the State’s home care and Medicaid waiver programs. Tenants may retain a personal needs allowance of $164. Residents pay a share of the rent and $330 a month for meals. Any remaining income is applied to the cost of the Medicaid, or state-funded, services. Family supplementation is allowed.
Reimbursement for core services (housekeeping, laundry, maintenance/chore, recreation, medical and nonmedical transportation, emergency response, and service coordination) is $8 per day. Meals are billed to the client. Per diem payments for four levels of personal assisted living services are reimbursed as follows:
Under the Demonstration project described above, each project sets its own rates for each level of care but cannot exceed a maximum amount for each level. For the other assisted living initiatives the State is sponsoring, the rate for each level of care is set by the State.
ALSAs must have at least one RN in addition to an on-site supervisor. A supervisor must be available 20 hours a week for every 10 or fewer licensed nurses or assisted living aides and a full-time supervisor for every 20 licensed nurses or aides. A sufficient number of aides must be available to meet residents’ needs. All aides must be certified Nurses Aides or Home Health Aides and must complete 10 hours of orientation and one hour of in-service training every 2 months.
Twenty-four hour awake staff are not required since the needs vary among managed residential communities. However, 24-hour staffing could be required if indicated by resident plans of care. An RN must be available on-call, 24 hours a day.
Residential care homes. There must be at least one attendant on duty at all times for every 25 residents.
Each ALSA must have a 10-hour orientation program for all employees which shall include but not necessarily be limited to the following:
Aides must pass a competency exam. Each agency shall have an in-service education policy that provides an annual average of at least 1 hour bimonthly for each assisted living aide.
The in-service training shall include but not be limited to current information regarding specific service procedures and techniques and information related to the population being served.
Residential care homes. New staff must receive an initial orientation prior to being allowed to work independently including, but not limited to, safety and emergency procedures for staff and residents, the policies and procedures of the residential care home, and resident rights.
Continuing education for program staff shall be required for 1 percent of the total annual hours worked (to a maximum of 12 hours) per year. Such education shall include, but is not limited to, resident rights, behavioral management, personal care, nutrition and food safety, and health and safety in general.
Not described.
ALSAs are required to establish a quality assurance committee that consists of a physician, a registered nurse, and a social worker. The committee meets every four months and reviews the ALSA policies on program evaluations, assessment and referral criteria, service records, evaluation of client satisfaction, standards of care, and professional issues relating to the delivery of services. Program evaluations are also to be conducted by the quality assurance committee. The evaluation examines the extent to which the managed residential community’s policies and resources are adequate to meet the needs of residents. The committee is also responsible for reviewing a sample of resident records to determine whether agency policies were followed, whether services are provided only to residents whose level of care needs can be met by the ALSA, and whether care is coordinated and appropriate referrals are made when needed. The committee submits an annual report to the ALSA summarizing findings and recommendations. The report and actions taken to implement recommendations are made available to the State Department of Public Health.
Agencies are inspected biennially. Penalties include revocation, suspension, or censure; letter of reprimand; probation; a restriction on acquisition of other entities; a consent order compelling compliance; and civil monetary penalties.
Fees are not required for ALSAs.
Assisted living facilities; Title 16 Health and Safety, Part II, Chapter
II, §63.0 et seq.
Rest residential homes; Delaware code, Part II
§59.0 et seq.
The State added an assisted living category in 1997. No additional rest residential homes will be licensed and most have converted to assisted living facilities. A Medicaid waiver was implemented in 1999.
Revised rules were adopted in October 2002. A new “purpose” section describes the goal of the regulations to “promote and ensure the health, safety and well-being of all residents of assisted living facilities…to ensure that service providers will be accountable to their residents and the Department and to differentiate assisted living from nursing facilities.” It replaces the purpose statement that directs that the “services are provided based on the social philosophy of care and must include oversight, food, shelter and the provision or coordination of a range of services that promote quality of life of the individual. The social philosophy of care promotes the consumer’s independence, privacy, dignity and is provided in a home-like environment.”
Further revisions were proposed in 2004. The definition of incident and reportable will be refined to include all reportable incidents and the additional occurrences or events listed in the regulations. The proposed changes will require emergency electrical generators in assisted living facilities and revise the prohibition against facilities serving an individual with a central line from an assisted living facility by creating an exception for subcutaneous venous ports.
| Supply | ||||||
|---|---|---|---|---|---|---|
| Category | 2004 | 2002 | 2000 | |||
| Facilities | Units | Facilities | Units | Facilities | Units | |
| Assisted living facilities | 29 | 1,738 | 27 | 1,300 | 18 | 927 |
| Rest residential homes | 3 | NR | 6 | 160 | 4 | 99 |
Assisted living is a special combination of housing, supportive services, supervision, personalized assistance, and health care designed to respond to the individual needs of those who need help with activities of daily living and/or instrumental activities of daily living.
Rest residential home is an institution that provides resident beds and personal care services for persons who are normally able to manage activities of daily living. The home should provide friendly understanding to persons living there as well as appropriate care in order that the resident’s self-esteem, self-image, and role as a contributing member of the community may be reinforced.
Assisted living. The rules require 100 square feet for single bedrooms in new facilities and converted facilities of more than 10 units, and 80 square feet per resident for rooms with two residents. No more than two residents may share a room. Bathrooms are provided in the unit or, if shared, one for every four residents. Consumers must have access to a readily available central kitchen if one is not provided in the unit. Bathing facilities must be provided in the unit or in a readily accessible area.
Rest residential homes provide 100 square feet for single occupancy and 80 square feet per resident for multiple occupancy rooms. No more than four people may share a room. One bathtub or shower and one toilet and wash basin are required for every four residents.
Assisted living. The rules do not allow agencies to admit people who require more than intermittent or short-term nursing care; require skilled monitoring, testing, and aggressive adjustment of medications and treatments; require monitoring of a chronic medical condition that is not essentially stabilized; are bedridden more than 14 days; have Stage III or IV pressure sores; require a ventilator; require treatment for a disease or condition which requires more than contact isolation; have an unstable tracheotomy or a stable tracheotomy of less than six months’ duration; have an unstable peg tube; require IV or central line; wander to the extent that facilities cannot provide adequate supervision or security arrangements; pose a threat to themselves or others; or are socially inappropriate. Waivers may be granted to allow facilities to temporarily care for people with excluded conditions for up to 90 days so long as services are provided by appropriate health professionals. Pending regulations would allow individuals needing an IV or central line to be served if the facility meets specified documentation and service requirements.
Rest residential homes. No specific requirements are stated other than in the definition of a resident.
Eligibility for the waiver is based on professional judgment concerning ADLs, and medication and safety supervision. Individuals must have impairments in two ADLs to receive waiver services in the home, and services in assisted living facilities are targeted to people with three ADL impairments.
Assisted living. A medical evaluation and an assessment by an RN must be completed 30 days prior to admission using the Department’s uniform assessment instrument and must be reviewed within 30 days after admission. Individual service agreements address all the physical, medical and psychosocial services to be provided: personal care, services by a licensed nurse, food, nutrition and hydration, environmental services (laundry, housekeeping, trash removal, and safety), psychosocial/emotional, banking, transportation, furnishings, assistive technology and durable medical equipment, rehabilitation services, and interpretive services.
Managed or negotiated risk agreements are used to describe mutually agreeable action that balances resident choice and independence with the health and safety of the resident and others. A managed/negotiated risk agreement is negotiated when the risks are tolerable to all parties participating in the development of the managed/negotiated risk agreement and a mutually agreeable action is negotiated to provide the greatest amount of resident autonomy with the least amount of risk. The resident must be capable of making choices and decisions and understanding consequences. The agreement clearly describes the problem, issue or service that is the subject of the managed/negotiated risk agreement; describes the choices available to the resident as well as the risks and benefits associated with each choice, the assisted living facility’s recommendations or desired outcome, and the resident’s desired preference; indicates the agreed-upon option; describes the agreed upon responsibilities of all parties and is a part of the service agreement.
Rest residential homes provide shelter, housekeeping, board, and personal surveillance or direction in activities of daily living.
Food services are covered in the tenant service agreement.
Prior to executing a contract, residents must receive a statement of all charges. The contract includes nonfinancial and financial components. The nonfinancial issues include a listing of basic and optional services; optional services that may be provided by third parties; a statement of resident’s rights and an explanation of the grievance procedure; occupancy provisions such as policies concerning modifications to the resident’s living area, procedures for changing the resident’s accommodations (relocation, roommate, number of occupants in the room), transfer procedures, security, staff’s right to enter a resident’s room, resident rights and obligations, temporary absence policy, interim service arrangement during an emergency, discharge policies and procedures, obligations of the facility, and a listing of the resident’s personal belongings. The financial areas include the party responsible for handling finances, obtaining equipment and supplies, arranging services not covered by the contract, disposing of belongings, and the rate structure and payment provisions.
Facilities offering special care must disclose the philosophy of care; the population served; admission and discharge process and criteria; the assessment, care planning and implementation process; staffing plan and training policies; physical environment and design features; resident activities; family role; psychosocial services; nutrition and hydration services; policies on wandering, safe storage of medications and costs.
Aides who have passed an examination are allowed to assist with self-administration of medications. Rules governing assistance with medications are covered by regulations issued by the Board of Nursing. An RN must review medications within 30 days of admission for people who self-administer to assess the resident’s cognitive and physical ability and need for assistance. Reviews are also conducted for residents who self-administer to ensure proper labeling and storage, that medications have been received, and to determine their effects and the presence of adverse side effects.
The State provides waiver services to elders and adults with disabilities in assisted living facilities with income below 250 percent of the federal SSI level. The SSI payment and state supplement is $704 a month. The room-and-board payment for SSI beneficiaries is $598 and residents retain a personal needs allowance of $106 a month. Residents with higher incomes may be charged a higher room-and-board amount.
Three levels of payment for services are available. Facilities receive a 10 percent additional payment for residents with cognitive impairments. The payment levels are based on spending for HCBS waiver clients living in their own homes and participants in the adult foster care program. Family members are allowed to supplement room and board payments.
The Medicaid waiver program coverage began late in 1999.
| Medicaid Participation | |||||
|---|---|---|---|---|---|
| 2004 | 2002 | 2000 | |||
| Facilities | Participation | Facilities | Participation | Facilities | Participation |
| 29 | 14 | 11 | NR | 7 | 20 |
| Reimbursement Levels | |||
|---|---|---|---|
| Level I | Level II | Level III | |
| Room and board | $598 | $598 | $598 |
| Services | $940 | $1,180 | $1,460 |
| Total | $1,538 | $1,778 | $2,058 |
Assisted living facilities must employ a sufficient number of trained staff to meet the needs of residents. They must also have a director of nursing who is a registered nurse who is full time in facilities over 25 beds, 20 hours a week in facilities with 5 to 24 beds, and 8 hours a week in facilities under 5 beds.
Assisted living--Administrators. Requirements for administrators vary with the size of the facility. Facilities over 25 units must have a full-time nursing home administrator; 5 to 24 beds, a half-time nursing home administrator. Facilities with four or fewer beds must have an administrator with a baccalaureate degree or associates degree with 2 years experience, an RN with 4 years experience or an LPN with 4 years experience or 5 years experience in a related health or social service field.
Staff. Resident assistant orientation covers fire and life safety and emergency disaster plans; infection control; basic food service; first aid and the Heimlich maneuver; job responsibilities; health and psychosocial needs of the residents served; the assessment process; use of service agreements; resident rights and reporting of abuse, neglect, and mistreatment; and hospice services. A minimum of 12 hours of annual training must be provided. Orientation is required for temporary staff.
Rest residential homes. Nurse aide/nurse assistant staff must complete a training course approved by the State Board of Nursing and the Board of Health. Aides/assistants must be certified prior to employment. Section 609 describes the curriculum and the competencies that must be measured in the following areas: nurse aide role and function; environmental needs; psychosocial needs; and physical needs. Section 59.610 describes the qualifications of instructors and the training instructors must receive.
Facilities must obtain a report of each employee’s entire criminal history record from the State Bureau of Identification and a report from DHSS regarding its review of a report of the person’s entire federal criminal history. The State also has a mandatory drug testing law. Civil money penalties of $1,000 to $5,000 per occurrence for violations of the criminal background check and drug testing law may be imposed by the licensing agency.
Assisted living. Facilities must develop and implement an ongoing quality assurance program that includes internal monitoring of performance and resident satisfaction. Satisfaction surveys of all residents must be conducted twice a year. Pending regulations will require reporting of falls without injury and falls with injuries that do not require transfer to an acute care facility or do not require reassessment of the resident; errors or omissions in treatment or medication; injuries of unknown source and lost items, in accordance with facility policy.
Fees are set by statute. The fee for an initial application and background examination is $500. Annual fees are $400 for facilities under 100 beds and $550 for facilities over 100 beds.
Community Residence Facilities; DC Law 5-48; DC Code §32-1301 et
seq.; Chapter 34, §3400 et seq.
Assisted Living Residences; DC Law
13-127 §60847 of DC Register, p. 2647
An RFP was issued in March 2004 to hire a contractor to develop a program to license and monitor Assisted Living Residences (ALRs). The goals of the program are to assure the quality of care provided in ALRs according to the Act, develop a monitoring system that is client centered, and develop an evaluation system that will measure the quality of care being given to residents. The Assisted Living Residence Regulatory Act was passed in June 2000. The assisted living law includes a philosophy of care that emphasizes personal dignity, autonomy, independence, privacy, and freedom of choice. The services and physical environment should enhance a person’s ability to age in place in a home-like setting by increasing or decreasing services as needed.
The HCBS Medicaid waiver was amended in June 2003 to include a new category of service for assisted living. The service will be implemented after licensure regulations for assisted living are developed.
| Supply | ||||||
|---|---|---|---|---|---|---|
| Category | 2004 | 2002 | 2000 | |||
| Facilities | Units | Facilities | Units | Facilities | Units | |
| Community residence facility | 200 | 1,866 | NR | NR | NR | NR |
An assisted living residence means an entity, whether public or private, for profit or not for profit, that combines housing, health services, and personal assistance--in accordance with individually developed service plans--for the support of individuals who are unrelated to the owner or operator of the entity.
A community residence facility is one that provides safe, hygienic sheltered living arrangements for one or more individuals aged 18 years or older (except in the case of group homes for mentally retarded persons, no minimum age limitation shall apply), not related by blood or marriage to the residence director, who are ambulatory and able to perform the activities of daily living with minimal assistance. The definition includes facilities, including halfway houses and group homes for mentally retarded persons, which provide a sheltered living arrangement for persons who desire or require supervision or assistance within a protective environment because of physical, mental, familial, or social circumstances, or mental retardation. The definition does not include facilities providing sheltered living arrangements to persons who are in the custody of the Department of Corrections of the District of Columbia.
Assisted living residences. Newly constructed or renovated rooms must have 80 square feet per resident. No more than two persons may share a bedroom. Full bathrooms must be available for every six residents. ALRs serving more than 16 residents may offer living units that include kitchenette, living rooms, and bathrooms. Units that do not include bathrooms must limit sharing of bathrooms to four residents.
Community residence facilities. No more than four persons may share a bedroom. Minimum square footage and bathing and toilet facilities requirements are specified in the DC Housing Code (14 DCMR).
Assisted living residences. ALRs may not accept those who are dangerous to themselves or others, exhibit behavior that negatively impacts the lives of others, are at risk for health or safety complications which cannot be addressed by the home, and requires more than 35 hours a week of skilled nursing and home health aide services, provided on less than a daily basis, and residents who require more than intermittent skilled nursing care, treatment of Stage III or IV skin ulcers, ventilator services, or treatment for an active, infectious, and reportable disease.
Residents have the right to remain in the facility despite a recommendation to transfer, if they obtain additional services that are acceptable to the ALR.
Community residence facilities. Prospective residents, the residence director and the resident’s physician must agree that the prospective resident does not need professional care and can be assisted safely and adequately within a community residence facility. Residents must be able to perform ADLs with minimal assistance, generally be oriented as to person and place, and capable of exercising proper judgment in taking action for self-preservation under emergency conditions. By special permission of the mayor, persons who are not generally oriented or who are substantially ambulatory but need minimal ADL assistance may be admitted if sufficient staff resources are available.
Assisted living residences. ALRs must offer or coordinate for payment 24-hour supervision, assistance with scheduled and unscheduled ADLs and IADLs as needed, as well as provision or coordination of recreational and social activities and health services in a way that promotes optimum dignity and independence for residents. Services include 24-hour supervision and oversight, three nutritious meals and snacks modified to meet individual dietary needs, at a minimum some assistance with ADLs and IADLs to meet scheduled and unscheduled needs, and laundry/housekeeping services. ALRs facilitate access to appropriate health and social services and provide or coordinate transportation to community based services.
An assessment must be completed within 30 days of admission. An individual service plan is required that is signed by the resident and identifies services provided, when they are provided, and by whom. The plan is based on a medical, rehabilitation, and psychosocial assessment; functional assessment; and reasonable accommodation of resident and surrogate preferences. A shared responsibility agreement is also required. Whenever disagreements arise as to lifestyle, personal behavior, safety, and service plans the ALR staff, resident or surrogate, and other relevant service providers shall attempt to develop a shared responsibility agreement.
The ALR must explain to the resident, or surrogate, why the decision or action may pose risks and suggest alternatives to the resident; and discuss with the resident, or surrogate, how the ALR might mitigate potential risks. If the resident decides to take action that may involve increased risk of personal harm and conflict with the ALR’s usual responsibilities, the ALR describes to the resident the action or range of actions subject to negotiation; and negotiate a shared responsibility agreement, with the resident as a full partner, acceptable to the resident and the ALR that meets all reasonable requirements implicated. The shared responsibility agreement shall be signed by the resident or surrogate and the ALR.
Community residence facilities. Meals, housekeeping, laundry, and dietary services are provided. Short-term nursing care, 72 hours, may be provided or arranged by the facility.
Assisted living residences. Written contracts cover the ALRs’ organizational affiliation, the nature of any special care offered, services included or excluded, residents’ rights and grievance process, unit assignment procedures, admission and discharge policies, responsibilities for coordinating health care, arrangements for notification in the event of the resident’s death, obligations for handling finances, renting of equipment, coordinating and contracting for services not provided by the ALR, purchase of medications and durable medical equipment, rate structure and payment provisions, 45-day notice for changes in rates, procedures to be followed in the event the resident can no longer pay for services, and terms governing refunds.
Not described.
Assisted living residences. Trained aides may administer medications. A medication aide training program approved by the board of nursing will be developed. ALRs must arrange for an on-site review by a registered nurse every 45 days that covers supervision of administration by trained medication aides, resident responses to medications, and resident ability to self-administer medications.
Community residence facilities. Facilities must provide each resident a means of storing medications. Assisting with self-administration is listed as an activity of daily living.
Assisted living residences. A Medicaid HCBS waiver amendment was approved by CMS in June 2003. The amendment added the 18 to 64 population with physical disabilities, and added two additional services: consumer-directed care and assisted living. Assisted living, while an approved service, will not be implemented until assisted living licensure regulations have been passed. The State has contracted with an independent consultant to develop a case-mix reimbursement system for nursing homes, and will also develop assisted living rates. This work cannot be completed until the assisted living licensure regulations are in effect.
Community residence facilities. The SSI payment standard is $564 a month and the PNA is $70.
Administrators must have a high school diploma or GED and at least 1 year’s experience as a direct care provider/administrator and have satisfactory knowledge of the philosophy of assisted living, the health and psychosocial needs of residents, assessment process, development and use of ISPs, medication administration, provision of ADL/IADL assistance, residents’ rights, fire and life safety codes, infection control, food safety and sanitation, first aid and CPR, emergency disaster plans, human resource management, and financial management.
The ALR must have a staffing plan to assure the safety and proper care of residents based on the needs of residents, the size and layout of the facility, and the capabilities and training of staff.
Forty hours of initial training is required on delivering care for bedbound residents, use of first aid kits, procedures for detecting and reporting abuse, managing difficult behaviors, advanced body mechanics, communicating with adults with communication deficits, recognizing the signs and symptoms of dementia, caring for people with cognitive impairments, techniques for assisting in overcoming trauma, awareness of changes in conditions, and basic competence in housekeeping.
Staff must complete 12 hours of in-service training annually on emergency procedures and disaster drills, and rights of residents. Staff must also complete 12 hours of annual training on managing residents with dementia conducted by a nationally recognized organization with experience in Alzheimer’s care.
Assisted living residences. Background checks as required by federal and district laws are required.
Community residence facilities. The licensing agency may conduct background checks on the licensee which include contacts with the police to determine criminal convictions.
Assisted living residences. The proposed system, as outlined in the RFP, will measure the ability of the ALR to fulfill customers’ expectations and to provide for the health and safety of the residents. Surveyors will gather information from a variety of sources including: a survey questionnaire; interviews with the residents, family, staff and other customers; and, from a review of the medical records. It will also include a customary inspection of life safety support, fire safety systems, emergency and disaster planning, physical plant, environmental services, food services, sanitation, medical administration and other systems.
