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HHS Logo Eagle IconU.S. Department of Health and Human Services

Regulatory Review of Adult Day Services: Final Report, 2014 Edition

Publication Date

Janet O'Keeffe, Dr.PH, RN, Christine O'Keeffe, BA, and Madhu Shrestha, BS

RTI International

ABSTRACT

Adult day services (ADS)--a non-residential service provides outside an individual's home for less than a full day--provides direct care to older adults and younger adults with physical disabilities. These services also meet caregivers' need for respite in order to work, fulfill other obligations, and recover from the demands of continuous caregiving. Many caregivers who use ADS are providing care to family members with dementia who need constant supervision to ensure their safety. By providing respite to unpaid caregivers, ADS can potentially delay or prevent nursing home placement. This report provides information about each state's approach to regulating this key community service.

DISCLAIMER: The opinions and views expressed in this report are those of the authors. They do not necessarily reflect the views of the Department of Health and Human Services, the contractor or any other funding organization.

TABLE OF CONTENTS

ACKNOWLEDGMENTS

ACRONYMS

EXECUTIVE SUMMARY

INTRODUCTION

  • Terms, Definitions, and Language
  • Data Collection and Methods
  • Organization of the Report

1. OVERVIEW OF ADULT DAY SERVICES REGULATIONS

  • Licensing, Certification, and Other Requirements
  • Inspection and Monitoring
  • Parameters for Who Can Be Served
  • Required and Optional Services
  • Provisions Regarding Medications
  • Staffing Requirements
  • Training Requirements
  • Public Funding of Adult Day Services
  • Conclusion

2. STATE REGULATORY PROFILES

NOTES

ACKNOWLEDGMENTS

We would like to acknowledge the following individuals for their contributions to this project: Emily Rosenoff, U.S. Department of Health and Human Services/Office of the Assistant Secretary for Planning and Evaluation Project Officer who provided guidance throughout the project; the staff in state regulatory and Medicaid agencies, and representatives of state adult day services provider associations who directed us to resources that could not otherwise be found and answered questions about the interpretation of specific regulations; Joshua Wiener, Senior Fellow, RTI International, and Teresa Johnson, Executive Director for the National Adult Day Services Association for comments on an early draft of the report; and Peter Notarstefano, Director of Home and Community-Based Services, Leading Age, and Damon Terzaghi, National Association of States United for Aging and Disabilities, for their assistance in identifying knowledgeable providers and state agency staff in each state. We greatly appreciate the willingness of these dedicated professionals to share their knowledge and expertise.

ACRONYMS

The following acronyms are mentioned in this report and/or state profiles.

AAA Area Agency on Aging
ACT Alabama Community Transition
ADC Adult Day Care
ADH Adult Day Health
ADH-M Adult Day Health Services-Mobile
ADHC Adult Day Health Care
ADHS Adult Day Health Services
ADL Activity of Daily Living
ADP Adult Day Program
ADS Adult Day Services
AIDS Acquired Immune Deficiency Syndrome
ALTCS Arizona Long Term Care System
APD Oregon Aging and People with Disabilities Division
ASA Maine Assessing Services Agency
ASPE HHS Office of the Assistant Secretary for Planning and Evaluation
BA Bachelor of Arts
BS Bachelor of Science
BSW Bachelor of Social Work
CARES Alabama Caregiver Assistance with Resources, Education, and Support
CCP Illinois Community Care Program
CCSP Georgia Community Care Services Program
CHOICE   Indiana Community and Home Options to Institutional Care for the Elderly and Disabled Program  
CMA Certified Medication Aide
CNA Certified Nursing Assistant
COPE Nevada Community Options for the Elderly
COPES Washington State Community Options Program Entry System
CPR Cardiovascular Pulmonary Resuscitation
CRMA Certified Residential Medication Aide
DAAS Arkansas Division of Aging and Adult Services
DADS Texas Department of Aging and Disability Services
DAHS Day Activities and Health Services
DAIL Vermont Department of Disabilities, Aging and Independent Living  
DAS Georgia Division of Aging Services
DC District of Columbia
DCOA District of Columbia Office on Aging
DD Developmental Disabilities
DHCFP   Nevada Department of Health Care Financing and Policy
DHEC South Carolina Department of Health and Environmental Control
DHHS Maine Department of Health and Human ServicesNebraska Department of Health and Human ServicesNew Hampshire Department of Health and Human Services
DHR Alabama Department of Human Resources
DHS Illinois Department of Human ServicesOklahoma Department of Human ServicesOregon Department of Human ServicesTennessee Department of Human Services
DHSS Delaware Department of Health and Social ServicesNew Jersey Department of Health and Senior Services
DMAS Virginia Department of Medical Assistance Services
DOA Ohio Department on Aging
DOH New Mexico Department of HealthNew York Department of HealthTennessee Department of Health
DPH Massachusetts Department of Public Health
DSDS Alaska Division of Senior and Disability Services
DSS Virginia Department of Social Services
E&D Elderly and Disabled Waiver
ECOP Enhanced Community Options Program
EDCD Elderly or Disabled Consumer-Direction Waiver
HHS U.S. Department of Health and Human Services
HIV Human Immunodeficiency Virus
IDAPA Idaho Administrative Procedure Act
IDD Intellectual and Other Developmental Disabilities
IDOA Illinois Department on Aging
LPN Licensed Practical Nurse
LTSS Long-Term Services and Supports
LVN Licensed Vocational Nurse
MAT Medication Administration Technician
MCO Managed Care Organization
MDoA Maryland Department of Aging
MLTC Managed Long-Term Care
MLTSS Managed Long-Term Services and Supports
OAA Older Americans Act
ORS Illinois Office of Rehabilitation Services
OSA Michigan Office of Services to the Aging
PACE Program of All-Inclusive Care for the Elderly
PASSPORT   Ohio Pre-Admission Screening System Providing Options and Resources Today waiver  
PRN Pro re nata (commonly used to mean "as needed" in Latin)
QExA Hawaii QUEST Expanded Access
QSP Qualified Service Providers
QUEST Hawaii Medicaid program for elderly, blind or disabled individuals
RN Registered Nurse
SADS Social Adult Day ServicesSpecialized Adult Day Services
SCA Maine Service Coordination Agency
TAP Texas The Alternatives Program
TB Tuberculosis
VA U.S. Department of Veterans Affairs

EXECUTIVE SUMMARY

Adult day services (ADS)--a non-residential service provided outside an individual's home for less than a full day--provides direct care to older adults and younger adults with physical disabilities. These services also meet caregivers' need for respite in order to work, fulfill other obligations, and recover from the demands of continuous caregiving. Many caregivers who use ADS are providing care to family members with dementia who need constant supervision to ensure their safety. By providing respite to unpaid caregivers, ADS can potentially delay or prevent nursing home placement.

This report provides information about each state's approach to regulating this key community service. Three ADS models are generally recognized: a social model; a health or medical model, which is sometimes combined with the social model; and a specialized model that provides services to meet the unique needs of individuals with a specific diagnosis, most often dementia.

The social model is designed for individuals who need supervision and activities but not extensive personal care and medical monitoring. The medical model provides more extensive personal care, medical monitoring, and rehabilitative services in addition to structured and stimulating activities.

States generally term these two models as ADS and adult day health services, and have more extensive requirements for the latter, particularly for nurse staffing. While some states license the models separately, others license providers to offer both models. The provision of health-related and medical services--particularly health monitoring, preventive health care, and ensuring the timely provision of primary care--can help to reduce health care costs.

While states vary in their approach to regulating ADS, all have some form of regulation and exercise oversight of ADS. About half require licensure, 11 require providers to meet certification standards, four require licensure for one ADS model and certification for another, and 13 use some other type of regulation, such as contractual requirements for providers receiving public funding. In over half the states, providers of Medicaid-funded ADS must meet additional Medicaid requirements.

Because ADS providers must meet Medicaid State Plan or waiver contracting requirements to furnish services to Medicaid beneficiaries--either in addition to or in lieu of state licensing or certification requirements--they are regulated at a level which allows them to furnish health-related and medical services, as well as long-term care services to elderly persons with a high level of nursing and medical needs.

