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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 gro