Not reported.
Assisted living facilities; Florida Statutes Chapter 400 Part 3; Florida Administrative Code Chapter 58A-5 et seq.
The State provides for several types of assisted living facility (ALF) licensing: standard, extended congregate care, limited nursing services, and limited mental health services. Following passage of legislation signed into law on May 15, 2001, requiring the filing of ALF adverse incident reports and liability claims, less than 5 percent of the facilities reported that liability claims have been filed. The regulations were revised in 2001. A number of technical changes are being considered. In July 2003, responsibility for training administrators and service staff were transferred from the Department of Elder Affairs to private organizations.
| Supply | ||||||
|---|---|---|---|---|---|---|
| Category | 2004 | 2002 | 2000 | |||
| Facilities | Units | Facilities | Units | Facilities | Units | |
| Assisted living facilities | 2,250 | 74,762 | 2,328 | 78,348 | 2,361 | 77,292 |
Assisted living facility means any building or buildings, section or distinct part of a building, private home, boarding home, home for the aged, or other residential facility, whether operated for profit or not, which undertakes through its ownership or management to provide housing, meals, and one or more personal services for a period exceeding 24 hours to one or more adults who are not relatives of the owner or administrator.
Standard: A facility licensed to provide housing, meals, and one or more personal care services for a period exceeding 24 hours. Personal services include direct physical assistance with or supervision of a resident’s activities of daily living and the self-administration of medication and similar services. The facility may employ or contract with a person licensed under Chapter 464, F.S., to administer medication and perform other tasks as specified in §400.4255, F.S., such as take vital signs, manage individual weekly pill organizers for residents who self-administer medication, give prepackaged enemas ordered by the physician, observe residents, and document in the resident’s record.
Limited nursing services: A facility licensed to provide any of the services under a standard license and those services specified in §58A-5.031(1)(a)-(m). Those services include: conducting passive range of motion exercises; applying ice caps or collars; applying heat; cutting toenails of diabetic residents or residents with a documented circulatory problem if the written approval of the resident’s health care provider has been obtained; performing ear and eye irrigations; conducting a urine dipstick test; replacing established self-maintained in-dwelling catheter or performing intermittent urinary catheterizations; performing digital stool removal therapies; applying and changing routine dressings that do not require packing or irrigation, but are for abrasions, skin tears, and closed surgical wounds; caring for Stage II pressure sores; caring for casts, braces, and splints; conducting nursing assessments if conducted by, or under the direct supervision of, a registered nurse; and for hospice patients, providing any nursing service permitted within the scope of the nurse’s license, including 24-hour supervision.
Extended congregate care: A facility licensed to provide any of the services under a standard license and LNS license, including any nursing service permitted within the scope of the nurse’s license consistent with ALF residency requirements and the facility’s written policy and procedures. A facility with this type of license enables residents to age in place in a residential environment despite mental or physical limitations that might otherwise disqualify them from residency under a standard or LNS license. This definition creates a higher level of care in assisted living which requires an additional license. Facilities with an ECC license must develop policies which allow residents to age in place and which maximize independence, dignity, choice, and decision making; specify the personal and supportive services that will be provided; specify the nursing services to be provided; and describe the procedures to ensure that unscheduled service needs are met.
Limited mental health license: An ALF that is licensed to serve three or more mental health residents. A mental health resident is an individual who receives social security disability income or SSI income due to a mental disorder as defined by the Social Security Administration and receives optional state supplementation. The facility, mental health resident, and case manager must complete a community living support plan that includes the needs of the resident that must be met in order to enable the resident to live in an ALF and the community. The mental health provider and the facility must execute a cooperative agreement with each mental health resident which provides procedures and directions for accessing emergency and after-hours care.
Facilities licensed to provide extended congregate care must provide private rooms or apartments, or semi-private room or apartment shared with a roommate of choice, with a lockable entry door. Facilities that offer rooms rather than apartments must have bathrooms shared by no more than four residents. Private rooms must be 80 square feet and shared rooms 60 square feet per resident.
Facilities that do not have the ECC license and were licensed after October 1999 may offer shared rooms (maximum of two per room), a bathroom for every six residents, and bathing facilities for every eight residents. Facilities licensed prior to October 1999 may allow four people to share a room.
Admission. The regulations for “admissions” to all assisted living facilities are specific (see matrix below).
Continued residency. Additional criteria affect continued residency. In standard assisted living facilities, people who are bedridden more than seven days or develop a need for 24-hour nursing supervision may not be retained. Residents with Stage II pressure sores may remain if the facility has a limited nursing license or the resident contracts with a home health agency or registered nurse.
In ECC facilities, residents may not be retained if they are bedridden for more than 14 days. Terminally ill residents may continue to reside in any assisted living facility if a licensed hospice agency coordinates services, an interdisciplinary care plan is developed, all parties agree to the continued residency, and all documentation requirements are maintained in the resident’s file.
To receive services under the Assisted Living for the Elderly (ALE) Medicaid waiver, which covers assisted living services, case management services, and incontinence supplies, tenants must be 60 years of age or older and meet the following requirements:
Only facilities with an ECC or LNS and semi-private rooms and bathrooms are allowed to participate in the ALE waiver program.
Eligibility for the waiver is higher than the nursing home criteria. Waiver eligibility is limited to the following conditions as determined by using the Comprehensive Client Assessment:
Four licensure types are available: standard, limited nursing service, limited mental health, and extended congregate care. Standard facilities provide personal care services, and may provide administration of medications if offered by the facility. Facilities with an ECC license may provide a higher level of service and must make available the following additional services if required by the resident’s service plan: total help with bathing, dressing, grooming and toileting; nursing assessments conducted more frequently than monthly; measurement and recording of basic vital functions and weight; dietary management including provision of special diets, monitoring nutrition, and observing the resident’s food and fluid intake and output; assistance with self-administered medications; or the administration of medications and treatments pursuant to a health care provider’s order. If the individual needs assistance with self-administration the facility must inform the resident of the qualifications of staff who will be providing this assistance, and if unlicensed staff will be providing such assistance, obtain the resident’s or the resident’s surrogate, guardian, or attorney-in-fact’s informed consent to provide such assistance; supervision of residents with dementia and cognitive impairments; health education and counseling and the implementation of health-promoting programs and preventive regimes; provision or arrangement for rehabilitation services; and provision of escort services to health-related appointments.
Other supportive services that may be provided include social service needs, counseling, emotional support, networking, assistance securing social and leisure services, shopping, escort, companionship, family support, information and referral, transportation, and assistance developing and implementing self-directed activities. In addition, facilities provide ongoing medical and social evaluation, dietary management, and medication administration.
ECC facilities may not provide oral or nasopharyngeal suctioning, assistance with nasogastric tube feeding, monitoring of blood gasses, intermittent positive pressure breathing therapy, skilled rehabilitative services; or treatment of surgical incisions, unless the surgical incision and the condition which caused it have been stabilized and a plan of care developed.
ECC facilities are allowed to use managed risk agreements which is defined as “the process by which the facility staff discuss the service plan and the needs of the resident with the resident and, if applicable, the resident’s representative or designee or the resident’s surrogate, guardian, or attorney in fact, in such a way that the consequences of a decision, including any inherent risk, are explained to all parties and reviewed periodically in conjunction with the service plan, taking into account changes in the resident’s status and the ability of the facility to respond accordingly.
“Shared responsibility” means exploring the options available to a resident within a facility and the risks involved with each option when making decisions pertaining to the resident’s abilities, preferences, and service needs, thereby enabling the resident and, if applicable, the resident’s representative or designee, or the resident’s surrogate, guardian, or attorney in fact, and the facility to develop a service plan which best meets the resident’s needs and seeks to improve the resident’s quality of life.
The Medicaid waiver includes the following services for recipients in ECC settings: personal care, homemaker, attendant and companion, medication administration and oversight, therapeutic social and recreational programming, physical, occupational and speech therapy, intermittent nursing services, specialized medical supplies, specialized approaches for behavior management for people with dementia, emergency call systems, and case management.
The State’s tenth edition of the recommended dietary allowances is the standard used to evaluate meals. The rules specify the servings of protein, vegetables, fruits, bread and starches, milk, fats, and water that must be served. All special diets must be reviewed annually by a registered dietician, licensed dietician/nutritionist, or a dietetic technician supervised by a register dietician or nutritionist. Therapeutic diets must be prepared as ordered by a health professional. The person responsible for food service must obtain 2 hours of continuing education in nutrition and food service. Staff who prepare or serve food must receive a minimum of 1 hour in-service training in safe food handling practices within 30 days of employment.
Information made available to potential residents through promotional brochures or resident contracts must contain residency criteria; daily, weekly, or monthly charges and the services, supplies, and accommodations included; personal care services provided and additional costs, if any; nursing services available and additional costs, if any; food service and the ability to accommodate special diets; availability of transportation and additional costs, if any; social and leisure activities; and any service that the facility does not provide but will arrange.
Facilities with an ECC license must describe the additional personal, supportive, and nursing services provided; the costs; and any limitations on where residents must reside.
Resident contracts must include a list of specific services, supplies and accommodations provided, including limited nursing services and extended congregate care services; the basic daily, weekly, or monthly rate; a list of any additional services available and their charges; a provision giving at least a 30-day notice of rate changes; rights, duties, and obligations of residents; purpose of advance payments or deposits and refund policy; bed hold policy; a statement of any religious affiliation; and a notice of transfer if the facility is not able to serve the resident.
Facilities may admit and retain residents with dementia. Training requirements have been increased for facilities advertising themselves as providing special care for persons with Alzheimer’s disease or related dementia. Facilities must provide supervision for all residents.
In addition to assisted living core training, staff must receive 4 hours of initial training covering understanding Alzheimer’s disease; characteristics of the disease; communicating with resident; family issues; resident environment; and ethical issues. Direct caregivers must obtain an additional 4 hours of training within 9 months of employment covering: behavior management; assistance with ADLs; activities for residents; stress management for the caregiver; and medical information. Direct caregivers must receive annually 4 hours of training on topics specified by the Department of Elder Affairs.
State law requires that facilities that provide special care for persons who have Alzheimer’s disease or other related disorders must disclose in its advertisements or in a separate document those services that distinguish the care as being especially applicable to, or suitable for, such persons.
Unlicensed staff who meet training requirements may assist with self-administration of medications. Assistance includes taking previously dispensed, properly labeled containers from where they are stored and bringing it to the resident; reading the label, opening the container, removing a prescribed amount of medication, and closing the container; placing an oral dosage in the resident’s hand or in another container and helping the resident lift the container to his or her mouth; applying topical medications; returning the medication container to proper storage; and keeping a record of when a resident receives assistance with self-administration. Licensed nursing staff may administer medications.
Services are reimbursed for low-income residents through SSI, SSDI, an optional state supplement to the federal SSI payment, and a Medicaid home and community-based services waiver, called Assisted Living for the Elderly (ALE), in qualified ALFs. In addition, coverage of assistive care services (ACS) under the state plan was implemented in September 2001 in all assisted living facilities. ACS include health support; assistance with activities of daily living; assistance with instrumental activities of daily living and assistance with self-administration of medication.
Beneficiaries of ACS must be ambulatory with or without assistance, may not exhibit chronic inappropriate behavior, are capable of taking their own medication, do not have Stage III or IV pressure sores, and do not require 24-hour supervision. Residents receive $642.40, retain $54 for personal needs, and pay the remaining $588.40 to the facility for room and board. Facilities can bill Medicaid at the rate of $9.28 per day for ACS services for eligible residents, for a total reimbursement of $866.80 for a 30-day month. To be eligible for the ACS services under the Medicaid state plan, ACS recipients must receive SSI or have income under 88 percent of the federal poverty level.
ALE waiver services are available in assisted living facilities licensed for extended congregate care and/or limited nursing services. The waiver reimburses providers up to $28 a day ($840 per 30-day month) for services. SSI beneficiaries in ALE facilities receive $642.40, retain $54 for personal needs and pay the remaining $588.40 to the facility for room and board. Recipients with incomes above this standard pay a share of cost. Payments are calculated to maintain a total provider reimbursement rate of $1,576 per month.
To be eligible for the waiver program, ALE recipients must be 60 years of age or older, require a nursing home level of care, receive SSI or have income under 300 percent of the federal SSI benefit, or have income under 88 percent of the federal poverty level.
Only facilities with an ECC or limited nursing services license may participate in the waiver program. The State allows and caps the amount of supplemental income that may be received. ALE waiver beneficiaries must be offered a private room or apartment or a unit that is shared with the approval of the beneficiary. Additionally, to be eligible for participation, a facility may not have had a Class I or Class II violation during the past 5 years, nor have had uncorrected Class III violations during the past 2 years.
Services reimbursed include: attendant call system; attendant care; behavior management; personal care services; chore and homemaker services; medication administration; intermittent nursing care services; occupational therapy; physical therapy; speech therapy; therapeutic social and recreational services; specialized medical equipment; and incontinence supplies.
Facilities may receive payment for both waiver services and assistive care services. Recipients eligible for both ACS and ALE waiver assistance must have a service plan in which services that are considered ACS are shown and identified separately from those provided under the waiver.
| Medicaid Participation | ||||||
|---|---|---|---|---|---|---|
| 2004 | 2002 | 2000 | ||||
| Facilities | Participation | Facilities | Participation | Facilities | Participation | |
| ALE | 581 | 4,167 | 299 | 2,681 | 210 | 1,410 |
| ACS | 1,527 | 14,188 | 1,565 | 9,990 | NA | NA |
In 2001, NCB Development Corporation awarded the Florida Department of Elder Affairs a Robert Wood Johnson Foundation Coming Home Program Grant designed to help bring affordability and accessibility to assisted living statewide. Through assisted living research, policy analysis, technical assistance, information dissemination, and the development of affordable assisted living models, Florida’s Coming Home Program has focused on the promotion of assisted living facilities and services for low-income, frail elders residing in rural and small towns, as well as in public housing. The Program and its partners have also worked diligently to develop effective collaborative relationships with vital long-term care and housing developers, providers, regulators, funding sources, and consumer service agencies with the goal of facilitating affordable assisted living through integrating and maximizing existing resources. Three affordable facilities are operating as a result of the Coming Home program and eight additional facilities are in the process of obtaining financing. The program created a searchable database that allows consumers to easily locate facilities based on cost, participation in Medicaid, services, and unit characteristics. The site may be found at <www.floridaaffordableassistedliving.org>.
Every ALF must be under the supervision of an administrator who is responsible for the operation and maintenance of the facility including the management of all staff and the provision of adequate care to all residents.
LNS facilities must employ or contract with a nurse(s) who must be available to provide nursing services as needed by residents. The LNS facility shall maintain documentation of the qualifications of nurses providing limited nursing services in the facility’s personnel files.
ECC facilities must provide, as staff or by contract, the services of a nurse who must be available to provide nursing services as needed by ECC residents, participate in the development of resident service plans, and perform monthly nursing assessments. An ECC staff member must serve as the ECC supervisor if the administrator does not perform this function. The ECC supervisor is responsible for the general supervision of the day-to-day management of an ECC program and ECC resident service planning.
Rules require that facilities must employ sufficient staff in accordance with required ratios (staff hours/week) and based on the physical and mental condition of residents, size and layout of the facility, capabilities of trained staff, and compliance with all minimum standards (up to five residents, 168 staff hours per week; six to 15 residents, 212 hours; 16 to 25 residents, 253 hours). Staff must be employed that are able to assure the safety and proper care of individual residents and implement the evacuation and emergency management plan. At least one staff must be awake in facilities with 17 or more residents.
Administrators must be at least 21 years old, have received a high school diploma or GED, or have been an administrator for one of the last 3 years of a licensed Florida ALF that met minimum standards. Effective July 1997, administrators must complete a competency exam following completion of ALF core training. Administrators must undergo Federal Bureau of Investigation (FBI) and Florida Department of Law Enforcement (FDLE) background screening.
Administrators and direct care staff must successfully complete a 26-hour ALF core training program and a competency test. The 26-hour core educational requirement must cover at least the following topics:
Nutrition and food service. The administrator or person responsible for the facility’s food service and day-to-day supervision of food services staff shall participate in continuing education a minimum of two hours annually.
Administrators must also receive 12 hours of continuing education every 2 years. The administrator of an ECC facility and the ECC supervisor must complete 6 hours of initial training on the physical, psychological, or social needs of frail elders or persons with Alzheimer’s disease and adults with disabilities, and 6 hours of continuing training every 2 years.
Staff. In addition to the core training, new staff must complete 1 hour of training in each of the following areas: infection control, including universal precautions and sanitation procedures. A minimum of 1 hour must cover reporting major incidents and emergency procedures. A minimum of 1 hour must also cover resident rights and recognizing/reporting abuse, neglect, or exploitation. Three hours is required on resident behavior and needs and providing assistance with ADLs. Staff who prepare or serve food must receive a minimum of 1 hour in-service training in safe food handling practices. HIV/AIDS training is required biennially. Staff that assist with self-administration of medications must receive 4 hours of training prior to assuming these responsibilities.
Two hours of in-service training that addresses ECC care, concepts, statutory and rule requirements and delivery of personal care and supportive services is required for ECC direct care staff.
Facilities which advertise that it provides special care for persons with Alzheimer’s disease or other related disorders or who maintain secured areas are required to ensure that staff who have regular contact with or provide direct care to residents with Alzheimer’s disease and related disorders receive 4 hours of initial training within 3 months of employment in understanding the disease, characteristics of Alzheimer’s disease, communication with residents with Alzheimer’s disease, family issues, resident environment, and ethical issues. An additional 4 hours is required for direct care staff within 9 months covering behavior management, assistance with ADLs, activities, stress management for caregivers, and medical information. Direct care staff must participate in 4 hours of continuing education each year.
Core training and Alzheimer’s disease training may be obtained from persons approved by the Department of Elder Affairs, or designee. The Department maintains a Web site listing approved trainers. Competency evaluations are conducted by the University of South Florida.
Florida law requires assisted living facility (ALF) owners (if individuals), administrators, and financial officers to be screened by the FBI and FDLE. ALF owners or administrators must screen all employees who provide personal services to residents through FDLE. An FBI and FDLE screening must also be conducted on an officer or board member of a firm, corporation, partnership, or association, or any person owning 5 percent or more of the facility if the agency has probable cause to believe that such person has been convicted of any offense in Section 435.04, F.S., Employment Screening.
A registered nurse or appropriate designee representing the licensing agency must visit ECC facilities quarterly to monitor residents and to determine facility compliance. An RN representing the agency must also visit LNS facilities twice a year to monitor residents who are receiving limited nursing services and to determine facility compliance.
Rules adopted in 2001 allow facilities to voluntarily adopt an internal risk management and quality assurance program. Facilities are required to file preliminary and full adverse incident reports within 1 and 15 days respectively. The reports are confidential as provided by law and cannot be used in civil or administrative actions, except in disciplinary proceedings by the Florida Agency for Health Care Administration or appropriate regulatory board. Facilities must also report monthly liability claims filed. The quality assurance program is intended to assess care practices, incident reports, deficiencies, and resident grievances and develop plans of action in response to findings.
The base biennial fee for a standard ALF license is $308 per license plus $51 per bed. Facilities providing ECC services pay an additional fee of $430, plus $10 per bed. Facilities with a limited nursing license pay $254, plus $10 per bed. Facilities do not pay a per-bed fee for any resident that is receiving Optional State Supplementation benefits (a monthly state supplement to a qualifying resident’s monthly income).
| Admission Requirements | |
|---|---|
| Basic Assisted Living, Limited Nursing Service, Limited Mental Health |
Extended Congregate Care |
|
|
Personal Care Homes; Georgia Code Annotated §31-2-4 et seq.;
§31-7-2.1 et seq.; Georgia Regulations §290-5-35.01 et seq.
Community Living Arrangements; Georgia Code Annotated §31-7-1 et seq.;
§37-1-22, et seq., Chapter 290-9-37
Rules for a new category, community living arrangements, were issued in 2002. The new category serves people with mental health, developmental disabilities and addictive diseases. The supply of personal care homes has been stable over the past 2 years although smaller homes comprise about 62 percent of the total supply compared to 80 percent a few years ago. The Department of Community Health administers a certificate of need requirement for facilities with 25 or more residents. The Office of Regulatory Services is planning to expand their Web site to include a frequently asked questions (FAQ) section to provide information about the regulations. The current FAQ section addresses requirements for criminal background checks that were implemented in 2002.
| Supply | ||||||
|---|---|---|---|---|---|---|
| Category | 2004 | 2002 | 2000 | |||
| Facilities | Units | Facilities | Units | Facilities | Units | |
| Personal care homes | 1,687 | 25,434 | 1,648 | 25,563 | 1,606 | 24,407 |
| Community living arrangements | 163 | 543 | NA | NA | NA | NA |
Personal care home means any dwelling, whether operated for profit or not, which undertakes through its ownership or management to provide or arrange for the provision of housing, food services, and one or more personal services for two or more adults who are not related to the owner or administrator by blood or marriage.