For all these reasons, ADS are an important component of states' long-term care systems. Every state provides funding for these services through either the Medicaid State Plan or a waiver program and 24 states fund them through non-Medicaid programs as well. In 2012, 273,200 participants were enrolled in ADS centers.

INTRODUCTION

Adult day services (ADS)--a non-residential service provided outside an individual's home for less than a full day--is a key community service that provides direct care to participants and meets caregivers' need for respite in order to work, fulfill other obligations, and recover from the demands of continuous caregiving. In 2012, 273,200 participants were enrolled in ADS centers.1

States fund ADS as part of their long-term care systems, through both Medicaid and non-Medicaid programs. In addition to providing an important service to individuals with functional limitations, states fund these services because of their potential to delay or prevent nursing home placement, primarily by supporting informal caregiving. ADS can also reduce health care costs by providing health monitoring, preventive health care, and ensuring the timely provision of primary care, particularly for individuals at risk for incurring high medical costs.

States also cover day services for adults with intellectual and other developmental disabilities (IDD), which are regulated through the state and local systems that serve this population, and are not included in this report.2 The report also does not include information about reimbursement rates, which vary according to the services ADS providers furnish, and thus are not comparable among states.3

In 2005, the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation (HHS/ASPE), published the first national review of state regulation of ADS--including licensing, certification, and/or contractual requirements. Its purpose was to better understand the role that ADS can and do play in meeting the health and long-term care needs of older adults and working-age adults with physical disabilities, by examining key regulatory provisions--including required and optional services, and staffing and training requirements. This report updates the 2005 review.

Terms, Definitions, and Language

Three major ADS models are generally recognized: a social model; a health/medical model, which is sometimes combined with the social model; and a specialized model.

The social model generally provides a secure environment, supervision, assistance with some activities of daily living (ADLs), and therapeutic activities aimed at helping participants to achieve optimal physical and mental functioning. The health or medical model provides many of the same services furnished in the social model and also medical, nursing, and rehabilitation services. Many programs combine both models.

Specialized models serve specific populations. For example, Colorado has a specialized services model called specialized ADS center, which provides intensive health supportive services for participants with a primary diagnosis of Alzheimer's disease or other dementias, multiple sclerosis, brain injury, chronic mental illness, or developmental disabilities, or for post-stroke participants who require extensive rehabilitative therapies.

States generally regulate one or two models of ADS programs--social and medical. Some states allow providers to offer both models in one program, called a combined model.

States use different terms for the three models; many use the terms adult day care (ADC) and adult day health care (ADHC) to distinguish the social from the medical model, but some states use the term adult day care for the medical model.4 For example, New Hampshire licenses adult day care as a medical model and adult day non-medical program services as a social model. New Hampshire's Medicaid program covers ADC under its State Plan and a 1915(c) waiver program but calls the service adult medical day services.

To avoid confusion, this report uses the term adult day services as a generic term covering the social, medical, combined, and specialized models5--and the term adult day health services (ADHS) specifically for the medical model. When discussing each state, the report uses state-specific terms. States also use different terms for individuals served in ADS settings, such as client and recipient. This report uses the term participant.

Virtually all of the information in the individual state profiles is taken directly from states' statutes, regulations, and rules. However, because many states' provisions are written in "legalese," in many cases we have edited the language to ensure grammatically correct and consistent usage; to eliminate redundancy; to use scientifically accurate terms; and to ensure that the provisions are easily understood and comparable across states.

Data Collection and Methods

We conducted extensive Internet searches of state departments and offices of health, human services, and aging to locate licensing, certification, and any other regulatory requirements for ADS providers. We also conducted Internet searches to identify Medicaid and non-Medicaid programs that cover ADS and any requirements they have for ADS providers.

To ensure that the regulations found online were the most current and not undergoing revision, we contacted knowledgeable individuals in each state--either state provider representatives or state agency staff. At the start of this project, Arizona, Georgia and Massachusetts were in the process of revising their ADS regulations. Arizona approved its revised regulations during the study period, and Georgia and Massachusetts approved their revisions in 2015 and their profiles include information current as of May 2015. All of the other state profiles are current as of December 2014.

We asked state agency staff to review the regulatory profiles, but not all did. In more than half the states, representatives of state provider associations either reviewed the profiles and/or responded to requests for clarifications.

Most states' regulatory information was understandable, but occasionally, questions about undefined terms and the interpretation of ambiguous rules arose. In these instances, we contacted state regulatory and Medicaid agency staff for clarification. In all but three states we were able to obtain the answers sought.

The final section of each state profile includes the names and affiliations of individuals who provided information. A few profiles do not include the name of any state agency staff--either because those contacted did not respond or because the person who provided information changed jobs.

Organization of the Report

Section 1 of this report provides a brief overview of states' approaches to regulating ADS in selected areas--those included in each individual state's profile--and highlights similarities and differences among them. The selected areas include the state's general approach to regulation, inspection and monitoring; parameters for who can be served; required and optional services; provisions regarding medication; and staffing and training requirements.

Section 2 provides a profile for each state that describes its overall approach to regulating ADS providers, selected regulatory provisions, and Medicaid and other public funder requirements (if any).

1. OVERVIEW OF ADULT DAY SERVICES REGULATIONS

This section provides a brief overview of states' approaches to regulating ADS providers in key areas and highlights similarities and differences among them.

Licensing, Certification, and Other Requirements

The majority of states regulate ADS through licensure or certification.

  • 26 states require licensure only;
  • 10 states require certification only;
  • 4 states require both licensure and certification; and
  • 11 states do not require licensure or certification.

In the 11 states that do not require licensure or certification, ADS providers that serve only private pay participants are not regulated. Those that serve publicly-funded participants--through Medicaid and non-Medicaid programs--must meet the requirements of these programs and enter into some type of contract or agreement with the state agency that administers the programs. In four states that license and/or certify ADS programs, providers must meet additional requirements to receive reimbursement from publicly-funded programs.

Exhibit 1 indicates whether a state requires licensure, certification, or both, and/or some other type of contractual arrangement. In addition to licensing, certification, and other contractual requirements, ADS providers are required to comply with all applicable state, county, and local building regulations, zoning, fire, and health codes or ordinances.

EXHIBIT 1. State Approach to Regulation

State   Licensure  Only   Certification  Only   Licensure +  Certification Other  Requirements  
Alabama --- --- --- X
Alaska --- X --- ---
Arizona X --- --- ---
Arkansas X --- --- ---
California --- --- X ---
Colorado --- X --- ---
Connecticut --- X --- ---
Delaware X --- --- ---
District of Columbia   --- --- --- X
Florida X --- --- ---
Georgia X --- --- X
Hawaii X --- --- ---
Idaho --- --- --- X
Illinois --- X --- ---
Indiana --- --- --- X
Iowa --- X --- ---
Kansas X --- --- ---
Kentucky --- --- X ---
Louisiana X --- --- ---
Maine X --- --- ---
Maryland --- --- X ---
Massachusetts X --- --- X
Michigan --- --- --- X
Minnesota X --- --- ---
Mississippi --- --- --- X
Missouri X --- --- ---
Montana X --- --- ---
Nebraska X --- --- ---
Nevada --- --- X X
New Hampshire X --- --- ---
New Jersey X --- --- X
New Mexico X --- --- ---
New York --- --- --- X
North Carolina --- X --- ---
North Dakota --- --- --- X
Ohio --- X --- ---
Oklahoma X --- --- ---
Oregon --- X --- X
Pennsylvania X --- --- ---
Rhode Island X --- --- ---
South Carolina X --- --- ---
South Dakota --- --- --- X
Tennessee X --- --- ---
Texas X --- --- ---
Utah X --- --- ---
Vermont --- X --- ---
Virginia X --- --- ---
Washington --- --- --- X
West Virginia X --- --- ---
Wisconsin --- X --- ---
Wyoming X --- --- ---
TOTAL 26 10 4 15
--- = not applicable.

Licensure

States have three basic approaches to licensure: (1) licensing a single model of ADS--social, medical, or combined; (2) licensing two models--generally ADS and ADHS--under a single licensing category; and (3) licensing two or more different models under two or more licensing categories.