Community living arrangement means any residence, whether operated for profit or not, that undertakes through its ownership or management to provide or arrange for the provision of daily personal services, supports, care, or treatment exclusively for two or more adults who are not related to the owner or administrator by blood or marriage and whose residential services are financially supported, in whole or in part, by funds designated through the Department of Human Resources, Division of Mental Health, Developmental Disabilities, and Addictive Diseases.
Personal care homes. Bedrooms must have at least 80 square feet of usable floor space per resident. There may be no more than four residents per bedroom. Spouses may be permitted, but not required to share a bedroom. Both the occupant and the administrator or on-site manager must be provided with keys for rooms with lockable doors.
Community living arrangement. Two people may share a room if there is sufficient space. One bathroom must be available for every four residents.
Personal care homes serve people 18 and older who meet the personal care definition of ambulatory, “a resident who has the ability to move from place to place by walking, either unaided or aided by prosthesis, brace, cane, crutches, walker or hand rails, or by propelling a wheelchair; who can respond to an emergency condition...and escape with minimal human assistance....” Personal Care Homes cannot admit or retain persons who need physical or chemical restraints, isolation, or confinement for behavioral control. Residents may not be bed-bound or require continuous medical or nursing care and treatment.
If short-term medical, nursing, health or supportive services are necessary, the resident (or representative) is responsible for purchasing them from licensed providers that are managed independently of the home. The home may assist in the arrangement for such services, but not the provision of those services. Applicants requiring continuous medical or nursing services shall not be admitted or retained. Facilities may receive waivers of the admission/retention requirements.
Community living arrangement. Facilities may not admit or retain anyone they are not equipped to serve.
Revisions to the criteria are being considered. Currently, to qualify for an intermediate level of care, the individual has a stable medical condition requiring intermittent skilled nursing services under the direction of a physician and a mental or functional impairment that would prevent self-executing of the required nursing care (see table).
| Intermediate Level of Care | ||
|---|---|---|
| Medical Condition | Mental Status | Functional Status |
One of the
following:
|
One of the
following:
|
One of the
following:
|
Personal care homes. Room, meals, and personal services which include, but are not limited to, individual assistance with, or supervision of, self-administered medication, assistance with ambulation and transfer, and essential activities of daily living. Homes are responsible 24 hours a day for the well-being of residents.
Community living arrangement. Services include meals, and services that are commensurate with the needs of residents, and social, recreational and educational activities. Each resident must have a service plan or a course of action written by an appropriate health professional that includes areas of the resident’s life that require services, supports, or care; goals, outcomes, and expectations; objectives; and interventions to be carried out.
At least three meals a day shall be provided that meet the general requirements for nutrition published by the department as found in the recommended daily diet allowances of the Food and Nutrition Board. One nutritious snack must be offered mid-afternoon and evening. At least one person qualified by training or experience shall be responsible for food preparation. Homes shall arrange for special diets as prescribed.
Personal care homes. Resident agreements must be made available prior to and upon move-in that cover all fees and daily, weekly, or monthly charges; services available for an additional fee; 60-day notice of changes; authorization to release medical records; provisions for ongoing assessment of resident needs; provisions for transportation services; refund policy; and a copy of house rules.
Community living arrangement. The agreement includes all services to be delivered; fees and charges and a description of how they are assessed; refund policy; a statement of the facility’s responsibility for personal belongings; a copy of the expectations of the resident; and the procedures for handling discharges and transfers.
Any program advertised as serving residents with Alzheimer’s disease must complete a disclosure form that describes the philosophy, services, the cost of services, admission and discharge criteria, staff ratios, training, the physical environment, frequency and type of activities, and family support programs.
Personal care homes. Staff may assist with self-administration by reminding, reading labels, checking dosage, and pouring medications. Generally, medications may only be administered by a licensed registered nurse from an outside agency. Injectable medications may be administered by an appropriately licensed person. Physicians may designate a staff person to inject insulin under an established medical protocol.
Community living arrangement. A licensed nurse, physician assistant or other certified staff may administer medications. Other staff may administer certain medications if they have been trained by a licensed nurse or physician assistant, and the person’s training and ability are verified.
A Medicaid HCBS waiver reimburses two models of personal care homes--group homes serving seven to 24 people and the family model agencies serving two to six people in the Community Care Services program. Group homes are reimbursed at $31.04 per day for Medicaid services. SSI beneficiaries receive $564 a month, from which $475 is paid for room and board and the beneficiary retains a personal needs allowance of $89 a month. Room-and-board payments may be supplemented by family members or other parties. Residents who do not receive SSI may be charged a higher amount for room and board.
| Medicaid Participation | |||||
|---|---|---|---|---|---|
| 2004 | 2002 | 2000 | |||
| Facilities | Participation | Facilities | Participation | Facilities | Participation |
| 465 | 2,851 | 444 | 2,759 | 442 | 2,261 |
Personal care homes. At least one administrator, on-site manager, or responsible staff person must be on the premises 24 hours a day. The minimum on-site, staff-to-resident ratio is one staff person per 15 residents during waking hours and one staff person per 25 residents during non-waking hours.
Community living arrangement. Facilities provide qualified and trained staff that is sufficient to meet the needs of residents.
Personal care homes. All employees must receive work-related training acceptable to the Department within the first 60 days of employment. This training must include: current certification in emergency first aid, except where the staff person is a currently licensed health care professional; current certification in CPR; emergency evacuation procedures; medical and social needs and characteristics of the resident population; residents’ rights; and a copy of the Long Term Care Resident Abuse Reporting Act.
Direct care staff are required to complete 16 hours of continuing education a year in courses approved by the Department covering but not limited to: working with the elderly; working with residents with Alzheimer’s disease; working with the mentally retarded, mentally ill, and developmentally disabled; social and recreational activities; legal issues; physical maintenance and fire safety; housekeeping; or topics as needed or determined by the Department.
Community living arrangement. Staff must be trained in medical, physical, behavioral and social needs; ethics and cultural competence; techniques of de-escalation and to prevent behavioral crises; fire safety and emergency evacuation techniques; policies and procedures for use of restraints, quiet time and other protection devices; and medications of residents.
Personal care homes. The Administrator and on-site manager must obtain a satisfactory fingerprint records check determination obtained from the local law enforcement agency.
The director or onsite manager and staff who provide personal services to a resident on behalf of the personal care home or to perform any duties at the personal care home which involve personal contact with any paying resident are required to have a criminal background check. The fee for a finger print check is $3 and $24 for a criminal records check.
Community living arrangement. Fingerprint and criminal background checks are required.
The Office of Regulatory Services (ORS) conducts initial, annual, and follow-up inspections and complaint investigations. Inspections are generally conducted on an unannounced basis. ORS has the authority to take the following actions against a licensee: impose fines, revoke a license, limit or restrict a license, prohibit persons in management or control, suspend any license for a definite period or for an indefinite period, or administer a public reprimand. ORS has the authority to take the following actions against applicants for a permit: refuse to grant a license, prohibit persons in management or control, or limit or restrict a license.
None.
Assisted living facilities; Hawaii Administrative Rules §11-90-1 et
seq.
Adult residential care homes; Hawaii Administrative Rules
§11-100-1 et seq.
Extended care adult residential care homes; Hawaii
Administrative Rules §11-101-1 et seq.
The licensing agency is planning to develop changes to structural requirements for assisted living facilities. The agency responsible for enforcing building codes has intervened with facilities that meet the R-1 (residential apartment) code. As a result, these facilities must only serve residents who are ambulatory and can evacuate in an emergency. Providers contend enforcement limits their ability to implement other aspects of the regulations supporting aging in place. The agency also worked with providers to develop guidelines for implementing managed risk agreements, disclosure, resident agreements, and transfer/discharge procedures.
One condominium association developed a service plan for owners. Because all the residents participate, it meets the requirements for licensing. A court decision upheld the agency’s position requiring a license. A new state law allows individuals who own a condominium unit to receive an assessment and to develop a service plan using outside providers without requiring that the entire project be licensed.
The licensing agency expects to receive approval to establish fees for licensing facilities that would be deposited into a special fund that could be used for training and other activities related to licensing.
Revised rules for adult residential care home and extended care adult residential care homes are pending.
| Supply | ||||||
|---|---|---|---|---|---|---|
| Category | 2004 | 2002 | 2000 | |||
| Facilities | Units | Facilities | Units | Facilities | Units | |
| Adult residential care homes | 542 | 2,882 | 545 | 2,882 | 552 | 2,866 |
| Assisted living | 7 | 1,008 | 3 | 354 | 0 | 0 |
Assisted living facility means a facility as defined in §321-15.1, HRS. This facility shall consist of a building complex offering dwelling units to individuals and services to allow residents to maintain an independent assisted living lifestyle. The environment of assisted living shall include one in which meals are provided, staff are available on a 24-hour basis, and services are based on the individual needs of each resident. Each resident, family member, and significant other shall work together with the facility staff to assess what is needed to support the resident in his or her greatest capacity for living independently. The facility shall be designed to maximize the independence and self-esteem of limited-mobility persons who feel that they are no longer able to live on their own.
Assisted living means encouraging and supporting individuals to live independently and receive services and assistance to maintain independence. All individuals have a right to live independently with respect for their privacy and dignity and to live in a setting free from restraints.
Adult residential care home means any facility providing 24-hour living accommodations, for a fee, to adults unrelated to the family, who require at least minimal assistance in ADLs, but who do not need the services of an intermediate care facility. There are two types of homes--Type I homes serve five or fewer residents and Type II serve six or more residents. Adult residential care homes may obtain an extended care license to serve a limited number of residents who meet the nursing home level of care.
Assisted living. The rules require apartment units with a bathroom, refrigerator, and cooking capacity, including a sink and a minimum of 220 square feet, not including the bathroom (sink, shower, and toilet). The cooking capacity may be removed or disconnected depending on the needs of the resident. Other requirements include wiring for phone and television, a private accessible mail box, and a call system monitored 24 hours a day by staff.
Adult residential care homes. The current rules for Type II facilities allow four residents to share a room. Single rooms must have 90 square feet and multiple-occupancy rooms 70 square feet per occupant. One toilet is required for every eight residents, one shower for every 14 residents, and one lavatory for every 10 residents.
Assisted living facility. Each facility must develop admission policies and procedures that support the principles of dignity and choice. Facilities must also develop discharge policies and procedures that allow a 14-day notice for behavior or needs that exceed the facility’s ability to meet, or based on the resident’s established pattern of non-compliance. The rules do not specify who may be admitted and retained. Rather, each facility may use its professional judgment and the capacity and expertise of the staff in determining who may be served.
To qualify for an ICF level, beneficiaries must need intermittent skilled nursing, daily skilled nursing assessment and 24-hour supervision provided by RNs or LPNs. They may also require non-skilled nursing services such as administration of medications, eye drops and ointments, general maintenance care of colostomies or ileostomies, and other services and significant assistance with ADLs.
Assisted living facilities shall provide awake, 24-hour, on-site staff; three dietician approved meals a day; laundry services; opportunities for individual and group socialization; services to assist with ADLs; nursing assessment, health monitoring and routine nursing tasks; housekeeping; medication administration; services for residents with behavior problems (staff support, intervention, and supervision); and recreational and social activities. Facilities must also arrange or provide transportation, ancillary services for medically related care (physician, pharmacist, therapy, podiatry), barber/beauty care, hospice, home health, and other services.
Managed risk agreements may be used by facilities. A separate form is used for the agreement and the provisions are included in the service plan.
Facilities provide three meals a day, snacks, and modified diets that have been evaluated and approved by a dietitian on a semiannual basis and are appropriate to the residents’ needs and choices.
Assisted living facilities. Residents’ agreements are required to be available prior to and upon move-in and describe the services provided, rates charged, and the conditions under which additional services or fees may be charged.
Adult residential care homes. Homes without an extended care license may not serve residents needing nursing home care. Type I extended care homes may serve no more than two residents qualifying for nursing home care and Type II homes may serve no more than 10 percent of its residents needing this level of care.
Not specified.
Assisted living facilities. The rules allow assistance with self-administration and administration of medication as allowed under the Nurse Practice Act. Residents may keep medications in their unit. Medications in units shared by two residents may be kept in a locked container in the unit. Medications administered by the facility must be reviewed at least every 90 days by a registered nurse or physician.
Assisted living was added as a Medicaid waiver service in 2000 for elders and people with disabilities. Assisted living facilities and extended adult residential care homes (E-ARCH) may participate; however, no assisted living facilities have contracted to participate in the program. Participation figures for E-ARCH were not available. The State offers a flat rate of $58.46 a day for services. Room-and-board charges are limited to $418 a month. The monthly SSI payment is $568.90.
Assisted living facilities must have licensed nursing staff available 7 days a week to meet care management and monitoring needs of residents.
Adult residential care homes. Licensees must submit a plan showing how they will obtain a registered nurse and case manager. Sufficient staff must be on duty 24-hours a day to meet resident needs.
Assisted living facilities. The administrator/director must have 2 years experience in the health and social services field and show evidence of having completed an assisted living facility administrator’s course acceptable to the Department.
All staff shall be trained in CPR and first aid. The facility shall have written policies and procedures that incorporate the assisted living principles of individuality, independence, dignity, privacy, choice, and home-like environment. In-service education consists of an orientation for all new employees to acquaint them with the philosophy, organization, practice and goals of assisted living; and ongoing in-service training on a regularly scheduled basis (minimum of 6 hours annually).
Adult residential care homes. A registered nurse must train and monitor primary caregivers.
Assisted living facilities. Licensure may be denied for convictions in a court of law or substantiated findings of abuse, neglect, or misappropriation of resident funds or property.
Adult residential care homes. All staff, including the licensee, must have no history of confirmed abuse, neglect, or misappropriation of funds.
Assisted living facilities. Facilities are inspected biannually. The agency may suspend, revoke, or refuse to issue a license for violations of regulations. Other enforcement steps include increased monitoring frequency, restrictions, requiring additional training, and monetary fines. The licensing agency holds quarterly meetings with providers to discuss general survey findings and other regulatory issues.
None. A plan to establish fees is being developed.
Residential or Assisted Living Facilities; Idaho Administrative Rules IDAPA 16, Title 03, Chapter 22
The title and scope of the regulations describes the philosophy that includes a humane, safe and home-like arrangement, a negotiated service agreement and the development of facilities that are tailored to meet the needs of individual populations that operate in integrated settings in communities where sufficient supportive services exist to give residents opportunities to participate in community activities and opportunities. Extensive changes made to the State’s regulations were effective in 2000. The State added coverage under the Medicaid state plan and the HCBS waiver during 2000.
Minor changes to the regulations were made in May 2003, including a changing of the name of the regulations from Residential and Assisted Living Facilities to Residential or Assisted Living Facilities, the addition of language concerning “authorized providers,” and a new definition for “substantial compliance.” The State is currently in the process of restructuring the assisted living program, reviewing the statute, rules, and the survey process. Draft rules are expected to be available in July 2004.
| Supply | ||||||
|---|---|---|---|---|---|---|
| Category | 2004 | 2002 | 2000 | |||
| Facilities | Units | Facilities | Units | Facilities | Units | |
| Residential care or assisted living | 266 | 6,193 | 253 | 5,815 | 226 | 5,185 |
Residential or assisted living facility means one or more buildings constituting a facility or residence, however named, operated on either a profit or nonprofit basis, for the purpose of providing 24-hour care for three or more adults who need personal care or assistance and supervision essential for sustaining activities of daily living or for the protection of the individual.
Specialized care units/facilities for Alzheimer’s and dementia residents “are specifically designed, dedicated, and operated to provide the elderly individual with chronic confusion, or dementing illness, or both, with the maximum potential to reside in an unrestrictive environment through the provision of a supervised life-style which is safe, secure, structured but flexible, stress-free and encourages physical activity through a well developed activity and recreational program. The program constantly strives to enable residents to maintain the highest practicable physical, mental, or psychosocial well-being.”
Facilities licensed after July 1, 1992, must not have more than two residents in each bedroom and provide 100 square feet of floor space per single-bed room and 80 square feet per resident in multi-bed rooms. There must be at least one toilet for every six persons, residents, or employees, and at least one tub or shower for every eight persons, residents, or employees. New construction must meet the requirements of the Americans with Disabilities Act Accessibility Guidelines. Existing facilities must remove as many barriers as possible without creating an undue burden on the facility.
Facilities are licensed by the level of care provided: minimal assistance, moderate assistance, and maximum assistance (see table).
| Levels of Care | ||
| Level I Minimum Assistance |
Level II Moderate Assistance |
Level III Maximum Assistance |
|---|---|---|
| Resident requires room, board, and supervision, and may require only minimal assistance with ADLs or non-medical personal assistance or minimal assistance with mobility (independently mobile), is capable of self-preservation, or does not require medication management or supervision or minimal behavior management. | Resident requires room, board, and supervision, and may require moderate assistance with ADLs or non-medical personal assistance or moderate assistance with mobility or self-preservation or medication management or behavior management. | Resident requires room, board, supervision, and 24-hour awake staff and may require extensive assistance with ADLs or personal assistance or mobility (may be non-mobile without assistance) or assistance in an emergency (may be incapable of evacuation without assistance) or medications or assistance with training or behavior management. |
Residents may not be admitted or retained if they require ongoing skilled nursing, intermediate care, or care that is not within the legally licensed authority of the facility unless there are specialized facility provisional agreements that allow for skilled nursing or intermediate care. Residents who require ongoing highly technical skilled nursing services may not be served. Residents who require 24-hour skilled nursing; have pressure ulcers or open wounds that are not healing; draining wounds; have needs beyond the fire safety rating of the facility or whose physical, emotional, or social needs are not compatible with the other residents may not be served. Residents may not be admitted without a written physician’s order, authorized provider, or Department, or if the resident places the facility over its licensed bed capacity.
Facilities may request a waiver to serve people if they show good cause for granting the waiver, describe the extenuating circumstances and any compensating factors such as additional floor space or staffing that have a bearing on the waiver.
Facilities are required to ask if the resident has an advance directive, and they may assist residents in developing advance directives.
The assessment areas are divided into critical, high, and medium indicators. To qualify for nursing home admission, applicants must have one or more critical indicators; two or more high indicators; one high and two medium indicators; or four or more medium indicators. The indicators are presented below.
| Criteria for Determining Nursing Home Need | |
|---|---|
| Indicators | Level of Need |
| Critical (one or more) |
|
| High (two or more; or one high and two medium) |
|
| Medium (four or more) |
|
Services include assistance with activities of daily living, arrangements for medical and dental services, provisions for trips to social functions, recreational activities, maintenance of self-help skills, special diets, arrangement for payments, and medication management. A licensed nurse must visit the facility at least once a month to conduct a nursing assessment of each resident’s response to medications and to assure that the medication orders are current. The nurse also assesses the health status of each resident and makes recommendations to the administrator regarding any needs.
A uniform assessment and a negotiated service agreement must be used with residents. The agreement covers the assessment, service needs, need for limited nursing, need for medication assistance, frequency of needed services, level of assistance, habilitation/training needs, behavioral management needs, physician signed and dated orders, admission records, community support systems, resident desires, transfer/discharge, and other items.
Larger facilities (>16 beds) must have written policies covering job descriptions and personnel responsibilities. Menu must reflect current recommended dietary allowances; as well as include foods commonly served within the community; seasonal food selections and residents’ food habits, preferences, and physical abilities. Menus must be reviewed, signed, and dated by a dietician, nutritionist, or home economist to ensure that current RDAs are met. Physicians’ orders must be received for therapeutic or modified diets.
Agreements must be signed prior to or on the date of admission. The agreements cover: services provided; whether or not the resident will be responsible for his or her own medication; whether the facility is responsible for personal funds; handling of a partial month’s refund; responsibility for valuables; 15- or 30-day written notice of transfer or discharge; conditions for emergency transfers; permission to transfer pertinent information; resident’s responsibilities; and other items. The agreement may be integrated with the negotiated service agreement provided all requirements for both are met.
An agreement may not be terminated except under the following conditions: a 15 day written notice; the resident’s physical or mental condition deteriorates to a level where the facility can no longer provide care; nonpayment; for the protection of the resident or other residents from harm; and other conditions.
Services in specialized care units for Alzheimer’s disease include habilitation services, activity program, and behavior management according to the individualized negotiated service agreement. Residents of specialized care units for Alzheimer’s disease must be evaluated by their primary care physician for the appropriateness of placement in the unlocked specialized care unit/facility prior to admission. No resident shall be admitted to these units without a diagnosis of Alzheimer’s disease or related disorder. Residents must be at a stage in their disease such that only periodic professional observation and evaluation is required. Residents in these units must be re-evaluated quarterly. No resident shall be admitted who requires physical or chemical restraints. Staff must have an additional 6 hours of training in addition to orientation, and must have an additional 2 hours of continuing education annually beyond the required 8 hours dedicated to the provision of services to people with Alzheimer’s disease or other dementias.
Facilities have to describe the population served; the philosophy, objectives, and beliefs upon which decisions will be made; admission and discharge criteria; security systems; staffing pattern; plan for specialized training; and the program and social activities.
Licensed nurses may fill medi-sets for residents. Aides who have passed required training may administer medications. The requirements are specified by the Board of Nursing.
Problems with medication administration occur frequently. Common problems include failure to follow doctors’ orders, failure to get medications from the pharmacy, and an unclear line between medication assistance and medication administration.
Personal care in assisted living was added as a state plan service in 2000. Services under a Medicaid HCBS waiver using the waiver application definition and including medication administration and assistance with personal finances was implemented in 1999. Elders, people with disabilities, and people with mental retardation, traumatic brain injuries, or developmental disabilities are eligible. Coverage was phased in across the State. The HCBS aged and disabled waiver program now serves 1,714 residents living in residential or assisted living facilities. Individuals are eligible for the waiver using the 300 percent SSI eligibility criteria. There are two programs covering services for individuals living in residential or assisting living facilities:
State supplementation to the SSI program has been phased out. In 2002, the Legislature directed the transition of individuals who were receiving the supplemental grant to the Medicaid state plan. Supplementation for the room-and-board payment is allowed in all categories. A uniform assessment instrument is used to determine the unmet ADL needs for all applicants. The unmet needs are converted to a payment that is available to the beneficiary regardless of where he or she lives: in assisted living or their own home or apartment. The process was developed to eliminate differences in payment and service delivery depending on where a person lived.
| Medicaid Participation | |||||
|---|---|---|---|---|---|
| 2004 | 2002 | 2000 | |||
| Facilities | Participation | Facilities | Participation | Facilities | Participation |
| 265 | 1,870 | 35 | 720 | NR | NR |
Facilities must have sufficient staff to serve residents in keeping with negotiated service plans. At least one staff member must be immediately available to residents at all times. Facilities admitting Level III residents or a combination of Level I, II, or III residents must have a minimum of one awake staff during sleeping hours. Waivers may be sought by small facilities. A full-time administrator must devote no less than 20 hours per week to the day-to-day administrative duties.
Administrators must have a valid residential care administrator’s license. Personnel must be given an orientation to the facility and participate in a continuing training program developed by the facility.
Staff. Each facility shall develop and follow a structured written orientation program for a minimum of 8 hours. Continuing training: staff providing personal assistance must receive a minimum of 8 hours of training a year. Evidence of the completed training and topics are kept on file. Staff, including housekeeping personnel and contract personnel must be trained in Universal Precautions.
Staff in specialized care units for Alzheimer’s/dementia residents must have an additional 6 hours of orientation covering information on Alzheimer’s and dementia, symptoms and behaviors of memory impaired people, communication with memory impaired people, resident’s adjustment, inappropriate and problem behavior of residents and appropriate staff response, activities of daily living for special care unit residents, and stress reduction for special care unit staff and residents. Staff must have an additional 2 hours of continuing education, beyond the required 8 hours of continuing training, on the provision of services to persons with Alzheimer’s disease.
Applicants for licensure must submit a criminal history clearance as described in IDHW rules Title 05, Chapter 06 which is repeated every 3 years. The rules include finger printing, FBI, National Criminal History Background Check System, state registries and Medicaid sanctions lists. Individuals pay $34 for the cost of the check which must be updated every 5 years.
With the exception of the initial surveys for licensure, all inspections and investigations shall be made unannounced and without prior notice. Inspections are conducted at least annually. Inspections entail reviews of the quality of care and service delivery, resident records, and other items relating to the running of the facility. If deficiencies are found, then plans of correction are made and follow-up surveys are conducted to determine if corrections have been made. Complaints against the facility are investigated by the licensing agency. A complainant’s name or identifying characteristics may not be made public unless “the complainant consents in writing to the disclosure; the investigation results in a judicial proceeding and disclosure is ordered by the court; or the disclosure is essential to the investigation. The complainant shall be given the opportunity to withdraw the complaint before disclosure.”
Inspections of specialized care units for Alzheimer’s disease are conducted by the licensing agency with participation from the Regional Department staff who have program knowledge of and experience with the type of residents to be served and the proposed program offered by the facility. Facilities that are specialized or have specialized care units must submit a synopsis of the program of care to be offered by the unit/facility.
Enforcement options include ban on admissions, ban on residents with certain diagnosis, civil monetary penalties, appointment of temporary management, suspension or revocation of the license, transfer of residents, issuing a provisional license and other remedies. Facilities operating without a license may be subject to six months in jail and fines up to $5,000.
Historically, the State has reported that the consultative process used during the monitoring process has positively impacted overall quality of care and compliance. Typically, surveyors would be able to provide input and suggestions to problems that were identified, and providers welcomed this feedback. In recent years, due to a shortage of staff, the State is working hard just to keep up with the surveys they are required to do. As a result, they do not have the time to provide feedback and suggestions to providers during the survey process. They also do not have the staff to go back and determine whether corrections have been made.
$500 for a building evaluation.
Assisted Living and Shared Housing Act Title 210 ILCS 9
Assisted
living and shared housing establishments; 77 ILL Admin. Code Part 295
Sheltered care facility; 77 ILL Admin. Code Part 330 et seq.
Supportive
living facilities; Title 89, Chapter I, Subchapter d, Part 146
Rules governing assisted living establishments and shared housing establishments were effective January 2002. These establishments are exempt from the certificate of need law. The law does not allow Medicaid to cover services in assisted living establishments; however, a “supportive living facility” (SLF) program has been implemented in “certified” locations that offers similar services. Because of budget deficits, a moratorium has been placed on the number of SLFs that may be approved. The State is considering lifting the moratorium. The program serves elderly and disabled Medicaid beneficiaries who need assistance with activities of daily living. It targets lighter need nursing facility residents who are unable to remain in their homes. An SLF may be converted nursing home units or free standing buildings that integrate housing, health, personal care, and supportive services in home-like residential settings. A maximum of 2,750 Medicaid residents can be served under a 1915 (c) waiver that applies only to the demonstration.
The Assisted Living and Shared Housing Establishment regulations are being amended to implement P.A. 93-141 which added a provision for a floating license and clarified requirements concerning care for residents with Alzheimer’s disease and dementia, hospice care, and unlicensed establishments.
The floating license rules will allow an establishment in which 80 percent of the residents are at least 55 years of age or older, that is operated as housing for the elderly, and meets the construction and operating standards contained in Section 20 of the Act, to request a floating license for any number of individual living units within the establishment, up to, but not including, total capacity. Living units designated as licensed living units shall be referred to as such. The establishment must have adequate staff to meet the scheduled and unscheduled needs of the residents living in the licensed living units, and all staff must meet the requirements of the assisted living regulations. All mandatory and optional services must be available to residents of the licensed units. Designation as a licensed living unit may be temporary to accommodate a resident’s changing needs without requiring the resident to move.
The Sheltered Care Facility rules were updated in 2003. The revisions update the incorporation by reference of National Fire Protection Association (NFPA) standards (Life Safety Code) applicable to construction of new facilities from 1997 standards to 2000 standards.
Legislation consolidating different licensing categories was considered by the legislature in 2004. The State is currently working with its assisted living advisory committee to discuss dedicating permanent state staff to the assisted living program.
| Supply | ||||||
|---|---|---|---|---|---|---|
| Category | 2004 | 2002 | 2000 | |||
| Facilities | Units | Facilities | Units | Facilities | Units | |
| Assisted living | 97 | 5,999 | 24 | 1,667 | NA | NA |
| Shared housing | 9 | 82 | NA | NA | NA | NA |
| Shelter care facilities | 149 | 8,484 | 156 | 8,740 | 156 | 8,302* |
* NOTE: The number of units was revised from the 2000 report due to an error that may have reported occupied rather than licensed beds.
Assisted living establishment means a home, building or residence, or any other place where sleeping accommodations are provided for at least three unrelated adults, at least 80 percent of whom are 55 years of age or older and where the following are provided consistent with the purpose of this act:
Shared housing establishment means a publicly or privately operated free-standing residence for 12 or fewer persons, at least 80 percent of whom are 55 years of age or older and who are unrelated to the owners and one manager of the residence, where the following are provided:
Sheltered care facility means a facility licensed under the nursing home care act that provides maintenance and personal care but does not provide routine nursing care.
Supportive living facility (SLF) means a residential setting that provides personal care services, 24-hour supervision and assistance (scheduled and unscheduled), activities, and health related services with a service program and physical environment designed to minimize the need for residents to move within or from the setting to accommodate changing needs and preferences; has an organized mission, service programs, and a physical environment designed to maximize residents’ dignity, autonomy, privacy, and independence; and encourages family and community involvement.
Assisted living establishments require single occupancy units unless shared by choice. Units must accommodate small appliances, include a sink, toilet, and assistive devices if needed. Bathing facilities may be in the unit or in a common room.
Shared housing establishments may have shared bathrooms (1:4) and tub/shower facilities (1:6).
Sheltered care facilities allow no more than four persons to share a room. Single rooms must be 70 square feet and multiple occupancy rooms 60 square feet per person. One lavatory is required for every 10 residents and one shower/bath is required for every 15 residents. A lavatory and shower/bath is required on each floor.
Supportive living facility. To participate in the Department of Public Aid program, facilities must have not less than 10 and no more than 150 apartments. Freestanding sites must provide apartments with 300 square feet of living space, including closets and bathroom. Apartments for individuals wishing to share the unit must have 450 square feet of living space, including closets and bathroom. Units must have a full bathroom, lockable doors, emergency call system, heating and cooling controls, wiring for private telephone, access to cable television or satellite dish, a sink, microwave oven or stove, and refrigerator. Nursing homes converting a portion of a facility must offer apartments with 160 square feet for single occupancy and 320 square feet if two people want to share a unit.
Assisted living establishments. Facilities may not accept residents who are a danger to themselves or others, are not able to communicate their needs and do not have a representative residing in the facility, require total assistance with two or more ADLs, require assistance of more than one paid caregiver with any ADL, require more than minimal assistance in moving to a safe area in an emergency. Persons with severe mental illness may not be admitted, which is characterized in the DSM-IV as substantially disabled for not less than one year in the areas of self-maintenance, social functioning, activities of community living and work skills. This does not include Alzheimer’s disease and other forms of dementia. They may also not accept residents who need the following health services unless self-administered or administered by a qualified, licensed health care professional who is not employed by the owner or operator of the establishment, its parent entity, or any other entity with ownership common to either the owner or operator or parent entity, including but not limited to an affiliate of the owner or operator:
In addition, residents may not be accepted who need five or more skilled nursing visits a week for 3 or more weeks unless the course of treatment is rehabilitative and the need is temporary.
If any of the above conditions are met, a resident’s occupancy agreement shall be terminated, except for individuals who are terminally ill who receive or would qualify for hospice and such care coordinated by a licensed hospice provider.
Proposed rules would require the establishment to advise the prospective resident to consult a physician to determine whether a pneumococcal pneumonia vaccine is recommended.
Sheltered care facility. No resident needing nursing care may be admitted or retained. Persons who have a communicable disease or are mentally ill, need treatment for mental illness, are likely to harm others, or are destructive of property or themselves may not be admitted or retained.
Supportive living facilities may serve elderly (age 65 or older) or disabled residents age 22 or over who have been screened and determined to meet the nursing facility level of care criteria. Residents may be discharged if they are a danger to self or others or have needs that cannot be met by the SLF. The SLF must develop a service plan and execute a written contract with each resident that includes services the resident will receive and other terms of the agreement.
Waiver eligibility is based on a Determination of Need score. The score is derived from the Mini-Mental State Examination (MMSE), six ADLs, nine IADLs (including ability to perform routine health and special health tasks and ability to recognize and respond to danger when left alone). Each ADL, IADL and special factors are rated by level of impairment (0-3) and unmet need for care (0-3). Scores for each area are summed and applicants with a DON score of 29 or more are eligible. The MMSE component is weighted toward people with moderate or severe dementia. The process is designed to target services to people with high levels of impairment who may have informal supports and people with lower levels of impairment without informal supports.
Assisted living establishments. No more than 180 days prior to admission, a comprehensive assessment that includes an evaluation of a prospective resident’s physical, cognitive, and psychosocial condition shall be completed by a physician. This assessment must be updated annually by a physician, or upon significant change in condition. Establishments may use their own evaluation/assessment tools, but this does not take the place of the physician assessment. Mandatory services include three meals a day, housekeeping, laundry, security, emergency response system, and assistance with ADLs. Optional services include medication reminders, supervision of self-administered medications and medication administration, and nonmedical services defined by rule.
Assisted living, which promotes resident choice, autonomy, and decision making, should be based on a contract model designed to result in a negotiated agreement between the resident or the resident’s representative and the provider, clearly identifying the services to be provided. This model assumes that residents are able to direct services provided for them and will designate a representative to direct these services if they themselves are unable to do so. This model supports the principle that there is an acceptable balance between consumer protection and resident willingness to accept risk and that most consumers are competent to make their own judgments about the services they are obtaining. Regulation of assisted living establishments and shared housing establishments must be sufficiently flexible to allow residents to age in place within the parameters of this Act. The administration of this Act and services provided must therefore ensure that the residents have the rights and responsibilities to direct the scope of services they receive and to make individual choices based on their needs and preferences. These establishments shall be operated in a manner that provides the least restrictive and most homelike environment and that promotes independence, autonomy, individuality, privacy, dignity, and the right to negotiated risk in residential surroundings.
“Negotiated risk” is the process by which a resident, or his or her representative, may formally negotiate with providers what risks each are willing and unwilling to assume in service provision and the resident’s living environment. The provider assures that the resident and the resident’s representative, if any, are informed of the risks of these decisions and of the potential consequences of assuming these risks. The rules allow assisted living and shared housing establishments to use a risk agreement that describes the problem, issue or service that is covered, the choices available to the resident and their risks or consequences, the resulting agreement, mutual responsibilities, and a review time frame. The agreement is limited to the individual’s care and personal environment and does not waive any requirements of the regulations.
Sheltered care facility may provide personal care, group and individual activities, assistance with self administration of medications or administration by a physician or licensed nurse.
Supportive living facilities must provide a combination of housing, personal, and health related services that promote autonomy, dignity, and quality of life and respond to the individual needs of residents. Room and board includes three meals per day. Services include nursing services, personal care, medication oversight and assistance in self-administration, housekeeping services, laundry service, social and recreational programs, 24-hour response/security staff, emergency call systems, health promotion and referral, exercise, transportation, and maintenance services. Nursing services include completion of a resident assessment and service plan, a quarterly health status evaluation, administration of medication when residents are temporarily unable to self-administer, medication set-up, health counseling, episodic and intermittent health promotion or disease prevention counseling, and teaching self-care in meeting routine and special health care needs that can be met by other staff under supervision of a registered nurse. Facilities are expected to involve family members in service planning. Residents must receive an initial assessment within 24 hours of admission and a comprehensive assessment within 14 days. Assessments are updated at least annually.
Assisted living and shared housing facilities offering special diets must contract with or employ a dietician. Meals must be nutritionally balanced and accommodate resident preferences.
Shelter care facilities must provide three meals or two meals and a breakfast bar. Meals must meet the requirements for a general diet for an adult recommended by the Food and Nutrition Board, National Research Council. Therapeutic diets ordered by a physician must be provided.
SLFs must contract with a licensed dietitian who is on-site at least twice a quarter for at least 8 hours (cumulative) to provide consultation and training.
Assisted living and shared housing. Contracts with residents include the duration of the contract; base rate and a description of services; additional services available and their fee; description of the process for terminating or modifying the contract; the complaint resolution process; resident obligations; billing and payment procedures; the admission, risk management, and termination procedures; resident rights; the department’s annual on-site review process; terms of occupancy; charges during absences; refund policy; notice for changes in fees; and policy concerning notification of relatives of changes in the resident’s condition. Contracts must also include statements that Medicaid is not available for payment of services and that there is a risk management procedure.
Supportive living facilities. Agreements cover services provided under Medicaid; arrangements for payment; grievance procedure; termination provisions; rules for staff, management, and resident conduct; and resident rights. The agreement includes services available for an additional fee and arrangements to share a unit.
Assisted living and shared housing facilities that offer special care programs for people with dementia must file a disclosure statement if they serve people with dementia. The statement includes the form of care or treatment; philosophy; admission and retention policies; assessment care planning and implementation guidelines; staffing ratios; physical environment; activities; role of family members; and the cost of care.
Facilities are not allowed to serve people with dementia whose mental or physical condition is detrimental to the health, welfare, or safety of the resident or other residents as determined by the resident’s physician prior to admission and annually thereafter. The rules specify that residents must be assessed prior to admission with any one or a combination of assessment tools, based upon the resident’s condition and stage in the disease process. The rules list a number of tools that may be used, such as the Functional Activities Questionnaire, Clock Drawing Test, and Functional Assessment Staging, among others.
Shelter care facilities. The law does not allow facilities to serve anyone with dementia if they do not have the staff with the skills to meet the individual’s needs. The rules will provide for use of a validated dementia specific standard to assess residents. The assessment must be completed and approved by the resident’s physician prior to move-in and annually. Residents cannot be accepted if they pose a danger that cannot be eliminated through treatment. Facilities offering special care units must disclose information about their program, ensure that residents have a designated representative, and develop and implement policies and procedures for people who wander, need supervision and assistance when evacuating. In addition, they must provide cognitive stimulation, appropriate staffing patterns, and emergency procedures. Facilities must provide each resident 1.4 hours of service per day (ADLs, activities, and other services to meet unique needs).
Managers of special care facilities must have a college degree with course work in dementia and one year of experience and must complete 6 hours of training a year. Staff receive 4 hours of orientation in dementia care, 16 hours of on-the-job training, and 12 hours in-service training a year. The rules list the topics that are covered under each requirement.
Assisted living and shared housing establishments may assist with self-administered medications, supervise, or administer medications. Policies related to administration must be approved by a physician, pharmacist, or registered nurse. Only a licensed health care professional employed by the establishment may administer medications including injections, oral medications, topical treatments, eye and ear drops, or nitroglycerin patches.
Sheltered care facilities. All medications taken by residents shall be self-administered, unless administered by licensed personnel. No person shall be admitted to a facility who is not capable of taking his or her own medications. Facility staff may remind residents when to take medications and watch to ensure that they follow the directions on the container. All medications must be stored in a locked area at all times. Although there is some conflict between the sections of the regulation governing medication administration, in practice, licensed staff are allowed to administer medications “to some residents for control purposes” when it is not safe for the resident to self-administer.
Assisted living and shared housing. The law does not permit the use of Medicaid funds in licensed facilities.
Supportive living facilities. The State has implemented a pilot program to serve elders and adults with disabilities who are Medicaid waiver beneficiaries in supportive living facilities (SLFs) (see http://www.slfillinois.com). SLFs are exempt from state licensing requirements. For Medicaid residents, participating facilities must be willing to accept the SSI rate, $564 a month in 2004 (less a $90 personal needs allowance) as payment for room and board. The service payment is based on 60 percent of the average nursing facility rate paid in the region. Because SLFs are not licensed, they may be certified as eligible food stamp vendors and receive these benefits for eligible residents. The average monthly service cost is $1,883 paid by Medicaid. Residents pay, on average, $455 for room and board and receive $96 in food stamp benefits. Income supplementation is allowed. Funding for services is included in the Medicaid nursing home budget and is not part of a separate appropriation.
A moratorium on new applications was instituted in November 2001 due to budget constraints. However, applicants that had submitted prior to the moratorium will be allowed to participate. The program has 41 operating SLFs with 2,983 units in fall 2004. Thirty more sites are approved. Eighty six percent of the SLF units are occupied and 63 percent (1,602 units) are occupied by Medicaid beneficiaries.
| Medicaid Participation | |||||
|---|---|---|---|---|---|
| 2004 | 2002 | 2000 | |||
| Facilities | Participation | Facilities | Participation | Facilities | Participation |
| 41 | 1,602 | 13 | 293 | NR | 35 |
The program targets “lighter” care nursing home eligible residents with a Determination of Need (DON) score (see below) between 29 and 47 on a 100-point scale. Residents with scores above 47 may be served if the facility has the capacity to do so.
| Rates by Geographic Area | |||||
|---|---|---|---|---|---|
| Region | Daily | R&B | Food Stamps | Medicaid | Total |
| Chicago | $61.94 | $474 | $97 | $1,883 | $2,454 |
| South suburb | $59.11 | $474 | $97 | $1,797 | $2,368 |
| Northwest | $53.90 | $474 | $97 | $1,639 | $2,210 |
| Central | $51.05 | $474 | $97 | $1,552 | $2,123 |
| West central | $47.54 | $474 | $97 | $1,552 | $2,016 |
| St. Louis | $50.75 | $474 | $97 | $1,445 | $2,114 |
| South | $45.54 | $474 | $97 | $1,384 | $1,955 |
Assisted living and shared housing. Establishments must have sufficient numbers of trained staff to meet the 24 scheduled and unscheduled needs of residents. Assisted living establishments must have at least one awake staff on duty who has CPR training.
Sheltered care facility. Facilities must have staffing patterns that are sufficient to meet the needs of residents. At least one awake staff member is required.