States that license a social and medical or combined model under a single licensing category generally have some requirements that providers of both models must meet, and some that only the medical model providers must meet. For example, Florida licenses ADC centers and adult day health care (ADHC) is not a specific licensing category. However, if an ADC center chooses to be an ADHC provider, it must provide additional services, such as nursing and rehabilitative therapies, and meet related staffing requirements.

Very few states require a separate license to provide specialized services to specific populations. Florida requires a separate license to operate a Specialized Alzheimer's Services Adult Day Care Center, and Maine requires a separate license for ADHS and social ADS programs that want to operate a night program for persons with dementia. Other states that serve participants with special needs specify additional requirements in the regulations rather than requiring separate licenses.

Specific Requirements for Participants with Special Needs

Twenty-five states have specific requirements for providers that serve people with dementia, as shown in Exhibit 2. States' requirements may apply to any ADS program that serves people with dementia or only to programs that exclusively serve this population. Any additional requirements generally relate to staffing and training, such as requiring lower staff-to-participant ratios and dementia-specific training for all staff. For example, Michigan requires ADS programs to have no less than one staff person for each ten participants but requires dementia programs to have a minimum staff/volunteer/student-to-participant ratio of 1:3. Ten states have additional requirements for participants with other conditions, such as mental illness.

EXHIBIT 2. States with Provisions for ADS Centers Serving Participants with Special Needs

State   Dementia     Other  
Alabama --- ---
Alaska X ---
Arizona --- ---
Arkansas X ---
California X X1
Colorado --- X2
Connecticut --- ---
Delaware X X3
District of Columbia   --- ---
Florida X ---
Georgia X ---
Hawaii --- X4
Idaho --- ---
Illinois --- ---
Indiana --- X5
Iowa X ---
Kansas X ---
Kentucky X ---
Louisiana X ---
Maine X X6
Maryland --- ---
Massachusetts X ---
Michigan X ---
Minnesota X ---
Mississippi --- ---
Missouri X ---
Montana --- ---
Nebraska --- ---
Nevada X ---
New Hampshire X ---
New Jersey X ---
New Mexico --- ---
New York --- X7
North Carolina X X8
North Dakota --- ---
Ohio --- ---
Oklahoma --- ---
Oregon --- ---
Pennsylvania X ---
Rhode Island X X9
South Carolina --- ---
South Dakota X ---
Tennessee X ---
Texas --- ---
Utah X ---
Vermont --- ---
Virginia --- ---
Washington --- ---
West Virginia X X10
Wisconsin --- ---
Wyoming --- ---
TOTAL 25 10
--- = not applicable.
  1. Mental illness and traumatic brain injury.
  2. Multiple sclerosis, brain injury, chronic mental illness, and stroke.
  3. IDD and severe cognitive or physical disabilities.
  4. Psychiatric illness.
  5. Mild to severe cognitive impairments and high physical acuity needs.
  6. Parkinson's disease.
  7. HIV/AIDS.
  8. Mental health disabilities, or other special needs, diseases, or conditions.
  9. Mental health conditions or other special needs, diseases, or conditions.
  10. Developmental disabilities, traumatic brain injury, mental illness, and HIV/AIDS.

Requirements for Co-Located ADS Providers

When ADS are co-located within other licensed settings such as nursing homes or assisted living facilities, states vary regarding licensure requirements. In Tennessee, if an ADC center is operated by a licensed facility such as a nursing home, the state may determine that its licensing provisions adequately regulate the ADC center's program and that a separate ADS license is not needed. But an ADC program, regardless of its affiliation or location, must comply with the program content requirements as detailed in the rules.

North Dakota requires licensed hospitals, nursing facilities, and basic care facilities that provide ADC services to individuals who do not remain in the facility overnight to obtain approval from the Department of Health, which licenses these facilities, and to enroll as qualified service providers (QSPs) and meet QSP standards. In West Virginia, a medical ADC program maintained and operated by a nursing home, hospital or other licensed health care facility must comply with the standards in the medical ADC licensing rule and compliance must be evaluated independently from compliance with other licensure standards. Sharing of staff, space, physical facilities, and equipment may be permitted only if the requirements of each applicable rule are satisfied in full.

Certification

Ten states require ADS providers to be certified rather than licensed. In three states--Alaska, Iowa, and North Carolina--certification is equivalent to licensure and is required for all providers, regardless of payment source. In Iowa, in addition to certification, a program may be voluntarily accredited by the Department's designated accreditation entity, the Commission on Accreditation of Rehabilitation Facilities.

Seven of the ten states require only ADS programs that receive funding from Medicaid or other publicly-funded programs to be certified--Colorado, Connecticut, Illinois, Ohio, Oregon, Vermont, and Wisconsin. In most of these seven states, the agency that oversees the program providing funding--for example, the Medicaid agency--certifies programs using its own standards.

Connecticut is an exception. To be reimbursed through public programs, adult day centers must meet the Connecticut Association of Adult Day Centers standards for certification, developed in cooperation with the Connecticut Department of Social Services. An adult day center may provide one or both models of care--social and/or medical. If both, each model requires separate certification.

Licensure Plus Certification

Two states require licensure for one model and certification for another. Kentucky licenses ADHC (medical model) and certifies ADC (social model). Maryland licenses ADC and medical day care but certifies a small social ADC program offered by the Maryland Department of Aging called Senior Center Plus. Providers must meet certification requirements for zoning and planning and Medicaid standards if serving waiver participants.

Two states require licensure for all providers and additional certification for Medicaid providers serving individuals in specific programs. California requires certification for licensed ADHC centers to become a Medi-Cal provider of Community-Based Adult Services in its managed care program. (Medi-Cal is the name of California's Medicaid program.) Nevada requires licensed Medicaid providers serving participants in the 1915(i) State Plan program to also be certified. In addition to meeting Medicaid's ADS-specific requirement, providers must meet the State Plan program's general provider qualifications and Medicaid program requirements.

Other Requirements

Eleven states do not license or certify ADS providers that serve only private pay participants. However, all of these states require ADS providers who wish to serve participants in publicly-funded programs to enter into official, most often contractual, agreements with the state agencies that administer these programs and to meet program requirements. Some of these states' contracting requirements are as detailed and exacting as other states' licensing or certification provisions.

For example, New York has two types of ADS programs: social ADS and ADHC. Providers of the social model serving Medicaid waiver participants and Medicaid managed long-term care participants must meet New York State Office for the Aging requirements. ADHC programs must be approved by the New York State Department of Health through New York's Certificate of Need Process and must comply with state rules and regulations governing this service.

Idaho's approach is somewhat different. ADC programs serving participants in the Commission on Aging Senior Services Program, must operate under guidelines established by the Idaho Commission on Aging that are in accordance with the standards developed by the National Council on Aging, National Institute on Adult Day Care (now known as the National Adult Day Services Association).

Four states that require licensure, certification, or both, also have other contracting requirements for certain programs. Massachusetts requires all providers of ADHS to be licensed, but providers of supportive day services and dementia day services do not require licensure. To be reimbursed through non-Medicaid public programs they must be operated in accordance with program standards issued by the Executive Office of Elder Affairs. Providers must agree to meet the standards as part of their provider agreement.

Oregon has operational standards, which ADS programs comply with on a voluntary basis. However, all ADS providers are required to register their programs on a registry administered by the Department of Human Services, Aging and People with Disabilities Division. When registering, providers are required to indicate on a checklist the extent to which they are voluntarily complying with the standards.

In Nevada, the Department of Human Resources Division for Aging Services funds ADS through grants to licensed providers who, in addition to licensure, must also comply with additional service specifications. Similarly, in New Jersey, the Department of Health and Senior Services administers a solely state-funded ADS program for persons with Alzheimer's disease, dementia, or memory disorders. The Department enters into letters of agreement with social ADC agencies and licensed ADHS providers, who must comply with the rules for this program.

Inspection and Monitoring

Regardless of how a state regulates ADS, ADS providers must comply with all applicable federal, state, departmental, or local statutes, laws, ordinances, rules, and regulations (e.g., fire safety, environmental, and food service requirements). Thus, providers may undergo multiple inspections in addition to the one conducted by the state licensing, certifying, or contracting entity.6 Generally, these inspections must occur before the inspection for licensing or certification.