Supportive living facilities must provide licensed and certified staff that are sufficient to meet the needs of residents in conjunction with contractual agreements. Personal care services and assistance with self-administration of medications must be provided by certified nurse assistants. SLFs must contract with a dietician.
Assisted living and shared housing. Administrators must be 21 and have a high school diploma or equivalency, 1 year management experience or 2 years of experience in health care, housing, or hospitality.
Staff must complete an orientation that addresses philosophy and goals; promotion of dignity, independence, self-determination, privacy, choice, and resident rights; confidentiality; hygiene and infection control; abuse and neglect prevention and reporting; and disaster procedures. Additional orientation covers needs of residents; service plans; internal policies; job responsibilities and limitations; and ADLs. Eight hours of annual training is required for staff and managers on topics listed above.
Sheltered care facility. The administrator shall arrange for facility supervisory personnel to annually attend appropriate education programs on supervision, nutrition, and other pertinent subjects. Staff training shall include an in-service program embracing orientation to the facility and its policies, skill training, and ongoing education carried out to enable all personnel to perform their duties effectively. Written records of program content and personnel attending shall be kept.
Supportive living facilities. Administrators must have at least 5 years’ experience in providing health care services in assisted living settings, in-patient hospital, long-term care setting, adult day care, or in a related field. The manager also must have at least 2 years of progressive management experience. Staff shall receive documented training by qualified individuals in their area(s) of responsibility prior to employment and semiannual training thereafter. Nurses’ assistants must be certified or enrolled in and pursuing certification. A trained staff person must be responsible for planning and directing social and recreation activities. Nurses must be licensed. Twenty-four-hour response staff must be certified in emergency resuscitation.
The State has introduced proposed rules titled “Health Care Worker Background Check Code” in 77 ILL Admin. Code 955. New qualifying crimes have been added, which become effective January 1, 2004. Two new provisions have been added that are not in any of the existing rules. Health care employers will be required to establish a policy concerning employment of individuals whose criminal history record checks indicate convictions for offenses that are not disqualifying. The employer will also be required to develop a policy concerning employment of individuals who have been granted waivers. Additionally, prior to hiring, proposed rules would require the establishment to check employee status with the Nurse Aide Registry.
Rules passed in November 2003 changed waivers of the health care worker criminal history background check requirements. The new rule specifies that waiver applicants must have met all court obligations (probation, adhering to a fine or restitution schedule) and satisfactorily completed a drug and/or alcohol recovery program, if applicable. Mitigating circumstances are expanded to reference drug/alcohol rehabilitation programs, anger management or domestic violence prevention programs, completion of court-ordered obligations, and nurse registry and criminal history status in other states.
Managers who provide direct care must complete a background check. The rules list specific offenses that preclude hiring of staff.
State legislation passed during the spring of 1995 prohibits sheltered care facilities from knowingly hiring, employing, or retaining any individual in a position with duties involving direct care for residents who have been convicted of committing or attempting to commit designated criminal offenses, unless a waiver has been granted by the Illinois Department of Public Health. Further, the legislation requires facilities to check the Certified Nurse Aid Registry in the State and ensure that appropriate background criminal history record checks are initiated or have been conducted. The legislation was expanded to include SLFs in 1999.
Assisted living and shared housing establishments are inspected annually. This is an annual unannounced visit. The annual visit focuses on compliance with rules, solving resident issues and concerns and the facility’s quality improvement (QI) process. Each facility must have a QI program that covers oversight and monitoring; resident satisfaction; and a QI process that has benchmarks, is data driven, and focuses on resident satisfaction. A system is needed to detect and resolve problems. The existence, results, and process of the QI system cannot be used as evidence in any civil or criminal proceeding.
Civil penalties may be applied up to $5,000 a day for violations and up to $3,000 a day for keeping residents who exceed the care needs in the law.
The monitoring process is collaborative in nature, with an emphasis on meeting the needs of the residents. During this process, the State provides information on best practices and shares concerns about the quality of care with suggestions for how to fix the problems or the names of individuals the facility may contact for assistance. Oversight is not enforcement-driven, but is based more on a social model promoting quality of care. The functions of surveying and providing education are the responsibility of the same staff. Currently, the surveyors are earning overtime in these positions. The surveyors are contractual employees of the State and many come from the nursing home model. The State is trying to hire its own staff to monitor assisted living. They are seeking individuals who come from a more social model background, with an understanding of the assisted living approach and philosophy.
Supportive living facilities. Participating facilities will be Medicaid certified and monitored, at least annually, by the Department of Public Aid. Monitoring includes contract requirements, resident autonomy, resident rights, adequacy of service provision, quality assurance process, safety of the environment, program policies and procedures, information provided to low-income residents, review of resident assessment and service plans, resident satisfaction surveys, check-in system, and food service.
Facilities must have a grievance process and a quality assurance process. Complaints may be heard informally. If not resolved or if the resident prefers, grievances may be submitted through the facility’s formal process. Residents may use the Medicaid appeals process for denial or delay of service.
Internal quality assurance procedures must encompass resident satisfaction, oversight and monitoring; peer review; utilization review; procedures for preventing, detecting and reporting resident neglect and abuse; and ongoing quality improvement. The committee must establish review schedules, objectives for improving service quality, including quality indicators and measures, and a mechanism for tracking improvements based on care outcomes. A system with outcome indicators must be developed that measures: quality of services; residents’ rating of services; cleanliness and furnishings in common areas; service availability and adequacy of service provision and coordination; provision of a safe environment; socialization activities; and resident autonomy.
Fees for sheltered care facilities are $200 per year. The fee for assisted living establishments is $300 per facility, plus $5 per unit. The fee for shared housing is $150.
Assisted living: House Enrolled Act 1630 (1997)
Residential care
facilities: 410 IAC 16.2-5 et seq.
Residential care facilities are licensed under the licensure category for health facilities. This licensure category also includes rules for comprehensive care facilities, commonly known as nursing homes. Disclosure documentation legislation for housing with services establishments was passed during the 1998 legislative session. This legislation is very broad, and includes many different types of licensed and unlicensed providers, including licensed residential care facilities. The purpose of the legislation was to require all licensed and unlicensed providers to complete a disclosure form on an annual basis and submit the form along with a copy of the resident contract to the Division of Disability, Aging and Rehabilitation Services. An establishment may not use the term “assisted living” if it has not filed a disclosure form. The form includes the following information: the name and address of the owner and managing agent, description of services provided and the base rate, additional services available and their fees, the resident’s designated representative, if any, referral procedures if the contract is terminated, the process for modifying and terminating the contract, description of the complaint resolution process, and criteria for determining who may continue to reside in the establishment. As of March 2004, approximately 300 housing with service establishments that may be called assisted living facilities have filed disclosure information.
Revised regulations for residential care facilities went into effect in March 2003. A separate Medicaid assisted living waiver was implemented in October 2001. The State recently received a 5-year waiver renewal. The number of slots requested was reduced from 2,250 to a maximum capacity of 400 in Year 5 due to provider capacity and budget projections.
| Supply | ||||||
|---|---|---|---|---|---|---|
| Category | 2004 | 2002 | 2000 | |||
| Facilities | Units | Facilities | Units | Facilities | Units | |
| Residential care facilities | 147 | 11,767 | 140 | 11,555 | 127 | 10,098 |
| Housing with services establishments | 300 | NR | NR | NR | NR | NR |
Residential care facilities. A health facility that provides residential nursing care and administers medications prescribed by a physician must be licensed as a residential care facility. A facility that provides services such as room, meals, laundry, activities, housekeeping, and limited assistance in activities of daily living, without providing administration of medications or residential nursing care is not required to be licensed.
A housing with service establishment is defined as an establishment providing sleeping accommodations to at least five residents and offering or providing for a fee at least one regularly scheduled health-related service or at least two regularly scheduled supportive services, whether offered or provided directly by the establishment or by another person arranged for by the establishment. Health-related services mean home health services, attendant and personal care services, professional nursing services, and central storage and distribution of medications. Supportive services mean help with personal laundry, handling or assisting with personal funds, arranging for medical services, health related services, or social services.
Residential care facilities. Rules require 100 square feet for single rooms and 80 square feet per bed for multiple occupancy rooms. For facilities licensed after 1984, no more than four people may share a room. One toilet and sink is required for every eight residents in facilities licensed after 1984.
Residential care facilities may not admit or retain individuals who require 24-hour comprehensive nursing care. Facilities that retain appropriate professional staff may provide comprehensive nursing care to residents needing care for a self-limiting condition. Residents must be discharged if the resident is a danger to self or others, requires 24 hour a day comprehensive nursing care or comprehensive nursing oversight; requires less than 24 hour per day comprehensive nursing care, comprehensive nursing oversight, or rehabilitative therapies and has not entered into a contract with an appropriately licensed provider of the resident’s choice to provide those therapies, is not medically stable or meets two of the following three criteria unless the resident is medically-stable and the facility can meet the resident’s needs: (1) requires total assistance with eating; (2) requires total assistance with toileting; and (3) requires total assistance with transferring.
Housing with services establishments. The establishment must, in the disclosure form, indicate when a resident must be transferred because the establishment and the resident are unable to develop a means for assuring that the resident is able to respond to an emergency in a manner that is consistent with local fire and safety requirements and when the establishment is unable to assure that the resident’s physical, mental, and psychosocial needs can be met. Except as stated in the contract, residency in the housing with services establishment may not be terminated due to a change in a resident’s health or care needs. Except where the resident’s health or safety or the health or safety of others are endangered, an operator shall provide at least thirty (30) days notice to the resident or the resident’s designated representative before terminating the resident’s residency.
Individuals are eligible if they have an unstable medical condition or three or more of 14 substantial medical conditions or ADL impairments. The list includes: supervision and direct assistance on a daily basis to ensure that prescribed medication is taken correctly; 24-hour supervision and/or direct assistance due to confusion; disorientation not related to a mental illness; inability to eat, transfer from bed or chair, change clothes, bathe, manage bladder and/or bowel functions or ambulate or use a wheelchair without direct assistance. The criteria allow a person with three ADLs or 2 ADLs and the need for medication assistance to receive waiver services.
Residential care facilities. Services offered to a resident must be appropriate to the scope, frequency, need and preference of the resident. Services must be reviewed and revised as appropriate and discussed with the resident as his or her needs change. If administration of medications and/or the provision of residential nursing services are needed, a licensed nurse must be involved in the determination and documentation of needed services. The administration of medications and the provision of residential nursing services must be ordered by a physician and supervised by a licensed nurse on the premises or on call.
The facility must provide activities programs appropriate to the ability and interests of the residents. Scheduled transportation must be provided or coordinated to community-based activities.
Each facility must determine whether it will administer medications or provide residential nursing services. This must be clearly stated in the admission agreement.
Residential nursing care may include, but is not limited to: identifying human responses to actual or potential health conditions, deriving a nursing diagnosis, executing a minor regimen based upon a nursing diagnosis or as prescribed by a physician, physician’s assistant, chiropractor, dentist, optometrist, podiatrist, or nurse practitioner, or administering, supervising, delegating, and evaluating nursing activities.
A minor regimen may include, but is not limited to: assistance with self-maintained ex-dwelling or indwelling catheter care for a chronic condition; prophylactic and palliative skin care; routine dressing that does not require packaging or irrigation; general maintenance care of ostomy; restorative nursing assistance; toileting care; routine blood glucose testing; enema and digital stool removal therapies; general maintenance care in connection with braces, splints, and plaster casts; observation of self-maintained prosthetic devices; administration of subcutaneous and intramuscular injections; metered dose inhalers, nebulizer/aerosol treatments self-administered by a resident, and routine administration of medical gases after a therapy regimen has been established.
Housing with services establishments. Except as stated in the contract and identified in the disclosure document, an operator may not restrict the ability of a resident to use a home health agency, home health provider, or case management service of the resident’s choice or require a resident to use home health services.
Residential care facilities. Facilities must make available three meals a day, seven days a week that provide a balanced distribution of the daily nutritional requirements. Facilities must meet daily dietary requirements and requests, with consideration of food allergies, reasonable religious, ethnic, and personal preferences, and temporary need for meals to be delivered to the resident’s room. All modified diets must be prescribed by a physician.
Housing with services establishments. Not specified
Residential care facilities. Some of the provisions typically included in resident agreements are contained in the section on resident rights. They include the right to receive (at the time of admission) a written notice of the basic daily or monthly rate; all facility services (including those offered on a need basis); information on related charges; and admission, readmission, and discharge policies. A 30-day notice of changes in rates or services is required.
An evaluation of the individual needs of each resident must be initiated before admission and must be updated at least semiannually or upon a significant change in condition. Subsequent evaluations must be used to compare against the baseline evaluation to assure that the care a resident requires is within the range of personal care and supervision provided by the facility. At a minimum the evaluation must include information on the resident’s physical and mental status, independence in activities of daily living, weight, and ability to self-administer medications.
Housing with services establishments. The disclosure document must be provided to a prospective resident or his or her legal guardian and made readily available at any time.
Residential care facilities. Staff caring for residents in dementia-specific units must have a minimum of 6 hours of dementia-specific training within 6 months and 3 hours annually thereafter.
Housing with services establishments. Not specified.
Residential care facilities. Medications may be administered under physician’s order by licensed nursing personnel or qualified medication aides. Other treatments may be given by nurse aides upon delegation by licensed nursing personnel except for injectable medications which may be given only by licensed staff. The resident must be observed for effects of medications and documentation of undesirable effects is required, followed by notification of the resident’s physician.
Residents who self-medicate may keep and use prescription and non-prescription medications in their unit as long as they are kept secure.
Assisted living. Services are covered under an HCBS waiver. The waiver renewal was approved to serve 186 beneficiaries in the first year, 282 in Year 2, 330 in Year 3, 359 in Year 4, and 400 in Year 5. Currently, 14 facilities have been approved for the waiver program and 71 beneficiaries are being served. Provider and client participation has not expanded as quickly as the State initially projected due to start up delays, and difficulty recruiting providers. Licensed facilities must meet additional requirements for private bedrooms and baths, and a number of additional service requirements. Existing unlicensed assisted living facilities that have submitted a disclosure form and are considered housing with services establishments and meet the waiver program requirements have not expressed an interest in becoming waiver providers because they would need to become licensed, and would need to serve a much higher acuity population than desired.
Medicaid contracting requirements provide for private apartments, shared only by choice, square footage, meal preparation, temperature controls, and door locks that differ from the licensing rules. A three-tiered payment system has been developed based on points from the assessment process (see table below). The rates do not include room and board. The SSI payment maximum is currently $564 (less a $52 personal needs allowance). The State has not issued a policy on family supplementation. The waiver uses the definition and covered services included in the HCBS waiver preprinted format: case management, RN oversight, personal care, homemaker, chore, attendant care, companion, medication oversight, and therapeutic and recreational programming.
The Residential Care Assistance Program is a state-funded program that covers limited services for residents who are aged, blind, mentally ill or disabled, low income, and/or cannot live alone but do not qualify for nursing home care. Payments are based on a flat rate. County home (housing with services establishments) rates are $27 per day for room, board, laundry, housekeeping, and limited oversight. Private residential care facility rates are $39.35 per day. Nineteen county homes and 42 RCFs served 418 county home residents and 1,121 people in private residential care facilities respectively as of March 2004.
| Medicaid Participation | |||||
|---|---|---|---|---|---|
| 2004 | 2002 | 2000 | |||
| Facilities | Participation | Facilities | Participation | Facilities | Participation |
| 14 | 71 | 8 | 22 | NA | NA |
| Indiana Service Payment System | |
|---|---|
| Level | Daily Rate |
| Level 1: (<36 points) | $45.86 |
| Level 2: (36-60 points) | $53.78 |
| Level 3: (61-75 points) | $61.68 |
Residential care facilities. Each facility must have one administrator who is responsible for the overall administration of the facility. Staff shall be sufficient in number, qualifications and training to meet the 24-hour scheduled and unscheduled needs of the residents and services provided. A minimum of one awake staff person, with CPR and first aid certificates, must be on duty at all times. If 50 or more residents require nursing services and/or administration of medication, at least one nursing staff person must be on staff at all times. For facilities with 100 or more residents requiring nursing services and/or administration of medication, at least one awake staff person must be on duty at all times, with an additional staff person required for every additional 50 residents.
A consultant pharmacist must be employed or under contract. The facility must designate an activities director who is a recreational therapist, an occupational therapist or a certified occupational therapist assistant, or someone who will complete, within 1 year, an activities director training course approved by the State.
Housing with services establishments. Not specified.
Residential care facilities. Administrators must be licensed.
Staff (residential care facilities). Prior to working independently, each employee shall be given an orientation of the facility by the supervisor. Orientation of all employees shall include:
Ongoing training must include resident’s rights, prevention and control of infection, fire prevention, safety, and accident prevention, the needs of specialized populations served, medication administration, and nursing care. For nursing personnel, training must include at least 8 hours of in-service per calendar year and 4 hours of training for nonnursing personnel.
Any unlicensed employee providing more than limited assistance with activities of daily living must be either a certified nurse aide or home health aide.
Not described.
Residential care facilities. Annual surveys are conducted by the Department of Health.
Housing with services establishments. The State may impose financial penalties for violations of the disclosure requirement. A housing with services establishment may request a review of the penalty. If the State determines that an establishment has had substantial and repeated violations, the State may prohibit an establishment from using the term “assisted living” to describe the establishment’s services and operations to the public. If the State determines that the establishment has made intentional violations of the disclosure requirement or has made fraudulent and material misrepresentatives to a resident, the State may request the attorney general to investigate and take appropriate action against the operator or administrator.
Licensure fees are collected annually: $200 for the first 50 beds and each additional bed is $10.
Assisted living programs: Iowa Code 231C and 321 IAC Chapter 25, 26, and
27; IAC 661--5.626 Assisted Living Housing (Life Safety)
Residential care
facilities: IAC Chapter 57 and Chapter 60
Related codes that affect but do
not specifically reference assisted living: 655 IAC Chapter 6-Nurse Practice;
645 IAC Chapter 63-Salons; Iowa Code Chapter 155A-Pharmacy; 481 IAC Chapters 30
& 32-Food Service Establishments
Revisions to the regulations were effective May 14, 2004. During the past few years, the level of care provided has received attention. Assisted living programs are viewed as a point along a continuum of settings and not appropriate for people who are dependent in ADLs, have late-stage dementia or compromised health conditions.
Responsibility for oversight and monitoring was transferred from the Department on Aging to the Department of Inspection and Appeals. The Department on Aging retains responsibility for issuing regulations. The shift has changed the monitoring from responding to events triggered by complaints to examining program operations and practices in relation to the regulations. The State continues to emphasize consumer choice and autonomy. The nursing and social work staff responsible for oversight are located in a separate monitoring (rather than survey) unit which is separate from the institutional survey staff.
A task force will issue a report recommending creation of a Medicaid assisted living benefit and a payment that includes waiver and state plan services.
| Supply | ||||||
|---|---|---|---|---|---|---|
| Category | 2004 | 2002 | 2000 | |||
| Facilities | Units | Facilities | Units | Facilities | Units | |
| Assisted living programs | 184 | 5,220* | 154 | 4,180* | 78 | 3,409 |
* The total capacity is 8,246 in 2004 and 6,199 in 2002, including double occupancy units.
“Assisted living means provision of housing with services which may include, but are not limited to, health related care, personal care and assistance with instrumental activities of daily living to six or more tenants in a physical structure which provides a home-like environment. Assisted living also includes encouragement of family involvement, tenant self-direction, and tenant participation in decisions that emphasize choice, dignity, privacy, individuality, shared risk, and independence. Assisted living includes the provision of housing and assistance with instrumental activities of daily living only if personal care or health related care is also included.” 96 Acts, Chapter 1192. SF 2193 modified the definition by including housing and IADLs only if personal care and health related services are included.
A dementia-specific assisted living program means an assisted living program that either serves five or more tenants with dementia or cognitive disorder at Stage 4 or above on the Global Deterioration Scale or holds itself out as providing special care for persons with cognitive disorder or dementia, such as Alzheimer’s disease, in a dedicated setting.
Assisted living programs may have private dwelling units with lockable doors and individual cooking facilities. In facilities built before July 2001, units must have at least one room with not less than 120 square feet of floor area. Other habitable rooms must have at least 70 square feet. Each single occupancy dwelling unit in buildings built after July 2001 must have at least 240 square feet of floor area, excluding bathrooms. Units used for double occupancy must have at least 340 square feet, excluding bathrooms. The space requirements are lower for dementia units.
Programs may not admit or retain tenants who are bedbound, require two person assistance with standing, transfer or evacuation; pose a danger to self or others; are in an acute stage of alcoholism, drug addiction or uncontrolled mental illness; are under age 18; require more than part-time or intermittent health related care (21 days); on a routine basis have unmanageable incontinence; or meet the program’s transfer criteria. Part-time or intermittent nursing care includes licensed nursing care for unstable conditions, daily medication injections (except stable diabetes), daily assessment or treatment of conditions such as an open wound or pressure ulcer, total care for unmanageable incontinence, or routine two-person assistance with standing, transfer, or evacuation. Managed risk statements must be used. The facilities policy is stated in the application for certification.