For example, Tennessee's Department of Human Services requires the receipt of approvals from all relevant entities prior to conducting a pre-licensure inspection. Additionally, Tennessee requires that all ADS facilities be inspected and approved annually by an environmentalist of the Tennessee Department of Health (or a local health department), or receive annual approval as another licensed facility, such as a nursing home or an assisted living facility.

The inspection and monitoring provisions presented below are in addition to health, safety, fire, and other environmental requirements.

Most of the 40 states that require licensure or certification require inspections prior to initial licensure and generally prior to license renewal. Most also stipulate that unannounced visits will be made either at specified intervals or at any time to ensure compliance with rules or to investigate complaints.

In the states that license or certify ADS providers, the frequency of inspections varies, as the examples that follow demonstrate.

  • Alaska conducts an on-site inspection as part of the initial certification process. Initial certification is for 1 year and renewal certification is for 2 years. An additional on-site visit is conducted during the certification period.

  • Kansas conducts at least one unannounced inspection of each ADC facility within 15 months of any prior inspection. An additional site visit is conducted every 15 months to ensure that a facility complies with construction standards.

  • Nebraska conducts inspections prior to and following licensure and may conduct an on-site inspection any time it deems necessary. Each year, it conducts an inspection of up to 25 percent of ADS providers based on a random sample. In addition, it conducts focused inspections in response to complaints and incidents, or when 5 years have passed without an inspection.

  • North Carolina conducts a precertification inspection. To ensure compliance with certification standards, ADS programs are recertified annually in addition to monthly monitoring of compliance by county departments of social services. ADHS programs receive additional monitoring at least quarterly by county departments of health.

  • Oregon inspects and monitors only those ADS programs contracting with Medicaid. The initial certification for a 2-year period requires an on-site inspection. Recertification requires a self-assessment demonstrating that the program continues to meet the certification standards as well as an on-site inspection. Unannounced on-site certification reviews may be conducted at any time.

  • Wyoming conducts initial and annual renewal on-site licensure evaluation surveys and may also conduct an on-site inspection at any time at its discretion, for example, in response to a complaint.

  • Virginia issues initial licenses and renewals for an ADC center for periods of up to 3 successive years. ADC centers issued a license for a period of 6 months are inspected at least twice during the 6-month period, and at least one of these inspections is unannounced. ADC centers issued a license for a period of 1 year are inspected at least three times each year, and at least two of these inspections are unannounced. ADC centers issued a license for a period of 2 years are inspected at least twice each year, and at least one of those inspections is unannounced. For any ADC center issued a 3-year license, an unannounced inspection must be conducted each year.

In the states that do not require licensure or certification, inspections and other monitoring requirements are the purview of the state agencies that contract with ADS providers to serve participants in publicly-funded programs. As in states that require licensure and/or certification, states vary in the frequency of their inspections.

  • Indiana's Division of Aging conducts an on-site inspection before an ADS provider is included as a provider in one or more of its programs. On-site inspections are conducted every 3 years thereafter. Indiana's Medicaid agency also conducts surveys to ensure compliance with program requirements every 3 years.

  • Mississippi's Department of Human Services monitors ADS programs three times a year and at least every 6 months. Area Agencies on Aging (AAA) monitor and evaluate local service providers for their efficiency and effectiveness in delivering services. Medicaid waiver program staff conduct an on-site visit after an application is approved and before a provider number is issued. Site visits are conducted at least every 2 years.

  • New York's State Office for the Aging and local AAA are responsible for the oversight of social ADS programs that they fund, and they monitor them on a regular basis. If funded under a managed care contract, the managed care entity monitors providers to ensure that they comply with state requirements. The state Department of Health surveys ADHC programs (which are offered only by nursing facilities), which may or may not coincide with the nursing home survey.

  • Texas's Department of Aging and Disability Services may monitor providers in its Day Activity and Health Services program. The Health and Human Services Commission--which oversees Texas Star+Plus, a managed care program--does not have specific inspection and monitoring requirements for day activity and health services. However, the Texas Star+Plus managed care organizations (MCOs) may have their own inspection and monitoring requirements, which can vary.

Internal Evaluations

Many states require ADS providers to have an internal evaluation process, which can include annual evaluations, utilization reviews, participant satisfaction surveys, and participant improvement, or care plan audits. States generally require that any evaluation involve the governing body and advisory board (if any), multidisciplinary staff, participants and their family members/caregivers, and other relevant entities.

For example, Washington requires ADS centers to develop a quality improvement plan, with specific measurable objectives, designed to meet the requirements of any licensing agency, funding source, or regulations, as well as professional standards. The center's administrator must develop policies and procedures for monitoring program quality and determining further action needed to address identified problems.

Alaska requires each ADS program to conduct an internal evaluation of its operation and services at least annually. The evaluation must include: (1) a review of the extent to which the program assisted participants and their families and caregivers; (2) measurement of the achievement of goals and objectives; (3) outcome measures as designed by the state agency; (4) an assessment of the program's cost-effectiveness; (5) an assessment of the relationship of the program to the rest of the community service network; and (6) recommendations for improvement, corrective action of problem areas, and future program directions.

Parameters for Who Can Be Served

A primary purpose of regulating ADS is to ensure that providers are able to meet the needs of the aged/disabled population they serve. One option for doing so is to specify admission, retention, and discharge criteria, thereby setting the parameters for who can be served in ADS settings.

State definitions of ADS usually include general statements about the type of individuals that ADS providers may or may not admit or retain. In addition, virtually all states have provisions related to involuntary discharge, which generally give providers discretion to determine whether they can meet an individual's needs. Examples of such general statements follow.

  • Providers may serve only individuals whose needs can be met by the ADS center within its certification category.

  • Individuals may not be admitted or retained if the provider cannot meet their needs.

  • Participants can be involuntarily discharged when their condition presents an immediate and serious risk to their or others' health, safety, or welfare.

  • The licensee may not admit individuals requiring ongoing or extensive nursing care nor admit or retain individuals requiring a level of service that the center is not licensed to provide or does not provide.

  • Providers may not serve individuals who have communicable diseases that constitute a danger to other participants.

Some states have additional specific provisions regarding the types or level of functional or health needs that should preclude admission and retention. For example, South Carolina prohibits the admission or retention of individuals who are confined to a bed, whether because of a physical or mental condition, as well as those whose needs exceed the resources outlined in the regulations.

Kansas prohibits providers from admitting persons in need of specialized services for mental illness unless they are under the care of a physician and unless they can provide appropriate treatment can be provided. Although Kansas allows providers to define the target population they wish to serve, they are not allowed to admit individuals with the following conditions, unless their negotiated service agreement includes resources to meet their needs:

  • Incontinence and an inability to participate in its management;
  • Immobility;
  • Requires a two-person transfer;
  • Behavior symptoms that are not manageable; or
  • A clinical condition that requires the use of physical restraints.

Michigan allows ADS providers to serve individuals who require assistance with ADLs and regular supervision in order to live in their own home or the home of a relative; are capable of leaving their residence, with assistance, to receive services; and need intervention in the form of enrichment and opportunities for social activities to prevent and/or postpone deterioration that would likely lead to institutionalization.

Michigan's providers of dementia ADC may serve individuals who have a diagnosis of Alzheimer's disease or another type of dementia; do not have an acute medical illness; have significant impairments in cognition, communication, and ADLs; are responsive to redirection and other supportive verbal interventions when angry, anxious, lost, or upset; and may require one or more of the following: (1) modifications in environmental cues, communication approach, and task breakdown to enhance comprehension and participation in identified activities; (2) supervision to maintain personal safety; and (3) hands-on assistance to perform toileting, grooming, hygiene, and bathing.

Many states allow ADS providers considerable flexibility in determining who they will and will not serve. For example, Virginia requires ADC centers to develop a written statement of the purpose and scope of the services to be provided, and a description of adults who will be accepted into the program as well as those whom the program cannot serve. The center may admit only individuals who meet its admission criteria.

However, if providers choose to serve individuals with specialized needs, they generally will have to meet specific staffing requirements. For example, if an ADS program wants to admit individuals with skilled nursing needs, then it must employ licensed nursing staff who are immediately available on site to meet those needs. Providers who choose to serve only persons who do not have medical and nursing needs are not required to employ or contract with licensed nurses.

Pennsylvania prohibits the admission of individuals who are bedfast; have a communicable disease; have emotional or behavioral disorders; are habitually addicted to alcohol or drugs and, as a consequence of the addiction, are disruptive in a group setting; or do not need the activities and services provided in an ADS center and need referral to other, more appropriate programs, such as a senior center or nutrition site.

Providers are allowed to involuntarily discharge participants for one or more of the following reasons: (1) a participant experiences a sudden change in level of functioning that the center determines to be a threat to the participant or others; (2) a participant is not capable of being transported to the center; (3) a participant does not have a functional impairment and is not in need of the structured program of activities or services offered by the center; or (4) a participant no longer meets the admission criteria.

Generally, states permit medical models--ADHS--to serve individuals with nursing and medical needs. However, most states do not have explicit provisions for determining who may be served in ADHS programs. New York is an exception, defining an ADHC participant as someone: (1) who is not a resident of a nursing home; is functionally impaired and not homebound; requires supervision and monitoring, and preventive, diagnostic, therapeutic, rehabilitative or palliative care or services, but does not require continuous 24-hour-a-day inpatient care and services; (2) whose assessed social and health care needs can be met satisfactorily in whole or in part by the delivery of appropriate services in the community setting; and (3) who has been admitted to an ADHC program based on an authorized practitioner's order and the ADHC program's interdisciplinary comprehensive assessment.

If ADHC providers serve Medicaid waiver program participants--who must meet a state's nursing home level of care criteria--then they can most likely serve a population with extensive ADL and nursing needs. Nursing home level of care criteria, however, vary among states, sometimes markedly. Thus, an individual who meets the criteria in one state may not meet it in another and so the characteristics of waiver program participants served in ADHS programs in one state may be very different from those in another state.

In most states, the parameters for who can be served are set indirectly through provisions regarding mandatory and optional services, and mandatory staffing. For example, if the regulations state that ADS providers may furnish skilled nursing services and require registered nurse (RN) staffing, one can infer that individuals who need these services can be served.

Required and Optional Services

ADS programs provide socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine whether the program can continue to meet participants' health and functional needs. In addition to these core services, our review focused on whether states considered the following services to be mandatory or optional:

  • ADL assistance;
  • Health education and counseling;
  • Health monitoring;
  • Medication administration;
  • Nursing services;
  • Physical, occupational, and speech therapy;
  • Skilled nursing services;
  • Social services; and
  • Transportation.

Most states' licensing, certification, or contractual requirements identify a range of services that ADS providers must and may offer. Many of these services are self-explanatory, for example, ADL assistance, physical, occupational and speech therapy, and transportation. But many states do not define health education and counseling, health monitoring, nursing and skilled nursing services, and social services. When they do, the definitions are not always consistent across states.

To determine whether a state required or permitted ADS providers to offer these services, we reviewed states' definitions of these services and used the following definitions, which incorporate the most common services mentioned in states' statutes, regulations, and rules. We used the following definitions to determine whether each state considered the service mandatory or optional:

  • Health Education and Counseling comprise teaching good health and safety practices and self-management of health conditions, encouraging self-care, and counseling regarding health conditions and health care. Some states consider these services to be nursing services. In these cases, we indicated that both were either required or optional.

  • Health Monitoring comprises health screening; monitoring of participants' general health and medical status, including daily checking of vital signs, hygiene, and general functioning; checking weight and dental health; andtaking appropriate action when there is a change in condition, including immediately reporting changes to the participants' caregiver, physician, RN, or other health professional involved in their care.

  • Nursing Services are generally defined as health or health-related services, such as routine skin care; simple dressing changes; medical screening emphasizing prevention and continuity of care, which includes routine blood pressure checks or blood glucose diabetic maintenance checks; and supervision of health services provided by program aides.

  • Skilled Nursing Services are those that must be provided by an RN or a licensed practical nurse/licensed vocational nurse (LPN/LVN) under the supervision of an RN according to the requirements of states' Nurse Practice Acts. Most states that require or allow ADS providers to furnish skilled nursing services define them explicitly but some states do not. For example, New Jersey defines skilled nursing services by providing examples of such services that can only be provided by an RN or an LPN, including, but not limited to: (1) medication administration, pacemaker checks, or the monitoring of urinary output, unstable blood glucose, or unstable blood pressure that requires physician and or advanced practice nurse intervention; (2) wound treatment; (3) stasis ulcer treatment; (4) intravenous or intramuscular injection; and (5) nasogastric or gastrostomy tube feeding.

    Washington defines skilled nursing services generally as medically necessary services provided directly or indirectly by an RN under physician supervision, or by an LPN under physician or RN supervision, that a licensed nurse acting within the scope of practice can provide or supervise. Skilled nursing services include the initial assessment of applicants for ADS and development of the nursing plan of care. They also include: (1) skilled care and assessment of an unstable or unpredictable acute or chronic medical condition; (2) skilled nursing tasks (such as medication administration, wound care, inserting or irrigating a catheter); (3) training or teaching participants or their caregivers to manage self-care for newly diagnosed, acute, or episodic medical conditions (such as self-administration of an injection and caring for a colostomy, and disease self-management); and (4) evaluation and management of a plan of care when skilled nursing oversight is needed to ensure that complex non-skilled care is achieving its purpose.

    Some states consider medication administration to be a nursing service and other states consider it a skilled nursing service. We assessed medication administration as a distinct service. Provisions regarding medications are discussed in detail in the next section.

  • Social Services comprise: (1) a social and psychosocial assessment of individuals' formal and informal support systems and mental and emotional status; (2) discharge planning; (3) activities to ensure participants' access to appropriate resources and supplemental services if needed to meet special needs; (4) referrals for persons not appropriate for ADS; and (5) individual and group counseling for participants and their families and caregivers, generally by a licensed social worker or other professional staff.

State Variation

States vary considerably regarding which services they require or allow ADS providers to furnish. Section 2 of this report includes specific information about required and optional services for ADS and ADHS providers in each state.

In contrast to the social model of care, states generally require providers of the medical model--ADHS--to furnish skilled nursing services, medication administration, and rehabilitation therapies.

Some states do not list specific services as either required or optional, but other provisions suggest that they are at least optional, and in such instances, we counted them as such. For example, Arizona does not list transportation as a required or optional service, but a provision regarding reimbursement for transportation implies that the service is offered by at least some ADS providers. In Hawaii, the regulations do not list transportation as a required or optional service but require that transportation be addressed in participants' individualized care plans.

Often, provisions regarding mandatory and optional services are included in sections of the regulations that do not relate specifically to services. For example, provisions regarding medications sometimes were found in rules regarding the physical environment, with references to how medications must be stored.

Other states indicate required services by including them in the definition of ADS. For example, Maine defines ADHS as a program that provides health monitoring and personal care services in addition to a group program of care, therapeutic activities, and supervision. Therapeutic activities are defined as restorative activities designed to maintain or improve the quality of life or delay skill deterioration. Examples of therapeutic activities include those aimed at improving or maintaining gross motor activities, social activities, sensory enhancement activities, crafts, outdoor activities, spiritual activities, and extensive ADL assistance.

Provisions Regarding Medications

Virtually all states require providers to have written policies for medication management and administration, which must be in accordance with applicable state laws, including each state's Nurse Practice Act.

Most states make a clear distinction between providing assistance to participants who administer their own medications (i.e., assistance with self-administration) and administering medications. Many states require providers of the social model to provide assistance with self-administration and providers of the medical model to administer medications. But there are exceptions. When medication administration is either a required or optional service, regulations generally state that the service must comply with applicable state laws.

Provisions regarding medication administration are closely related to staffing requirements. For example, New Jersey requires ADHS to provide medication administration and defines this service as a procedure in which a prescribed medication is given to a participant by an authorized person in accordance with all laws and rules governing such procedures. ADHS providers are required to hire an RN, who must not perform the functions of any other position while functioning as the director of nursing services.