Exceptions to the limit on part-time or intermittent health care may be requested for residents who need hospice care or temporarily need more than part-time or intermittent health care for more than 21 days. Approvals may be given for limited time periods if the resident makes an informed choice to remain, the program has the staff to meet the extended needs, and the health and welfare of other tenants is not jeopardized.
Intermediate level of care can be approved if the individual requires daily supervision with dressing and personal hygiene in conjunction with one of the following: cognitive functions, mobility, skin, pulmonary status, continence, physical functioning--eating, medications, communication/hearing/vision patterns, or prior living circumstances--psychosocial.
Intermediate level of care can also be approved if the individual requires physical assistance by one or more persons to perform dressing and personal hygiene.
The certification application includes the process for assessing tenants’ functional and cognitive ability and a copy of the assessment tool. Individualized service plans are required. Programs must provide some personal care or health related services and at least one meal a day. Health related services mean less than daily skilled nursing services and professional therapies for temporary but not indefinite periods of time of up to 21 days a month. Skilled services and therapies combined with personal care and nurse delegated activities may not total more than eight hours a day. Service plans must be developed for each tenant, and plans for tenants needing personal care or health related services must be developed with a multidisciplinary team (including a health professional and human services professional) and the tenant.
The rules allow a managed risk statement which includes the tenant’s or responsible person’s signed acknowledgment of the shared responsibility for identifying and meeting needs and the process for managing risk and upholding tenant autonomy when tenant decision making may result in poor outcomes for the tenant or others.
Facilities must have the capacity to provide hot or other appropriate meals at least once a day or to coordinate with other community providers to make arrangements for the availability of meals. Therapeutic diets may be provided.
Each tenant signs an occupancy agreement and managed risk statement prior to occupancy. The agreement includes a shared responsibility/managed risk policy, all fees, charges, and rates describing tenancy and basic services covered, any additional and optional services and their cost. It also includes a statement regarding the impact of the fee structure on third party payments and whether they will be accepted by the program; procedure for non-payment of fees; identification of the person responsible for making payment; guarantee of a 30-day written notice of any changes in the agreement unless the tenant’s health status or behavior creates a substantial threat to health and safety; occupancy and transfer criteria; grievance policies; emergency response policy; the staffing policy including whether or not staff are available 24-hours a day, whether delegation will be used and how staffing will be adapted to meet changing needs. Additional provisions are added for programs serving people with dementia; refund policy; statement regarding billing, telephone number to make a complaint; a copy of the tenant’s rights provisions; and a statement that tenant landlord law applies to assisted living programs.
Units built in a neighborhood design offer 150 square feet of floor excluding bathroom for single occupancy and 250 square feet for double occupancy. The difference in square footage must be added to the common areas. Facilities must have an operating door alarm system. Visual or audible alarms may be disconnected if it is disruptive to a tenant. The tenant agreement must include a description of the services and programming.
Programs must have a system, program, or staff procedure that responds to emergency needs in lieu of a personal emergency response system. Training for all employees includes 6 hours on specified topics that include: explanation of the disease; philosophy and program; skills for communicating with residents and family; family issues; importance of planned and spontaneous activities; providing ADL assistance; service planning and social history; working with challenging tenants; simplifying cuing and redirecting; and staff support and stress reduction.
Written medication plans are required. Medications may be administered in accordance with state rules governing administration. Nurse delegation rules allow administration and supervision of routine, oral medications by trained unlicensed personnel. Registered nurses may delegate injections to licensed nursing staff. Delegation rules are issued by the Board of Nursing. Registered nurses must monitor administration, ensure orders are current and are administered consistent with the orders. They must also document the resident’s health status and progress every 90 days.
Assisted living is covered through a Medicaid HCBS waiver, state service funds, and a state funded rent supplement program.
Medicaid: Certified or accredited assisted living programs may be providers of Medicaid home and community based waiver services including: assistive devices, chore, consumer directed attendant care, emergency response, home delivered meals, home health aide, homemaker, nursing, nutritional counseling, respite, senior companions, and transportation.
Services are reimbursed on a fee-for-services basis according to the care plan. There is a maximum cap of $1,025 per month on care plans.
One affordable facility has opened under the Coming Home Program. The Iowa Finance Authority will be tracking the state/federal dollar savings on a monthly basis. The State estimates that it saves $905.52 a month in state and federal Medicaid expenditures for each resident served.
| Medicaid Participation | |||||
|---|---|---|---|---|---|
| 2004 | 2002 | 2000 | |||
| Facilities | Participation | Facilities | Participation | Facilities | Participation |
| 73 | 126 | 54 | 129 | 12 | NR |
The SSI payment standard is $564 and the personal needs allowance is $30. The resident’s room-and-board payment is separate from the Medicaid service amount. The State uses the 300 percent Medicaid eligibility option. Residents may retain up to $1,692 a month of their income to cover room and board and other costs. Family supplementation of resident income for room and board costs is allowed up to the $1,692 limit.
State Supplementary Assistance: This state funded program provides up to $483 a month in payments for in-home health related services that are not covered under other programs or for HCBS assisted living residents who need more care than is available under the service cap. Services may include nursing and personal care tasks when certified by a physician that the services can be provided in a person’s home, including assisted living.
State rental assistance program: This program works like HUD’s Section 8 program and pays rental expenses for low income beneficiaries who do not have access to rent subsidies. Beneficiaries pay 30 percent of their income for rent. The program can pay the difference between the tenant’s payment and the fair market rent set by HUD. Participants must be eligible for waiver services. A special one-time grant of $500 is available to pay for household furnishings and supplies for people who are moving from an institution.
Sufficient staffing must be available at all times to meet the needs of residents. Programs administering medications or providing health related services must provide for a registered nurse to monitor medications, ensure physician orders are current (30 days), and assess and monitor health status (90 days). Each program must provide access to a 24-hour emergency response system.
Administrators. The owner or sponsor of the assisted living program is responsible for ensuring that both management and direct service employees receive training appropriate to the task.
Staff. The assisted living program shall have a training and staffing plan on file and shall maintain documentation of training received by staff. All personnel of the assisted living program shall be able to implement the assisted living program’s accident, fire safety, and emergency procedures.
Not described.
Monitoring staff hold community meetings with tenants during their site reviews. The meetings often identify concerns about quality and practice for the monitors. A protocol based on the certification requirements is used to guide the review. Tenants, program staff, and family members are interviewed. During the review, rules may be clarified and explained. Monitoring staff often participate in training meetings organized by three associations representing assisted living programs.
The fee structure was changed in 2004. Distinctions between small and large programs were eliminated. The regulations require a $900 fee for reviewing blue prints. The 2-year initial certification fee is $750. The recertification fee for a nonaccredited program is $1,000 and $125 for an accredited program.
Assisted living/Residential Health Care Facilities: KAR §28-39-144-148, KAR 28-39-240-256
Licensing rules were last amended in October 1999 and the recent focus has been on monitoring, training and improving outcomes. The law created an overall framework of adult care homes which includes nursing facilities, nursing facility for mental health, intermediate care facility for the mentally retarded, assisted living facility, residential health care facility, home plus, boarding care home, and adult day care facility. The regulations differentiate among the categories of adult care homes.
Responsibility for regulating assisted living facilities has been transferred from the Department of Health and Environment to the Department on Aging. A Money Follows the Person pilot program began in 2003 to support the service costs for people who move from a nursing home to a community setting.
| Supply | ||||||
|---|---|---|---|---|---|---|
| Category | 2004 | 2002 | 2000 | |||
| Facilities | Units | Facilities | Units | Facilities | Units | |
| Assisted living facilities | 191 | 7,971 | 129 | 5,658 | 80 | 4,521 |
| Residential health care facilities | 98 | 2,918 | 43 | 2,355 | ||
| Home plus | NR | NR | 44 | 94 | 51 | 224 |
Assisted living facility means any place or facility caring for six or more individuals not related within the third degree of relationship to the administrator, operator, or owner by blood or marriage and who, by choice or due to functional impairments, may need personal care and may need supervised nursing care to compensate for activities of daily living limitations and in which the place or facility includes apartments for residents and provides or coordinates a range of services including personal care or supervised nursing care available 24-hours a day, seven days a week for the support of resident independence. The provision of skilled nursing procedures to a resident in an assisted living facility is not prohibited by this act. Generally, the skilled services provided in an assisted living facility shall be provided on an intermittent or limited term basis, or, if limited in scope, on a regular basis.
The rules provide that the administrator or operator of facilities ensure that written policies and procedures are developed and implemented which incorporate the principles of individuality, autonomy, dignity, choice, privacy, and a home-like environment.
Each facility must offer apartments which include areas for sleeping, living, storage, kitchen (with sink, refrigerator, stove or microwave, and space for storage of utensils and supplies), and bathroom. They must also offer at least 200 square feet of living space, excluding bathroom, closets, lockers, wardrobes, other built-in fixed items, alcoves, and vestibules. Facilities licensed prior to January 1, 1995, as an intermediate personal care facility, are not required to offer kitchens and private baths.
Residential health care facilities are required to have individual living units with at least 100 square feet of living space and a private toilet room with a bathing facility.
Each facility develops admission, transfer, and discharge policies which protect the rights of residents. Facilities may not admit or retain people with the following conditions unless the negotiated service agreement includes hospice or family support services which are available 24 hours a day or similar resources:
A Standard Client Assessment Referral Evaluation (CARE) is used to assess impairments in ADLs and IADLs and risk. ADLs and IADLs are weighted. ADLs: dressing and mobility (3); bathing and eating (4); toileting and transfer (5). IADLs: meal preparation and medical management (5); money management (4); and shopping, transportation, telephone use, laundry, and housekeeping (3). The weightings are multiplied by a factor based on the need for no assistance (0); physical assistance or supervision (1), and unable to perform (3). Risk factors include: bladder incontinence (5), risk of abuse, neglect, or exploitation by others (5), falls (3), lack of support (4), and impaired cognition (4).
To be eligible, applicants must have a minimum of two ADLs with minimum combined weight of six; impairments in a minimum of three IADLs with a minimum combined weight of nine; and a total minimum score of 26, or a minimum score of 26 with at least 12 points in IADL impairments and the remaining 14 in any combination of IADL, ADL, and risk factor points.
Services may include meals; health care services based on an assessment by a licensed nurse; housekeeping; medical, dental, and social transportation; and other services necessary to support the health and safety of the resident. Health care services include personal care, supervised nursing care, and wellness and health monitoring. The service agreement contains the skilled nursing services to be provided and the licensed person or agency providing services.
The Medicaid waiver includes assisted living facilities as a provider of respite and health care attendant services. The services covered by the waiver include respite care, sleep cycle support, health care attendant (Level I and Level II), adult day care, and wellness monitoring. Sleep cycle support means “non-nursing physical assistance and supervision during the consumer’s normal sleeping hours in the consumer’s place of residence, excluding nursing facilities” and includes “physical assistance or supervision with toileting, transferring and mobility, prompting and reminding of medication.”
Health care attendant “provides physical assistance with activities of daily living and instrumental activities of daily living for individuals who are unable to perform one or more activities independently.” IADLs, excluding medication management or medication administration, may be performed without nurse supervision. These services are limited to 12 hours a day.
Level I activities include assistance with ADLs and IADLs (bathing, grooming, toileting, transferring, feeding, mobility, accompanying to obtain necessary medical services, shopping, house cleaning, meal preparation, laundry, and life management).
Level II activities are health maintenance activities and include monitoring vital signs, supervision and/or training of nursing procedures, ostomy care, catheter care, enteral nutrition, medication administration/assistance, wound care, range of motion, and reporting changes in function or condition. These services must be authorized by a physician or a nurse.
A dietetic services supervisor or licensed dietician must provide scheduled on-site supervision in facilities with 11 or more residents. Therapeutic diets are provided if included in the negotiated service agreement, based on instructions from a physician or licensed dietician. Menus must be planned based on the dietary guidelines for Americans, 4th edition, published by USDA and DHHS.
Facilities must develop a negotiated service agreement with each resident in collaboration with the resident, the resident’s legal representative, family (if agreed to by the resident), or case manager. The agreement describes the services to be provided, the provider of service, and the parties responsible for payment when services are provided by an outside agency. The agreement supports the dignity, privacy, choice, individuality, and autonomy of the resident. The agreement is reviewed at least annually or when requested by any of the participating parties. The agreements also address services that are refused by the resident; the potential negative consequences; and the resident’s acceptance of the risks involved.
People with special needs may be served if the facility has admission and discharge criteria that identify the diagnosis, behavior, or specific clinical needs of the residents to be served. A written physician’s order is required for admission. Prior to admission, the resident or their legal representative must be informed of the services and programs available. Staff must complete training on the needs of the residents to be served. Exits must be controlled in the least restrictive possible manner.
A drug regimen review conducted by a pharmacist is required for residents who receive assistance with medication administration or whose medications are administered by facility staff. Medication aides may administer oral and topical medications and assist with medication administration. Medication reminding may be performed by a licensed nurse, medication aide, or nurse aide. Medication reminding includes asking if the medication has been taken, handing the medication to the resident, and opening the container. Medication reminding does not include taking the medication out of the container.
A “Money Follows the Person” pilot program began in 2003. Using available HCBS waiver slots for 75 nursing residents, the State uses funds from the nursing home appropriation to pay for services in the community, many of whom are moving to assisted living facilities.
Medicaid waiver services have been available since 1997 to elderly recipients who meet the nursing home level of care criteria and have income below 300 percent of the federal SSI payment. The room-and-board amount is negotiated between the facility and the resident but the amount of income that may be retained by the resident is limited to $716 a month, which is the maintenance allowance. SSI beneficiaries retain a $30 personal needs allowance.
The State uses a “care plan” method for paying for services. The care plan is developed by a case manager in the Area Agency on Aging. Services are billed fee for service. The maximum rate for health care attendant services is $3.18 per unit (15 minutes) for Level I tasks and $3.52 per unit for Level II tasks. Plans requiring a mix of both levels are reimbursed at the Level II rate. Family members may supplement resident income for room and board costs.
| Medicaid Participation | |||||
|---|---|---|---|---|---|
| 2004 | 2002 | 2000 | |||
| Facilities | Participation | Facilities | Participation | Facilities | Participation |
| 155* | 769* | 155 | 769 | NR | NR |
Sufficient numbers of qualified personnel must be available to ensure that residents receive services in accordance with negotiated service agreements.
Administrator. The licensee shall appoint an administrator or operator who holds a Kansas license as an adult care home administrator or has successfully completed an operator training program as designated by the secretary. The hours of training for operators was increased from 24 to 32 to spend more time on regulatory requirements and nursing issues.
Staff. Facilities shall provide orientation to new employees and regular in-service training for all employees to ensure that services provided assist residents to attain and maintain their individuality, autonomy, dignity, independence, and ability to make choices in a home-like environment.
In-service education must include: principles of assisted living; fire prevention and safety; disaster procedures; accident prevention; resident rights; infection control; and prevention of abuse, neglect, or exploitation of residents.
In-service education on treatment of behavioral symptoms shall be provided to all employees of facilities that admit residents with dementia.
Not described.
Surveyors inspect every facility annually. Consistent enforcement of the regulations has been credited with improved compliance and fewer complaints. Deficiencies are written more concisely with a focus on the consumer and outcomes. Under a new survey process, facility staff accompany the surveyor during the review. Problem areas are identified and discussed with the staff. Educational efforts have been increased. The licensing agency conducts regular one-day training courses for nurses, owners and operators on the role of nursing in assisted living, how to conduct an assessment and develop a service plan, managing medications and the nurse practice act. During the training, scenarios are presented and participants prepare a care plan based on the information presented.
$50, plus $15 for each resident.
Assisted living community certification 910 KAR 1:240; relates to KRS
194A.700-729; 42 USC 3029
Statutory authority: KRS 194A.050(1), 194A.707(1)
Personal care homes 902 KAR 20:036
An assisted living community must be certified by the State in order to operate and market itself as an assisted living community. Assisted living communities are considered private business entities. There is no public funding. A bill (HB 174) was passed in 2001 that requires coverage of services in assisted living facilities by long-term care insurance policies. Regulations were promulgated in 2001.
| Supply | ||||||
|---|---|---|---|---|---|---|
| Category | 2004 | 2002 | 2000 | |||
| Facilities | Units | Facilities | Units | Facilities | Units | |
| Personal care homes | 204 | 7,389 | 204 | 7,792 | 201 | NR |
| Assisted living communities | 83 | NA | 73 | NA | 6 | NA |
Assisted living community (ALC) means a series of living units on the same site, operated as one business entity, and certified under KRS 194A.707 to provide services for five or more adult persons not related within the third degree of consanguinity to the owner or manager.
Personal care homes (PCHs) are establishments with permanent facilities including resident beds. Services provided include continuous supervision, basic health and health-related services, personal care services, residential care services, and social and recreational activities.
ALC. Each living unit in an assisted living community shall have at least 200 square feet for single occupancy, or for double occupancy if the room is shared with a spouse or another individual by mutual agreement; include at least one unfurnished room with a lockable door, private bathroom with a tub or shower, provisions for emergency response, window to the outdoors, and a telephone jack; and have an individual thermostat control if the assisted living community has more than 20 units. Units may be shared only by choice. Any assisted living community that was open or under construction on or before July 14, 2000, is exempt from the requirement for each living unit to have a bathtub or shower, or for each living unit having 200 square feet for single occupancy, or for double occupancy if the room is shared with a spouse or another individual by mutual agreement. Such communities must have a minimum of one bathtub or shower for every five residents.
PCH. No requirements are specified for room size. The maximum number of beds per room is four. At least 66 percent of the beds in the facility must be located in rooms designed for one or two beds. Facilities using central bathing areas must have bathrooms and showers/baths for each sex on each floor. One toilet is required for every eight residents, a lavatory for every 16 residents, and a shower/bath tub for every 12 residents.
ALC. A client shall be ambulatory or mobile non-ambulatory, unless due to a temporary health condition for which health services are being provided in accordance with KRS 194A.705(2) and (3) not be a danger to self or others.
PCH. Personal care homes may admit persons who are 16 years or older and who are ambulatory or mobile nonambulatory and whose care needs do not exceed the capability of the home. Persons who are nonambulatory or nonmobile may not be admitted to a personal care home. Residents must be able to manage most of the activities of daily living. Residents must have a complete medical evaluation upon admission or within 14 days prior to admission. Residents whose care is not within the scope of services of a personal care home must be transferred to an appropriate facility.
ALC. The assisted-living community shall provide each client with the following services according to the lease agreement: assistance with activities of daily living and instrumental activities of daily living; three meals and snacks made available each day; scheduled daily social activities that address the general preferences of clients; and assistance with self-administration of medication. Clients of an assisted-living community may arrange for additional services under direct contract or arrangement with an outside agent, professional, provider, or other individual designated by the client if permitted by the policies of the assisted-living community. Upon entering into a lease agreement, an assisted living community must inform the client in writing about policies relating to the contracting or arranging for additional services. Assisted living communities may not provide health care services.
PCH. All homes must provide basic health and health-related services including: continuous supervision and monitoring; supervision of self-administration of medications, storage, and control when necessary; and arrangements for obtaining therapeutic services ordered by the resident’s physician which are not available in the facility; activities; housekeeping and maintenance services; laundry; three meals a day; and personal care.
ALC. No provisions specified.
PCH. Three meals and snacks are required. Therapeutic diets may be provided. If provided, consultation with a qualified dietician or nutritionist is required unless the person responsible for food service has those qualifications. Menus must meet the nutrition needs of residents as contained in the current recommended dietary allowances of the Food and Nutrition Board. All staff must be trained in accordance with their duties. Training for food staff must cover therapeutic diets.
ALC. A lease agreement is required that includes: client data for the purposes of providing services which includes a functional needs assessment pertaining to a client’s ability to perform activities of daily living and instrumental activities of daily living; emergency contact name; name of responsible party or legal guardian; attending physician’s name; information regarding personal preferences and social factors; advance directives; optional information helpful to identify services that meet the client’s needs; general services and fee structure; information regarding specific services provided, unit, and associated fees; a minimum 30-day notice for a change in fee structure; a minimum 30-day notice for move-out notices for nonpayment; refund and cancellation policies; payment responsibilities and arrangements; the owner’s covenant to comply with appropriate laws and regulations; conditions for termination; terms of occupancy; reasonable rules of conduct for staff, management, and tenant; grievance policies; and a copy of the tenant’s rights. It may also include additional services that will be provided or arranged. Agreements must provide for single occupancy apartment unless shared by mutual agreement. An assisted-living community must assist a client in making alternative living arrangements in the event of a move-out notice.
PCH. Upon admission the resident and a responsible family member must be informed in writing of the home’s policies, fees, reimbursement, visitation rights during serious illness, visiting hours, types of diets offered, and services rendered.
ALC. Resident lease agreements contain a description of special programming, staffing, or training for serving clients with special needs. Facilities serving people with special needs are required to provide consumers with information about the special programming, staffing, or training that is offered.