Assistance with Self-Administration versus Medication Administration

Most states' provisions related to assistance with self-administration of medications include provisions for determining whether a participant is capable of self-medication. For example, Virginia's rules state that unless it is contrary to an ADC program's policy, participants may take their own medication if a physician has deemed them capable of doing so and has given written authorization for them to self-administer medications.

Texas requires that licensed nurses ascertain on a monthly basis whether participants who are self-administering their medications continue to be capable of self-administration. If participants cannot--or choose not to--self-administer their medications, Texas requires that they be administered by a person who holds a current license under state law that authorizes the licensee to administer medications.

To be considered capable of self-administration of medications, Pennsylvania requires that a participant be able to identify the medication, acknowledge the amount of medication to be taken and the schedule for taking it, remember to take the medication on schedule with infrequent reminders from staff persons, and obtain medication from its container without assistance or with minimal assistance.

A major difference among states is that some define assistance with medication administration to include activities that other states define as medication administration. The component--pouring the prescribed dosage according to the medication profile record--is considered by those states to be an integral part of medication administration --not assistance with self-administration. For example, New Jersey defines medication administration as a procedure that includes removing an individual dose from a previously dispensed, properly labeled container (including a unit dose container), verifying it with the prescriber's orders, giving the individual dose to the participant, seeing that the participant takes it, and recording the required information, including the method of administration.

Texas defines assistance with self-medication to include, but not be limited to: (1) reminders to take medications at the prescribed time; (2) opening containers or packages and replacing lids; (3) pouring prescribed dosage according to the medication profile record (emphasis added); (4) returning medications to the proper locked areas; (5) obtaining medications from a pharmacy; and (6) listing on an individual participant's medication profile record the medication name, strength, dosage, amount received, directions for use, route of administration, prescription number, pharmacy name, and the date each medication was issued by the pharmacy.

Wyoming defines administering medicine to encompass reading the label, opening the container of medicine, removing the prescribed dosage, and giving it to the person for whom it is prescribed. Persons authorized to administer medicine under the Act include licensed physicians, RNs, LPNs, and physicians' assistants.

Tennessee's definition of self-administration does not include removal of the medication dose from the container, but requires the person assisting to check the self-administered dose against the dosage shown on the prescription and reassure participants that they are taking the correct dosage, which in effect, requires the staff person to ensure that the correct dosage is being taken. The regulations are silent on what should be done if the self-administered dose is not the same as the prescribed dose.

In Wisconsin, if an adult day center employs an RN, she may set up and label medications and delegate responsibility for administering them to ADS staff. She may also delegate medication setup and labeling to an LPN.

Licensed Personnel versus Unlicensed Personnel

Most likely reflecting differences in State Nurse Practice Acts, states vary regarding provisions about who is authorized to administer medications.

Vermont requires ADS centers to provide medication management under the supervision of an RN or an LPN under an RN's direction. Further, the state requires that all staff responsible for medication administration be licensed by the state to administer medications or successfully complete the most current medication training program developed by the state and the Board of Nursing. They must also complete the current approved refresher course every 3 years.

If a participant requires medication administration, unlicensed staff may administer medications under certain conditions--for example, if there is a physician's written order on file and an RN, or an LPN under the direction of an RN has delegated administration of specific medications to designated staff for designated participants. Vermont is one of just a few states with provisions addressing PRN (as needed) medications, stating that the use of PRN medications is prohibited unless certain conditions exist: (1) a participant is capable of determining when the medication is needed; (2) a licensed health care professional administers the medication; or (3) the participant's physician has provided detailed written or documented verbal instructions.

Other states have much less exacting standards for medication administration by unlicensed personnel. For example, New Hampshire requires that personnel who are not otherwise licensed practitioners, nurses, or medication nursing assistants, and who assist a participant with self-administration or administration of medication through nurse delegation, must complete, at a minimum, only a 4-hour medication supervision education program covering both prescription and non-prescription medication. The program must include the following:

  • Infection control and proper hand washing techniques.

  • The "five rights" of medication administration (the right participant, the right medication, the right dose, at the right time, and through the right route).

  • Documentation requirements.

  • General categories of medications such as anti-hypertensives or antibiotics.

  • Desired effects and potential side effects of medications.

  • Medication precautions and interactions.

Staff Requirements

States require ADS providers to employ specific types of staff. Virtually all states require the hiring of a director who will be responsible for the day-to-day operation and management of the facility. However, some states require the director to be a full-time position, whereas others allow one person to hold the director position and another position. For example, Texas requires a director, an activities director, a facility nurse (RN or LVN), an RN nurse consultant (for 4 hours per week) if an LVN is hired, a dietician consultant (at least 4 hours per month), and attendants (i.e., direct care workers). One person is permitted to fill two of the first three staff positions--if he or she has the required qualifications--but not all three positions.

In addition to a director, the type of staff required depends in large part on the services that an ADS program is required to offer. As states vary considerably regarding required and optional services, they also vary regarding staffing.

For example, New York requires ADHC programs--which provide a high level of medical and nursing care--to have a director, a full-time RN, a social worker, a certified nursing assistant, a physical therapist, an occupational therapist, a dietitian, a pharmacist consultant, and a medical director. The ADHC program is also required to employ or contract with speech therapists.

Louisiana requires ADHC programs to hire a full-time director, an RN (full-time or part-time), a program manager, a social services designee/social worker, and direct service workers (the last three are called key positions). They must also designate one staff member who is employed at least 10 hours per week as a food service supervisor.

Louisiana's staffing requirements--like those of a few other states--differ depending on licensed capacity. Programs with a licensed capacity of 16-30 participants must employ at least two full-time persons or full-time equivalents to fulfill key staff requirements. Those with more than 30 participants must employ at least three full-time persons or full-time equivalents to fill key staff positions.

Some states' regulations specify that only a director needs to be hired and allow providers the flexibility to determine the type and number of staff needed to meet participants' needs.

Licensed Nurses

A major difference between staffing requirements for the social and medical models is that the latter are generally required to have licensed nurses available in some capacity--as full-time or part-time employees or as consultants. Because most states require staffing consistent with participants' needs, if an ADS provider is required to furnish services that only licensed nurses can provide (or sometimes delegate), then they must hire or contract with a licensed nurse.

In some states, the licensing regulations do not require that licensed nurses be hired, but Medicaid requirements for providers serving waiver program participants do. For example, in South Carolina, Medicaid requires ADHC providers serving waiver program participants to have an RN on staff to provide nursing services, which include observing participants' functional level and noting changes; supervising medication administration; and coordinating treatment plans with physicians, therapists, and other involved service delivery agencies.

Although many states require that licensed nurses be employed or under contract, the number of hours they must work varies considerably: from 8 hours a month, to 8 hours per day, or whenever participants are present, with many variations in between. In Virginia, for example, an ADHC provider must have an RN at the program a minimum of 8 hours each month, or more, depending on the number of participants in attendance and according to their medical and nursing needs. Although an RN does not need to be employed full-time, he or she must be available, either in person or by telephone, to the center's participants and staff during all times that the center is in operation.

ADHS programs in Massachusetts must provide nursing coverage on-site for at least 6 hours per day for programs with a licensed capacity of 35 or fewer participants, and at least 8 hours per day for programs with a capacity of 36 or more participants. Programs must increase licensed nursing staff by 4 hours for each additional 1-12 participants attending the program.

In North Carolina, adult day health (ADH) centers must have a health care coordinator to organize the delivery of health care services and participate in direct care, who must be either an RN or LPN. If the health care coordinator is an LPN, an RN must provide supervision consistent with the Nursing Practice Act, and on-site supervision by the RN must occur no less frequently than every 2 weeks.

Staffing Ratios

All but six states require minimum direct staff-to-participant ratios. As shown in Exhibit 3, mandatory staff ratios range between 1:4 and 1:10 with the majority of states requiring ratios of 1:6 or 1:8. Some states have more than one required staff-to-participant ratio, requiring different ratios for different types of ADS; some have different ratios for Medicaid providers, and some require different ratios for participants with a high level of need or those with dementia. (For more detailed information about staff-to-participant ratios, consult the individual state profiles in Section 2.)