PCH. Not specified.
ALC. Not specified.
PCH. Medications shall not be administered or provided to any resident except on the order of a licensed physician or other ordering personnel acting within the limits of their statutory scope of practice. Administration of all medications must be kept in the resident’s record. All medications must be kept in a locked place.
No Medicaid funds are available for either category.
ALC. Staffing in assisted-living communities shall be sufficient in number and qualification to meet the 24-hour scheduled and unscheduled needs of its clients and services provided. One awake staff member must be on site at all times. A designated manager who is at least 21 years of age with a high school or GED diploma must be employed.
PCH. Based on the needs of residents. One attendant must be awake and on duty on each floor in the facility at all times. The home must identify a staff person responsible for the activities program.
ALC. Assisted-living community staff and management shall receive orientation and in-service education on the following topics as applicable to the employee’s assigned duties: client rights; community policies; adult first aid; cardiopulmonary resuscitation; adult abuse and neglect; Alzheimer’s disease and other types of dementia; emergency procedures; aging process; assistance with ADLs and IADLs; particular needs or conditions if the assisted-living community markets itself as providing special programming, staffing, or training on behalf of clients with particular needs or conditions; and assistance with self-administration of medication.
PCH. All personal care home employees shall receive in-service training to correspond with the duties of their respective jobs. Documentation of in-service training shall be maintained in the employee’s record and shall include: who gave the training, date and period of time training was given, and a summary of what the training consisted of. In-service training shall include but not be limited to the following:
ALC applicants must assure that no officer, director, trustee, limited partner, or shareholder has ever been convicted of a felony, Class A misdemeanor or abuse of a person.
ALC. Unless there is a formal complaint lodged against a facility, the State does not conduct oversight and monitoring of the quality of care in assisted living communities. The State conducts a certification review upon application, and an annual recertification review. These reviews ensure compliance with the certification requirements. Any assisted-living community that provides services or markets itself as assisted living without filing a current application or receiving certification may be fined up to $500 per day.
ALC. $20 per unit, $300 minimum, and $1,600 maximum. A fee of $250 is charted for architectural review, lease agreement, and notification of conditional compliance to a lender.
SB 1560 (1997). Adult residential care facility: Louisiana Revised Statutes Annotated §2151 et seq.; LA administrative code title 48, §8901 et seq.
The regulations for adult residential care facilities, which include assisted living facilities, were initially approved in 1999, and created core requirements for adult residential care facilities plus three modules for assisted living facilities, personal care homes, and shelter care facilities. The modules contain separate requirements for administrators, staff training, and living units. The rules state that the purpose of the regulations is to promote the availability of appropriate services for elderly and disabled persons in a residential environment; to enhance the dignity, independence, privacy, choice, and decision-making ability of the residents; and to promote the concept of aging in place.
The regulations may be revised later in 2004 or 2005 to address issues related to caring for people with Alzheimer’s disease, negotiated risk agreements and other issues. A report to the legislature was filed in response to legislation that directed that Department of Health and Hospital nurses who conduct nursing home surveys accompany Department of Social Service surveyors on a sample of facilities.
| Supply | ||||||
|---|---|---|---|---|---|---|
| Category | 2004 | 2002 | 2000 | |||
| Facilities | Units | Facilities | Units | Facilities | Units | |
| Assisted living facilities | 67 | 4,157 | 66 | 3,906 | 66 | 3,119 |
| Personal care homes | 44 | 286 | 29 | 176 | 33 | 216 |
| Shelter care homes | 17 | 543 | 26 | 841 | 26 | 670 |
Adult residential care home means a publicly or privately operated residence that provides personal assistance, lodging, and meals (for compensation) to two or more adults who are unrelated to the residence licensee, owner, or director.
Assisted living home/facility means an adult residential care facility that provides room, board, and personal services, for compensation, to two or more residents that reside in individual living units which contain, at a minimum, one room with a kitchenette and a private bathroom.
Personal care home means an adult residential care facility that provides room, board, and personal services, for compensation, to two but not more than eight residents in a congregate living setting and is in a home that is designed as any other private dwelling in the neighborhood.
Shelter care home means an adult residential care facility that provides room, board, and personal services, for compensation, to nine or more residents in a congregate living and dining setting.
Assisted living facilities must offer apartment style units with lockable doors to ensure privacy, dignity, and independence. Efficiency/studio units must provide 250 square feet excluding bathrooms and closets and may be shared by no more than two people by choice. Units with separate bedrooms shall have a living area of at least 190 square feet, excluding bathroom and closets. Each separate bedroom must have 120 square feet.
Personal care homes offer a home-like atmosphere with 100 square feet in single occupancy rooms and 70 square feet per resident for double occupancy rooms.
Shelter care facilities must have 100 square feet in single occupancy rooms and 160 square feet for double occupancy rooms. No more than two residents may share a room, and they must agree in writing to share a room. Facilities must have adequate toilet, bathing, and hand washing facilities in conformance with the state sanitary code.
Residents may include those who need or wish to have available room, board, personal care, and supervision due to age, infirmity, physical disability, or social dependency. Residents with advanced or higher care needs may be accepted or retained if the resident can provide or arrange for care through appropriate private duty personnel, does not need continuous nursing care for more than 90 days, and the provider can meet the resident’s needs. Facilities may not enter into contracts with outside providers to deliver health related services. These services must be arranged by the resident, family members, or the resident’s representative. Residents must be discharged if a physician certifies that more than 90 days of continuous care is needed or the resident is a danger to himself or others.
The State has criteria for skilled nursing care and two levels of intermediate care. The minimum criteria for admission to a nursing home include: requiring supervision or assistance with personal care needs, assistance in eating, administration of medications, injections less than daily, skin care, protection from hazards, mild confusion or withdrawal, medications for stable conditions or those requiring monitoring once a day, and stable blood pressure requiring daily monitoring. The determination is made by a physician based on his or her professional judgment of the above factors.
Basic services provided include assistance with ADLs and IADLs, three meals a day, personal and other laundry, opportunities for individual and group socialization, housekeeping, services for residents who have behavior problems, recreation services, and assistance with self-administration of medications. Providers must plan or arrange for health assessments, health care monitoring, and assistance with health tasks as needed or requested. Facilities must have the capacity to provide transportation for medical services, personal services (barber/beauty), personal errands, and social/recreational activities.
Menus must be reviewed and approved by a nutritionist or dietician to assure nutritional appropriateness. Facilities must make reasonable accommodations to meet dietary requirements and religious and ethnic preferences; to make snacks, fruit, and beverages available when requested; and to provide meals in a resident’s room (on a temporary basis). Medically prescribed special diets must be provided and planned or approved by a registered licensed dietician.
Agreements must include: clear and specific occupancy criteria and procedures (admission, transfer, and discharge); basic services available; optional services available; payment provisions (covered and non-covered services; service packages; and á la carte, regular, and extra fees; payer; due date; funding source); modification provisions including at least a 30-day notice of rate changes; refund policy; authority of the licensing agency to examine records; general facility policies/house rules; responsibilities of the facility, resident, and family for overseeing medical care, purchasing supplies/equipment, and handling emergencies and finances; and the availability of a service plan. Facilities must allow review by an attorney.
None specified. Regulations in this area may be developed later in 2004 or early 2005.
Facilities may provide assistance with self-administration of medications, however, residents may be assisted with pouring or otherwise taking medications only if they are cognitive of what the medication is, what it is for, and the need for the medication. Residents may contract with an outside source for medication administration. Staff assisting with medications must have training on the policies and procedures for assistance.
A four-year pilot program approved by the legislature in 1997 to test the feasibility of covering assisted living under Medicaid has been deferred by budget problems. Legislation passed in 2000 extended authority for the project until 2005. Funds to implement the project have been requested in the 2005 budget, which was pending before the legislature. The project, intended to serve 60 people in two sites, will be implemented by the Department of Health and Hospitals. The project will include two assisted living facilities and serve elderly Medicaid beneficiaries who can no longer live at home because they need additional care with ADLs but do not require continuous nursing care and have no alternative under the traditional model except institutional care. The pilot “shall maximize the independence of the elderly while providing the assistance that the special needs of this population require.” The bill defines assisted living as “a residential congregate housing environment combined with the capacity by in-house staff or others to provide supportive personal services, 24-hour supervision and assistance, whether or not such assistance is scheduled, social and health related services to maximize residents’ dignity, autonomy, privacy, and independence and to encourage facility and community involvement.” Residents must be offered a chance to live in private quarters with a lockable door, bedroom, kitchenette, and bathroom.
The RFP will request that bidders propose a flat monthly rate to serve beneficiaries. Room and board will be limited to the SSI payment, less $100 for personal needs. The State plans to use the 300 percent eligibility option.
Providers must demonstrate that sufficient staff are scheduled and available to meet the 24-hour scheduled and unscheduled needs of residents and show adequate coverage for each day and night. Assisted living facilities and shelter care facilities must have at least one awake staff on duty at night.
Administrators must be 21 years of age. Assisted living administrators must have a bachelor’s degree plus two years of experience in the field of health, social, management administration, or in lieu of a degree, 6 years of experience and education or a master’s degree in geriatrics, health care administration, or a human service related field.
Shelter care home administrators must have 2 years of college and 2 years experience or 4 years experience in lieu of college or a bachelor’s degree. Personal care home administrators must have 2 years of college training plus 1 year experience or 3 years of experience in lieu of college or a bachelor’s degree.
Staff. An orientation program shall include but not be limited to thorough coverage of the following areas: facility policies and procedures, emergency and evacuation procedures, residents’ rights, procedures for and legal requirements concerning the reporting of abuse and critical incidents, and instruction in the specific responsibilities of each employee’s job. Direct care staff orientation must cover training in resident care services (personal care), infection control, and any specialized training to meet resident needs. All direct care staff must receive certification in first aid. An annual training plan must be developed that includes the topics covered by the orientation.
Licenses may be denied based on a criminal conviction of any board member, owner, or staff if the act that caused the conviction would cause harm to a resident if repeated. Providers must include the results of a criminal history check in each employee’s personnel file.
The Department of Health shall make at least annual inspections. Complaints are to be reviewed and investigated by the appropriate state agency.
The annual licensing fee for ALFs is $175 for two to four beds; $200 for five to eight beds; and $250 for nine or more beds. The fee for personal care homes is $200.
Assisted Living Programs 10-144 Chapter 113
The State licenses five types of facilities providing assisted living services--assisted living programs and four levels of residential care facilities. The levels vary primarily by size. Residential care facilities may offer the same services assisted living programs do, but provide bedrooms rather than apartment units. The scope sections of the rules establish a philosophy of regulation to support services that are individualized to meet resident needs and encourage each resident’s right to independence, choice and decision-making, while providing a safe environment.
Regulations implementing the legislation passed (Chapter 1664) in 2002 were effective in September 2003.
| Supply | |||||||
|---|---|---|---|---|---|---|---|
| Category | 2004 | Category | 2002 | 2000 | |||
| Facilities | Units | Facilities | Units | Facilities | Units | ||
| Level I RCF | 95 | 161 | Leve I residential care | 473 | 1,711 | 509 | 1,799 |
| Level II and III RCF | 415 | 1,785 | Level II residential care | 192 | 5,220 | 189 | 4,904 |
| Level IV RCF | 201 | 5,647 | |||||
| ALP | 30 | 1,429 | Congregate housing | 24 | 1,133 | 14 | 799 |
Assisted living services means the provision by an assisted living program, either directly by the provider or indirectly through contracts with persons, entities or agencies, of assisted living services which include personal supervision; protection from environmental hazards; assistance with activities of daily living and instrumental activities of daily living; diversional, motivational or recreational activities; dietary services; care management services; administration of medications; and nursing services.
Assisted living services may be provided in two types of settings--assisted living programs and residential care facilities. Residential care facilities are further divided into four subgroups.
Assisted living program means a program of assisted living services provided to consumers in private apartments in buildings that include a common dining area, either directly by the provider or indirectly through contracts with persons, entities or agencies. The types of assisted living programs governed by these regulations include:
Residential care facility means a house or other place that, for consideration, is maintained wholly or partly for the purpose of providing residents with assisted living services. (Note: both assisted living programs and residential care facilities provide assisted living services. The definition of the living unit differs.)
Residential care facilities provide housing and services to residents in private or semi-private bedrooms in buildings with common living areas and dining areas. There are four types of residential care facilities:
Alzheimer’s/dementia care unit means a unit, facility, or distinct part of a facility that provides care/services in a designated separate area for residents with Alzheimer’s disease or other dementia. The unit, facility, or distinct part provides specialized programs, services, and activities and is locked, segregated, or secured to provide or limit access by a resident outside the designated or separated area.
Assisted living programs are multi-unit residential buildings that provide apartments and must meet state and local building codes.
Level I-IV residential care facilities must offer 100 square feet for single room and 80 square feet for double rooms. Level IV facilities provide one toilet and sink for every six residents. Facilities licensed on or after May 30, 2002, must have one bathing facility for 10 users (one for 15 residents for facilities licensed prior to May 30, 2002). No more than two residents may share a room.
The rules encourage aging in place and have very flexible policies to achieve that goal. In its application, all facilities must describe who may be admitted and the types of services, including the scope of nursing services, to be provided. Facilities may discharge tenants who pose a direct threat to the health and safety of others, damage property, or whose continued occupancy would require modification of the essential nature of the program. The rules also require facilities to permit reasonable modifications at the expense of the tenant or other willing payer to allow persons with disabilities to reside in licensed facilities. Providers may require the disabled individual to return the premises to its prior condition.
In brief, individuals must meet medical, medical/functional or cognitive/behavior requirements. Individuals must have a need for daily skilled nursing or extensive assistance in three of the following ADLs: bed mobility, transfer, locomotion, eating and toileting; or a combination of three needs in the following areas: skilled nursing, cognition, behavior, and at least limited assist in 1 of the following ADLs: bed mobility, transfer, locomotion, eating and toileting. The list of nursing services includes any specified physician-ordered services provided on a frequent rather than daily basis; professional nursing assessment, observation and management for impaired memory, and impaired recall ability, and impaired cognitive ability; professional nursing assessment, observation, and management for problems including wandering, physical abuse, verbal abuse or socially inappropriate behavior; administration of treatments, procedures, or dressing changes that involve prescription medications and require nursing care and monitoring; and professional nursing for physician-ordered radiation therapy, chemotherapy, or dialysis. Skilled services also include physician-ordered occupational, physical, or speech/language therapy or some combination of the three, which must require the professional skills of a licensed or registered therapist.
The cognition and/or behavior requirements apply for individuals who do not require professional nursing intervention at least 3 days per week but are eligible if they have a qualifying score on the Cognitive Screen and/or Behavioral Screen, in combination with a need for at least “limited assistance” with an ADL, for a total of three service needs. The qualifying scores are cognitive score = 13 points and two ADL’s; or cognitive score = 13 points and behavioral score = 14 and one ADL; or behavioral score = 14 points and two ADL’s.
All facility levels are required to describe the scope of services provided, including scope of nursing services consistent with applicable state and federal law as part of their licensing application.
Assisted living programs must offer service coordination, housekeeping services, assistance with ADLs and IADLs, at least one nutritious meal a day, chore services and other services identified in a service plan.
Level I, II, and III residents have the right to receive assistance from the provider to implement any reasonable plan of service developed with community or state agencies.
Level IV residents are able receive individualized services that help them age in place, function optimally in the facility and in the community, engage in constructive activity, and manage their health conditions and accommodate individual choices and preferences. The regulations require reasonable accommodation in regulations, policies, practices or services, including permitting reasonable supplementary services to be brought into the facility/program unless it imposes an undue financial burden or results in a fundamental change in the program.
Residents must be assessed within 30 calendar days of admission and reassessed annually or when there is a significant change in condition. A service plan must be developed and implemented within 30 calendar days of admission based upon the assessment. The plan addresses areas in which the resident needs encouragement, assistance or an intervention strategy. The plan describes strategies and approaches to meet the resident’s needs, names of who will arrange and/or deliver services, when and how often services will be provided and goals to improve or maintain the resident’s level of functioning. Residents are encouraged to be as independent as possible in their functioning, including ADLs and normal household tasks if they choose, unless contraindicated by the resident’s duly authorized licensed practitioner.
Assisted living program. A registered dietician must approve menus and menu cycles annually. Menus must be planned in accordance with resident needs and preferences. Therapeutic diets must be ordered by any duly licensed practitioner in all levels. A least one nutritious meal a day must be delivered by the assisted living program.
Levels I-IV require a nourishing, well-balanced diet that meets the daily nutritional and special dietary needs of each resident and that meets the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences. Level IV facilities must have a meal plan that provides three meals in a 24-hour period and a dietary coordinator who has experience and/or training in food service suitable to the size of the facility.
The State requires adoption of a standard contract for all assisted living services. All resident contracts will contain standard provisions regarding services and accommodations to be provided and the rates and charges for such and any other related charges not covered by the facility/program’s basic rate. Each contract may not contain a provision for the discharge of a resident that is inconsistent with state law or rule; a provision that may require or imply a lesser standard of care or responsibility than is required by law or rule; provide for at least 30 calendar day’s notice prior to any changes in rates, responsibilities, services to be provided or any other items included in the contract; may not require a deposit or other prepayment, except one month’s rent in an assisted living program, which may be used as a security deposit provided there is a statement of the explicit return policy of the facility with regard to the security deposit; and may not contain a provision that provides for the payment of attorney fees or any other cost of collecting payments from the resident. Additional information is appended to the contract--grievance procedure, tenancy obligations, resident rights, and a copy of the admissions policy.
In addition, an information packet must also be provided that contains advance directives information; information regarding the type of facility and the licensing status; the Maine Long Term Care Ombudsman Program brochure; toll-free telephone numbers for the Office of Advocacy of the Department of Behavioral and Developmental Services (BDS) if the facility has residents who receive services from BDS; Adult Protective Services; Assisted Living Licensing Services and Division of Licensing and Certification; the process and criteria for placement in, or transfer or discharge from, the program; and the program’s staff qualifications.
The provisions for serving people with dementia apply to all levels. Facilities must provide written information about their philosophy; the process used for resident assessment and establishment of a residential services plan and its implementation; the physical environment and design features that support the functioning of adults with cognitive impairments; the frequency and types of group and individual activities provided by the program; a description of family involvement and the availability of family support programs; a description of security measures provided by the facility; a description of in-service training provided for staff; and policies with criteria and procedures for admission and discharge of residents to and from the facility/unit.
The design must include secured outdoor space and walkways; high contrast between floors, walls, and doorways; nonreflective surfaces; and even lighting to minimize glare. Residents may not be locked inside or outside of their rooms. Residents are encouraged and assisted to decorate their unit with personal items and furnishings. Facilities try to individually identify each resident’s room to help with recognition. Facilities also have policies and procedures to deal with wandering. Electronic locking devices may be used on exterior doors if they release in an emergency.
These facilities must provide individual and/or group activities covering gross motor skills, self care, social interaction, crafts, sensory enhancement, as well as outdoor and spiritual activities.
For pre-service training, all facilities with Alzheimer’s/dementia care units must provide a minimum of 8 hours of classroom orientation and 8 hours of clinical orientation to all new employees assigned to the unit. The trainer(s) shall be qualified with experience and knowledge in the care of individuals with Alzheimer’s disease and other dementias. In addition to the usual facilities orientation, which should cover such topics as resident rights, confidentiality, emergency procedures, infection control, facility philosophy related to Alzheimer’s disease/dementia care, and wandering/egress control, the eight hours of classroom orientation should include the following topics: a general overview of Alzheimer’s disease and related dementias, communication basics, creating a therapeutic environment, activity focused care, dealing with difficult behaviors, and family issues.
Unlicensed staff who have successfully completed a training program approved by the licensing agency may administer medications and/or treatments. All residents are assessed for their ability to self-administer medications or their need for assistance. A standard curriculum for training in medication administration was adopted for use statewide.
Maine uses two programs to cover services in residential care facilities: a Medicaid state plan option and state revenues. While assisted living is not listed as a covered waiver service, residents of residential care facilities could receive HCBS waiver services (personal support services, homemaker, chore, home health, transportation, personal emergency response) as long as there is no duplication between the services covered in the residential care facility payments and the waiver services. The state plan program provides reimbursement for personal care services through contracts with Private Non-Medical Institutions (PNMIs) licensed as Residential Care Facilities. Payment levels are based on the average acuity of residents in the facility. The same reimbursement restrictions on duplication of payment apply to HCBS waiver services for people living in assisted living programs.
| Medicaid Participation | |||||
|---|---|---|---|---|---|
| 2004 | 2002 | 2000 | |||
| Facilities | Participation | Facilities | Participation | Facilities | Participation |
| 150 | 3,762 | 151 | 3,096 | 141 | 3,190 |
The state SSI payment standard was changed July l, 2004, to $574 which includes personal needs allowance of $70/month ($50 if there is no earned income). State general fund are available to supplement the resident’s room and board payment when the allowable cost of room and board exceeds the resident cost of care.