EXHIBIT 3. Staff-to-Participant Ratios, by State

State   1:4     1:5     1:6     1:7     1:8     1:9     1:10  
Alabama --- --- --- --- --- --- X
Alaska X --- --- --- X --- ---
Arizona --- --- --- --- --- --- ---
Arkansas --- X --- --- X --- ---
California --- --- --- --- X --- ---
Colorado --- --- --- --- X --- ---
Connecticut --- --- --- X --- --- ---
Delaware X --- --- --- X --- ---
District of Columbia   --- --- X --- --- --- ---
Florida --- --- X --- --- --- ---
Georgia X --- --- --- X --- ---
Hawaii --- --- X --- --- --- ---
Idaho --- --- X --- --- --- ---
Illinois --- --- X --- --- --- ---
Indiana X --- X --- X --- ---
Iowa --- --- --- --- --- --- ---
Kansas --- --- --- --- --- --- ---
Kentucky --- X --- --- --- --- ---
Louisiana --- --- --- --- --- X ---
Maine --- --- X --- --- --- ---
Maryland --- --- --- X X --- ---
Massachusetts X --- X --- X --- ---
Michigan1 --- --- --- --- --- --- X
Minnesota --- X --- --- X --- ---
Mississippi X X X X X X X
Missouri --- --- --- --- X --- ---
Montana --- --- --- --- --- --- ---
Nebraska --- --- --- --- --- --- ---
Nevada --- --- --- --- --- --- ---
New Hampshire --- --- --- --- X --- ---
New Jersey --- X --- --- --- X ---
New Mexico --- X --- --- --- --- ---
New York --- --- --- X --- --- ---
North Carolina --- X X --- X --- ---
North Dakota --- --- --- --- X --- ---
Ohio --- --- X --- --- --- ---
Oklahoma X --- --- --- X --- ---
Oregon X --- X --- --- --- ---
Pennsylvania --- --- --- X --- --- ---
Rhode Island --- --- X --- --- X ---
South Carolina --- --- --- --- X --- ---
South Dakota X --- X --- --- --- ---
Tennessee --- --- --- --- X --- ---
Texas --- --- --- --- X --- ---
Utah --- --- X --- X --- ---
Vermont --- --- --- X --- --- ---
Virginia --- --- X --- --- --- ---
Washington --- --- X --- --- --- ---
West Virginia --- --- X --- --- --- ---
Wisconsin --- --- X --- --- --- ---
Wyoming --- --- X --- --- --- ---
TOTAL 9 7 20 6 20 4 3
--- = not applicable.
  1. Dementia ADC programs must have a minimum staff/volunteer/student-to-participant ratio of 1:3.

For example, Indiana recognizes three levels of care in ADS programs and requires different ratios for each. Basic (level 1): the staff-to-participant ratio must be a minimum of 1:8. Enhanced (level 2): the staff-to-participant ratio must be a minimum of 1:6. Intensive (level 3): the staff-to-participant ratio must be a minimum of 1:4.

Many states give providers the flexibility to determine the ratio beyond the minimum required. For example, Vermont requires a minimum direct services staff-to-participant ratio of 1:7 but allows providers to determine how much the staff-to-participant ratio must be adjusted as the number of participants with functional or cognitive impairments or the severity of the impairment increases.

Wisconsin requires a minimum of one staff person for each eight non-severely impaired participants and a minimum of one staff person for each four severely impaired participants at the ADS site, but the state does not provide guidelines for determining what constitutes severe impairment.

Virginia requires an ADHC center to employ sufficient interdisciplinary staff to adequately meet the participants' health, maintenance, and safety needs. The center must provide at least two staff members awake and on duty at all times when there are Medicaid waiver participants in attendance, and maintain a minimum staff-to-participant ratio of at least 1:6 (waiver and other participants). However, The Virginia Department of Medical Assistance Services (DMAS) reserves the right to require an ADHC center to employ additional staff if, on review, DMAS staff find evidence of unmet participant needs.

States with minimum staff-to-participant ratios define which workers are to be counted in determining the ratio. For example, Minnesota's regulations state that only those employees whose primary duties, as defined in their job descriptions, are to work directly with participants by providing care, supervision, and assistance in achieving care plan objectives must be counted as staff members in calculating the staff-to-participant ratio.

The six states without minimum staff-to-participant ratios allow providers to determine the number of staff to employ. Nebraska requires only that ADHC programs maintain a ratio of direct care staff member to participants sufficient to ensure that participants' needs are met. Arizona requires that sufficient staff be present on an ADHC facility's premises when participants are present, and they must have the qualifications, skills, and knowledge necessary to: (1) provide the services in the ADHC facility's scope of services; (2) meet participant's needs; and (3) ensure participants' health and safety.

Although Hawaii requires ADC programs to have a staff-to-participant ratio of 1:6, it does not have a minimum ratio for ADH programs. Instead, it requires a sufficient number of employees qualified and competent to provide the services for which the center is licensed; and a sufficient number of aides to perform necessary duties.

Other Staffing Requirements

Virtually all states require that a minimum of one or more staff members be available when participants are present and that at least one staff member with current certification in cardiovascular pulmonary resuscitation (CPR) be present at all times during the hours of operation. Other states additionally require that at least one staff person certified in the provision of first-aid also be present during the hours of operation.

Virtually all states also have provisions regarding the use of volunteers, requiring them to have the same qualifications, orientation, and training as regular staff; and requiring their supervision by a paid staff member. States also address the specific conditions that must be met for volunteers to be counted in the staff-to-participant ratio. In Virginia, for example, volunteers may be counted only if both of the following criteria are met: (1) they have the same qualifications as compensated employees and meet the same training requirements; and (2) for each volunteer, at least one compensated employee is also counted in the staff-to-participant ratio.

A few states restrict the use of volunteers. For example, in Mississippi, volunteers may not be used in place of required staff, and they can be used only on a periodic and temporary basis.

Training Requirements

Virtually all states have requirements for orientation and initial training for workers. For example, prior to assuming job responsibilities, Delaware requires all personnel to receive training in fire safety; first-aid; emergency procedures; infection control; and special needs of the elderly and persons with cognitive or other disabilities, including the specific needs of the participants being served.

States vary somewhat regarding required training topics. West Virginia requires that training include, at a minimum: (1) emergency procedures and disaster plans; (2) the center's policies and procedures; (3) participants' rights; (4) confidentiality; (5) abuse prevention and reporting requirements; (6) complaint procedures; (7) specialty care based on individualized participants' needs and service plans; (8) the provision of group and individual participant activities; (9) infection control; and (10) needs of the elderly and disability populations.

Wyoming requires that before assuming job responsibilities or within 1 week of hire, all staff persons must receive an orientation that includes training specific to the staff person's assigned responsibilities, as well as training on more general topics, including: (1) the purposes of the ADC facility; (2) state procedures for addressing abuse and neglect; (3) confidentiality of personal information; (4) employee responsibilities; (5) capabilities and special needs of the elderly and disabled; (6) the facility activity schedule; and (7) record-keeping responsibilities. Additionally, all staff persons must be trained in the appropriate procedures for handling emergencies before job responsibilities are assumed, including--at least--fire, illness, or injury, and lost or missing person emergencies.

Some states require that all employees have current first-aid and CPR training; most require that at least one staff trained in first-aid and CPR be on duty at all times.

Some states, such as Mississippi, do not specify topics that need to be covered, stating only that all staff and volunteers who have contact with and responsibility for special populations should receive specific training in serving that population.

Many states require specific training about dementia. Some states require training about dementia only for ADS providers who present themselves as providing special services for this population. For example, Minnesota requires ADS centers that serve persons with Alzheimer's disease and other dementias to ensure that the direct care staff and their supervisors are trained in dementia care. Required topics include: (1) an explanation of Alzheimer's disease and other dementias; (2) ADL assistance; (3) problem solving with challenging behaviors; and (4) communication skills.