A State-funded demonstration program serves 175 beneficiaries in seven affordable assisted living programs. Services are based on a plan of care. The resident pays standard HUD rents, and contributes 30 percent of his or her income toward services retaining at least $100 for their personal needs. On July 1, 2004, these services were covered as Medicaid state plan services. Payments are based on Medicaid beneficiary-specific rates according to their acuity.
Assisted living programs. The sponsor must assure that services will be provided to residents in accordance with individual service plans. Administrators must hold a professional license related to residential or health care or have a combination of 5 years of related education and experience.
Residential care facilities. Level IV administrators must demonstrate capacity to operate and manage the facility and allow access to records of professional licensing boards or registers, any criminal record, child protective record or adult protective record relating to the applicant/licensee and administrator, and other records.
Administrators must successfully complete a Department-approved training program for administrators unless they have a license from the Nursing Home Administrators Licensing Board as a Residential Care Administrator or Multi-Level Facility Administrator. They must obtain 12 hours a year of continuing education.
Levels I and II. Operators must have a person available to provide supervision in their absence. Staffing must be adequate to implement service plans. The department may require additional staff based on the needs of residents and the size and lay out of the facility.
Level III. Staffing must be adequate to implement service plans. Additional staffing may be required by the Department. The licensing agency has the authority to require that Level I-III facilities obtain services from a consulting nurse, pharmacist or dietician and a consulting dietician for Level IV facilities.
Level IV. RCFs serving over ten residents must have two awake staff on duty at night (one must be direct care staff. The rules require a ratio of one direct care staff to12 residents from 7 a.m. to 3 p.m.; one direct care staff to 18 residents from 3 p.m. to 11 p.m.; and one direct care staff to 30 residents from 11 p.m. to 7 a.m. The revised rules require a registered nurse on staff or contract to observe signs and symptoms; review records, medication records, medication administration practices and procedures, and therapeutic diets; and recommend staff training. The frequency of these activities varies with the size of the facility from weekly for larger facilities to quarterly for smaller facilities.
Level IV facilities with more than 10 beds must have a pharmacy consultant no less than quarterly to review written policies and procedures for pharmaceutical services; medication areas for labeling, storage, temperature, expired medications, locked compartment, access to keys and availability and completeness of a first aid kit; review to ensure that only approved drugs and biologicals are used in the facility; review medication records and initial and date the records when reviewed; review adherence to stop orders; and review staff performance in carrying out pharmaceutical policies and procedures.
Administrators must successfully complete a department approved training program. Ongoing training of at least 12 classroom hours annually is required in areas related to care of the population served.
Staff. Level I, II, III. Residential care staff must attend and show evidence of successful completion of any training that the department determines to be necessary.
Level IV. All staff, other than certified nursing assistants (CNAs) and licensed professional staff, whose job responsibilities include direct service to residents for at least 20 hours per week, shall successfully complete a Personal Support Specialist certification course within 120 days of hiring. Additional training specific to a facility’s programs may be identified and required by the Department for any staff.
Any person working in the facility must demonstrate the following: conduct which demonstrates an understanding of, and compliance with, residents’ rights; the ability and willingness to comply with all applicable laws and regulations; the ability to provide safe and compassionate services; and a history of honest and lawful conduct.
Additional requirements for individuals who administer medications in Levels III and IV. Staff must complete a training program approved by the department and must have 8 hours of refresher training every 2 years. If the training program is substantially revised, they must be re-certified within 1 year of the change.
During the licensure process, a criminal background check is conducted for the applicant and the administrator. Facilities must contact the CNA Registry and determine that the CNA or CNA-M is on the Registry and has not been annotated. Facilities may not employ a CNA or CNA-M who is not on the Registry, or who has been annotated for abuse, neglect or misappropriation of patient/client/resident funds in a health care setting. Further changes are pending that would expand the types of individuals for whom the registry must be checked and who may not be employed if there is a positive finding.
The department is authorized to make regular and unannounced inspections of all facilities. The regulations specify the grounds for imposition of intermediate sanctions and the method of calculating penalties. The State ombudsman program is authorized to visit facilities and receive and investigate complaints.
Chapter 1664 sets fees of $10 per bed for residential care facilities and $200 for assisted living programs.
Assisted living programs Title 10.07.14
The opening section of the rules state that the purpose of the chapter is to set minimum, reasonable standards for licensure of assisted living programs that are intended to maximize independence and promote the principles of individuality, personal dignity, freedom of choice, and fairness for all individuals residing in assisted living programs.
Assisted living program rules were revised in 2002 to clarify medication administration requirements and to add disclosure provisions for facilities serving residents with Alzheimer’s disease. The HCBS waiver has been expanded to include all assisted living facilities.
Legislation passed in 2004 requiring an 80-hour training course for managers. The curriculum is being drafted by the licensing agency.
The uniform assessment tool was revised in 2003. The previous tool did not adequately assess and determine a level of care for people with behavior problems and dementia. As a result, more residents are likely to be assigned to level three.
A workgroup was formed in 2003 to initiate a thorough review of the regulations and current trends. A preliminary report was submitted to the legislature in 2003. The workgroup will continue to meet and submit recommendations to the legislature in the fall of 2004. A major focus of the workgroup is the definition of assisted living which currently requires that people caring for one person to be licensed. The group is considering setting a minimum number of people served and setting different requirements for small and larger programs. The group is likely to recommend requiring awake overnight staff and nursing oversight in homes serving more than 17 residents.
| Supply* | ||||||
|---|---|---|---|---|---|---|
| Category | 2004 | 2002 | 2000 | |||
| Facilities | Units | Facilities | Units | Facilities | Units | |
| Assisted living programs | 1,248 | 17,148 | 2,000 | 14,273 | 2,500 | NR |
* 2000 and 2002 reports were based on estimates as the State converted from its previous regulatory structure to one that consolidated difference.
An assisted living program is “a residential or facility-based program that provides housing and supportive services, supervision, personalized assistance, health related services, or a combination thereof to meet the needs of residents who are unable to perform, or who need assistance in performing, the activities of daily living or instrumental activities of daily living in a way that promotes optimum dignity and independence for the residents.” The term “assisted living program” may not be used in advertising unless the facility is licensed.
Programs licensed after the effective date of the regulations must provide a minimum of 80 square feet of functional space for single occupancy and 120 square feet for double occupancy rooms. No more than two residents may share a room. Facilities previously licensed as domiciliary care homes must provide a minimum of 70 and 120 square feet for single and double occupancy, respectively. Buildings with one to eight occupants must have one toilet for every four occupants and larger buildings must also have at least one toilet on each floor. Showers/baths must be available for every eight occupants.
Facilities are licensed by the level of impairment of residents. Residents are assigned to a level based on an assessment score. The assessment includes 12 questions that cover medical illnesses/conditions and additional questions covering cognitive and psychiatric conditions, treatment requirements, medication management, ADL assistance, risk factor management, and management of problematic behaviors.
In general, programs may not serve anyone who, at the time of admission, requires more than intermittent nursing care; treatment of Stage III or IV skin ulcers; ventilator services; skilled monitoring, testing, and aggressive adjustment of medications and treatments where there is the presence of, or risk for, a fluctuating acute condition; monitoring of a chronic medical condition that is not controllable through readily available medications and treatments; treatment for an active reportable communicable disease; or treatment for a disease or condition which requires more than contact isolation. Residents may not be admitted if they are a danger to self or others and the danger cannot be eliminated through appropriate treatment modalities or if they are at risk for health or safety complications which cannot be adequately managed.
A program may request a waiver to care for residents with needs that exceed the licensure level. It must demonstrate that it can meet the resident’s needs and others will not be jeopardized.
Waivers for Level I and Level II programs may not be granted for more than 50 percent of the licensed bed capacity. Level III programs may not receive waivers for more than 20 percent of capacity or 20 beds, whichever is less.
Nursing home care is covered when an individual requires health related services provided on a daily basis by or under the supervision of a nurse due to medical, cognitive or physical disability. The need for intermittent, part-time services does not qualify (for example home health nursing), nor does the need for unlicensed care (e.g., personal care) even if care is needed full time. There is some overlap in how the term intermittent nursing care is applied under the licensing and Medicaid level of care policies.
Before move-in, the assisted living manager determines whether the resident may be admitted and whether the resident’s needs can be met by the program based on an assessment and an examination by a health care professional. A functional assessment is completed within 30 days of admission that includes: level of functioning in activities of daily living; level of support and intervention needed, including any special equipment and supplies required to compensate for the individual’s deficits in activities of daily living; current physical or psychological symptoms requiring monitoring, support, or other intervention by the assisted living program; capacity for making personal and health care-related decisions; presence of disruptive behaviors, or behaviors which present a risk to the health and safety of the resident or others; and specified social factors.
Services include three meals in a common dining area, special diets, personal care, laundry, housekeeping, social and spiritual activities, and medication management. The program must facilitate access to health care and social services (social work, rehabilitation, home health, skilled nursing, physician services, oral health, counseling, psychiatric care, and others).
Three meals a day and snacks that are well-balanced, palatable, varied, properly prepared, and of sufficient quantity and quality to meet daily nutritional needs are required. As part of the licensing process, facilities submit a 4-week menu cycle with documentation by a licensed nutritionist or licensed dietician that the menus are nutritionally adequate. Special diets as ordered by a physician or needed by the resident must be provided.
Agreements must include a clear and complete reflection of commitments and actual practices and a recommendation for review by an attorney. The agreement includes: the level of care for which the facility is licensed; the level of care needed by the resident; a statement that describes that a resident may be discharged if the level of care increases and a waiver is not approved; a list of services provided and not provided; complaint/grievance procedure; occupancy provisions (room assignment, relocation, change in roommate, transfer policy, availability of locks for storage); the staff’s right to enter a room (if any); resident rights; bed hold policy; admission and discharge policy; obligations of all parties for arranging for and overseeing medical care and monitoring health status.
The agreements must also include financial information that includes: obligations for payment; handling finances; purchase of rental equipment; arranging and contracting for services not provided by the facility; durable medical equipment; and disposition of resident property upon discharge or death. Also included are the rate structure for the service package, fee-for-service rates; notification of changes; third-party payments; person responsible for payment; procedures if the resident is no longer able to pay; and terms governing refunds. If the resident’s needs change significantly, the agreement must be amended.
Programs with an Alzheimer’s special care unit or program must complete the department’s disclosure form that describes: a statement of philosophy or mission; staff training and staff job titles, including the number of hours of dementia-specific training provided annually for all staff by job classification and a summary of training content; admission procedures, including screening criteria; assessment and care planning protocol, including criteria to be used that would trigger a reassessment of the resident’s status before the customary 6-month review; staffing patterns, including the ratio of direct care staff to resident for a 24-hour cycle, and a description of how the staffing pattern differs from that of the rest of the program; a description of the physical environment and any unique design features appropriate to support the functioning of cognitively impaired individuals; a description of activities, including frequency and type, how the activities meet the needs of residents with dementia, and how the activities differ from activities for residents in other parts of the program; the program’s fee or fee structure for services provided by the Alzheimer’s special care unit or program as part of the disclosure form that is required in §E(1) of this regulation; discharge criteria and procedures; and any services, training, or other procedures that are over and above those that are provided in the existing assisted living program.
Aides who have passed required training may administer medications. Untrained aides may assist with self-administration. Management must arrange for quarterly, on-site reviews of medications by a registered nurse, authorized prescriber, or licensed pharmacist for each resident who self-administers medications.
The State administers an HCBS waiver and a state funded program that serves beneficiaries age 50 and older in residential settings. A waiver amendment included assisted living services as part of a broad package of services available to people 50 years of age or older in their own or in residential settings. Amendments to the waiver raised eligibility to 300 percent of the federal SSI benefit. Room and board, paid by the resident, is capped at $420 a month. Medicaid pays the lesser of the provider’s usual and customary charge or $1,602.75 a month for Assisted Living Level II services and $2,021.75 for Level III services. The Level I licensing level of care does not qualify for the Medicaid waiver. Non-SSI beneficiaries are allowed a personal needs allowance of $60 and all additional income is applied to the cost of care. SSI beneficiaries retain SSI benefits above the amount paid for rent and do not pay toward the cost of services. The Medicaid waiver program served 1,473 beneficiaries in 763 facilities in 2004, up from 730 beneficiaries in 362 facilities in 2002.
| Medicaid Participation | ||||||
|---|---|---|---|---|---|---|
| 2004 | 2002 | 2000 | ||||
| Facilities | Participation | Facilities | Participation | Facilities | Participation | |
| Medicaid | 763 | 1,473 | 362 | 730 | 132 | 135 |
| State | NR | 350 | 259 | 520 | NR | NR |
Additional payments are available for assistive equipment and environmental modifications. Medicaid will pay the actual costs and payment is capped at $1,000 per participant for 12 months. Medicaid will pay 67 percent of the costs of environmental modifications (the provider pays 33 percent), up to a maximum of $3,000 per participant. Exceptions to the maximum are allowed at the discretion of the Department on Aging.
The state-subsidized Senior Assisted Housing program served 350 participants in 2004. Participants with incomes no greater than 60 percent of the statewide median income and assets no greater than $11,000 apply their income (less a $60 needs allowance) toward the cost of care. State-funded subsidies may cover the difference between the participant’s contribution and the monthly fee, up to a maximum of $550 a month.
The law directs the Office of Aging to develop assisted living programs in conjunction with public or private, profit or nonprofit entities, maximizing the use of rent and other subsidies available from federal and state sources. These activities can include finding sponsors; assisting developers formulating design concepts and meeting program needs; providing subsidies for congregate meals, housekeeping and personal services; developing eligibility requirements in connection with the subsidies; adopting regulations governing eligibility; and reviewing compliance with relevant regulations.
| Maryland Medicaid Payment System | ||
|---|---|---|
| Level II | Level III | |
| Services | $1,610.66 | $2,030.86 |
| Room and board | $420 | $420 |
| Total | $2,031.66 | $2,451.86 |
| Assistive equipment add on | up to $1,000 | up to $1,000 |
| Environmental modification | up to $3,000 | up to $3,000 |
NOTE: Rates reflect a .5% increase effective July 1, 2004.
Based on the number of residents to be served and their needs, the facility develops a staffing plan that identifies the type and number of staff needed to provide the services required. The staffing plan includes on-site staff sufficient in number and qualifications to meet the 24-hour scheduled and unscheduled needs of the residents. A staff member must be present when a resident is in the facility.
Programs must have staff capacity to deliver the care for which they are licensed (see table below). Facilities contracting with Medicaid must have one staff member for every eight residents during daytime hours.
Administrators. Assisted living managers must have adequate knowledge of the health and psycho-social needs of the population served; resident assessment process; use of service plans; cuing, coaching and monitoring residents who self-administer medications with and without assistance; providing assistance with ambulation, personal hygiene, dressing, toileting, and feeding; residents’ rights; fire and life safety; infection control; basic food safety; basic first aid; basic CPR; emergency disaster plans; and individual job requirements of all staff.
Staff must participate in an orientation and ongoing training program to ensure that residents receive services that are consistent with their needs and generally accepted standards of care for the specific conditions of those residents to whom staff will provide services. Staff must receive initial and on-going training in: fire and life safety; infection control, including standard precautions; basic food safety; basic first aid; emergency disaster plans; and individual job requirements as appropriate to their job.
Staff must have knowledge in: health and psycho-social needs of the population served as appropriate to their job responsibilities; resident assessment process; use of service plans; and resident rights.
If job duties involve the provision of personal care services, staff must have knowledge in cuing, coaching, and providing assistance with ADLs.
Facilities participating in the Medicaid waiver: staff must complete an 8-hour training on medication administration and pass a performance test.
Applicants must document any felony conviction of the applicant, assisted living manager, or household member (in small, owner-occupied facilities). Management must conduct either a criminal history records check or a criminal background check consistent with §19-1901 et seq. Annotated Code of Maryland.
Under the law, the Department of Health and Mental Hygiene may delegate monitoring and inspection of programs to the Office on Aging and the Department of Human Resources or to local health departments through an interagency agreement. Survey findings and plans of correction must be posted in the facility.
$25 a year for programs monitored by the Department of Human Resources or the Department on Aging; $100 a year for programs inspected and monitored by the Department of Health and Mental Hygiene. Programs with 16 beds or more pay $100 a year plus $6 for each bed over 15.
| Maryland Level of Care Differences--Staff Capacities | |||
|---|---|---|---|
| Area | Level I-- Low (0-25) |
Level II-- Moderate (26-60) |
Level III-- High (61+) |
| Health and wellness | Ability to recognize the cause and risks associated with a resident’s health condition once these factors are identified by a health care professional. Provide occasional assistance in accessing and coordinating health services and interventions. | Ability to recognize and accurately describe and define a resident’s health condition and identify likely causes and risks associated with the resident’s condition. Provide or ensure access to necessary health services and interventions | Ability to recognize and accurately describe and define a resident’s health condition and identify likely causes and risks associated with the resident’s condition. Provide or ensure ongoing access to coordination of comprehensive health services and interventions |
| Functional | Provide occasional supervision, assistance, support, set up, or reminders with some but not all ADLs. | Provide or ensure substantial support with some, but not all, ADLs or minimal supports with any number of ADLs. | Provide or ensure comprehensive support as frequently as needed to compensate for any number of ADLs. |
| Medication and treatment | Ability to assist with self-administration of medications or coordinate access to necessary medications and treatments. | Provide or ensure assistance with self-administration of medications or administer necessary medications and treatments, including monitoring their effects. | Provide or ensure assistance with self-administration of medications or administer necessary medications and treatments, including monitoring or arranging for monitoring the effects of complex medication and treatment regimens. |
| Behavioral | Monitor and provide uncomplicated intervention to manage occasional behaviors that are likely to disrupt or harm the resident or others. | Monitor and provide or ensure intervention to manage frequent behaviors which are likely to disrupt or harm the resident or others. | Monitor and provide or ensure ongoing therapeutic intervention or intensive supervision to manage chronic behaviors which are likely to disrupt or harm the resident or others. |
| Psychological | Monitor and manage occasional psychological episodes or fluctuations that require uncomplicated intervention or support. | Monitor and manage frequent psychological episodes or fluctuations that may require limited skilled interpretation or prompt intervention or support. | Monitor and manage a variety of psychological episodes involving active symptoms, condition changes, or significant risks that may require some skilled interpretation or immediate interventions. |
| Social and recreational | Occasional assistance in accessing social and recreational services | Ability to provide or ensure ongoing assistance in accessing social and recreational services. | Provide or ensure ongoing access to comprehensive social and recreational services. |
Assisted living: 651 CMR 12.00 et seq.
Chapter 354 (Acts of 1994) created a certification process for assisted living facilities by the Executive Office of Elder Affairs. The law provides that the regulations “shall be sufficiently flexible to allow assisted living residences to adopt policies and methods of operation which enable residents to age-in-place.” To be certified, residences must submit information such as the number of units and number of residents per unit, location of units, common spaces, and egress by floor; base fees to be charged; services to be offered and arrangement for delivering care; number of staff to be employed; and other information required by the Executive Office of Elder Affairs. The buildings are considered residential use for applying appropriate building codes.
Revisions to the regulations were final in December 2002. The State initiated a major review of the assisted living statute and regulations during summer 2004. The review will examine the experience in other states with particular attention to quality, the quality improvement process, and how quality can be woven into the regulations.
The Governor announced a new initiative, “Helping Our Massachusetts Elders” (HOME) that will provide alternatives to nursing home care. This new initiative creates an interagency task force of government agencies and establishes a $4 million trust fund as part of the state supplemental budget to support programs that allow elders to remain in home and community-based settings and supports a voluntary managed care program that emphasizes preventative care. Elder Affairs believes this new initiative will have a significant impact on assisted living and other residential alternatives in the State. The request for funding is pending.
| Supply | ||||||
|---|---|---|---|---|---|---|
| Category | 2004 | 2002 | 2000 | |||
| Facilities | Units | Facilities | Units | Facilities | Units | |
| Assisted living residences | 171 | 10,585 | 139 | 9,796 | 139 | 8,200 |
Assisted living residence is any entity, however organized, whether conducted for profit or not for profit, which meets all of the following criteria:
Provides room and board; provides, directly by employees of the entity or through arrangements with another organization which the entity may or may not control or own, assistance with activities of daily living for three or more adult residents who are not related by consanguinity of affinity to their care provider; and collects payments or third-party reimbursements from or on behalf of residents to pay for the provision of assistance with the activities of daily living.
Units must be single or double occupancy with lockable doors. New construction must provide for private baths. Existing buildings may qualify if they provide private half baths and one bathing facility for every three persons. All facilities must provide, at a minimum, either a kitchenette or access to cooking capacity for all living units. Cooking capacity is defined as each resident having access to a refrigerator, sink, and heating element. Facilities must comply with all federal and state laws and regulations regarding sanitation, fire safety, and access by persons with disabilities. The Secretary of Elder Affairs is authorized to waive the requirements for bathrooms and bathing facilities when determined to meet public necessity and to prevent undue economic hardship as long as the resi