Iowa requires that all personnel employed by or contracting with a dementia-specific program receive a minimum of 8 hours of dementia-specific education and training prior to--or within 30 days of--employment or the beginning date of the contract. The dementia-specific education or training must include, at a minimum, the following topics: (1) an explanation of Alzheimer's disease and other types of dementias; (2) the program's specialized dementia care philosophy and program; (3) skills for communicating with persons with dementia; (4) skills for communicating with family and friends of persons with dementia; (5) an explanation of family issues such as role reversal, grief and loss, guilt, relinquishing the caregiving role, and family dynamics; (6) the importance of planned and spontaneous activities; (7) skills in providing assistance with ADLs; (8) the importance of the care plan and social history information; (9) skills in working with challenging participants; (10) techniques for simplifying, cueing, and redirecting; and (11) staff support and stress reduction.

Other states require dementia training for all ADS providers, as in West Virginia, which requires at least 2 hours of training on Alzheimer's disease and other dementias that includes: (1) basic understanding about Alzheimer's disease and other dementias; (2) communication approaches and techniques for use when interacting with persons with Alzheimer's disease or other dementias; (3) prevention and management of problem behaviors; and (4) activities and programming appropriate for persons with dementia.

Amount of Training Required

States vary considerably regarding the amount of staff training required. Wyoming requires that all staff primarily responsible for the direct care of participants attend at least 8 hours of staff development activities annually, which must consist of in-service training programs, workshops, or conferences related to ADC or gerontology, provided that both subject areas are addressed during the year. In contrast, Texas requires 18 hours of initial training, and Minnesota requires ADS centers to provide all employees with 20 hours of orientation within the first 40 hours of employment at the center. Minnesota also requires at least 4 hours of supervised orientation before employees work directly with center participants and a minimum of 8 hours in-service training annually in areas related to the care of center participants, including the provision of medication assistance.

Virginia requires 24 hours of initial training, but allows it to be provided through self-study of material provided by the ADS center, as well as formal lectures, observation, supervised practice, and audiovisual training. Staff who are primarily responsible for the direct care of the participants must attend annually at least 8 additional hours of staff development activities that must consist of in-service training programs, workshops, or conferences relevant to the needs of the population served. These staff development activities must be in addition to first-aid, CPR, or orientation training.

Delaware requires the most hours: aide orientation and training must include at least 40 hours of instruction and a supervised practicum in body mechanics.

Several states require the director of an ADS center to obtain continuing education annually: 8 hours in West Virginia, 12 hours in Texas, and 24 hours in Virginia.

Public Funding of Adult Day Services

Exhibit 4 shows the public funding sources for ADS in each state. As can be seen, with the exception of West Virginia and the District of Columbia, all states cover ADS under their Medicaid programs, and 24 cover ADS under at least one non-Medicaid program--generally funded by a combination of state general revenues, Older Americans Act funds, and Social Services Block Grant funds (listed as "non-Medicaid programs" in Exhibit 4).

States have several options for covering ADS under their Medicaid programs. The majority--40 states--use the 1915(c) waiver authority for the aged/disabled populations; 14 states use a managed care authority; nine offer it under the Medicaid State Plan; one state uses the State Plan (i) authority, and one uses the State Plan (k) authority.

Medicaid requires ADS providers to meet all state regulatory requirements and some states require them to meet additional requirements. California, for example, licenses ADHC centers as health facilities but to be a Medi-Cal provider, a licensed ADHC center must also be certified by the California Department on Aging as a Community-Based Adult Services center.

EXHIBIT 4. Public Funding for ADS as of October 2014

State   State  Plan 1915(i)  State Plan   1915(k)  State Plan   1915(c)  Waiver   Managed  Care Waiver     Non-Medicaid  Program
Alabama --- --- --- X --- ---
Alaska --- --- --- X --- ---
Arizona --- --- --- --- X ---
Arkansas --- --- --- X --- ---
California1 --- --- --- --- X ---
Colorado --- --- --- X --- X
Connecticut --- --- --- X --- X
Delaware --- --- --- X X ---
District of Columbia   --- --- --- --- --- ---
Florida --- --- --- X X X
Georgia --- --- --- X --- X
Hawaii --- --- --- --- X X
Idaho --- --- --- X --- ---
Illinois --- --- --- X --- ---
Indiana --- --- --- X --- ---
Iowa --- --- --- X --- ---
Kansas --- --- --- X --- X
Kentucky --- --- --- X --- ---
Louisiana --- --- --- X --- ---
Maine X --- --- X --- X
Maryland X --- --- X --- X
Massachusetts X --- --- X --- X
Michigan --- --- --- X --- X
Minnesota --- --- --- X X X
Mississippi --- --- --- X --- ---
Missouri --- --- --- X --- ---
Montana --- --- --- X --- ---
Nebraska --- --- --- X --- ---
Nevada --- X --- X --- X
New Hampshire X --- --- X --- ---
New Jersey X --- --- --- X X
New Mexico --- --- --- --- X X
New York X --- --- X X ---
North Carolina --- --- --- X --- X
North Dakota --- --- --- X --- X
Ohio --- --- --- X --- X
Oklahoma --- --- --- X --- X
Oregon --- --- X --- --- X
Pennsylvania --- --- --- X --- X
Rhode Island X --- --- --- --- ---
South Carolina --- --- --- X --- ---
South Dakota --- --- --- X --- X
Tennessee --- --- --- --- X ---
Texas X2 --- --- X X ---
Utah --- --- --- X --- ---
Vermont X --- --- --- X ---
Virginia --- --- --- X --- ---
Washington --- --- --- X X X
West Virginia --- --- --- --- --- X
Wisconsin --- --- --- X X ---
Wyoming --- --- --- X --- X
TOTALS 9 1 1 40 14 24
--- = not applicable.
  1. In 2011, ADHC services were eliminated as an optional Medi-Cal State Plan benefit. A class action lawsuit challenged the elimination, and a Settlement Agreement was reached in March 2012. On April 1, 2012, Community-Based Adult Services became a mandated "Long-Term Services and Supports" benefit within California's 1115 Medi-Cal waiver program.
  2. Most State Plan participants receive day activity and health services in the state's 1115 managed care waiver program, but individuals who are not mandatory enrollees in managed care, and individuals who for various reasons do not consistently remain eligible for Medicaid, continue to be served in the State Plan.

Medicaid Managed Long-Term Care

The last 10 years have seen an increase in the number of states providing long-term services and supports (LTSS) through risk-based managed care arrangements outside of the Program of All-Inclusive Care for the Elderly (PACE) programs. In 2004, eight states were operating managed care programs that covered some LTSS outside of PACE programs with 105,000 enrollees. In September 2014, 21 states had such programs and the projected number of enrollees was 1,170,000.7

As shown in Exhibit 4, 14 states cover ADS through some form of managed care program. Managed care arrangements may alter traditional Medicaid contracting requirements. For example, Florida covers ADHC covered in the state's Medicaid Managed Long-Term Care Program, which has replaced six 1915(c) waiver programs that formerly served the aged/disabled populations. Licensed ADHC providers do not have to become a Medicaid-contracted provider if they contract directly with one of the state's MCOs. Managed long-term care plans may limit the providers in their networks based on credentials, quality indicators, and price, but they must include a minimum number of providers of all covered services.

Conclusion

In sum, while states vary somewhat in their approach, all have some form of regulation and exercise oversight of ADS. States generally distinguish between ADS and ADHS, with the latter having more extensive requirements for nurse staffing.

Only West Virginia and the District of Columbia do not use Medicaid to fund ADS. In the states that cover ADS under Medicaid--either through the State Plan or a waiver program--providers who want to be reimbursed by Medicaid must meet Medicaid contracting requirements. Depending on whether a state licenses, certifies, or otherwise regulates ADS providers, Medicaid requirements may be more prescriptive, particularly for providers who are serving participants in waiver programs who meet nursing home level of care criteria.

ADS are a key community-based service that enables individuals with long-term care needs--including significantly impaired nursing home eligible participants--to remain at home or living with family. To the extent that ADS--both the social and health models--enable informal caregivers to continue providing care in the home, institutionalization can be prevented or delayed. Additionally, ADS that provide basic preventive and primary health care may prevent more costly illnesses.

2. STATE REGULATORY PROFILES

Profiles for each of the 50 states and the District of Columbia follow. Each state is also available as a separate PDF file. A full list of URLs is available at the end of this document.

ALABAMA

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-alabama

Overview

In Alabama, adult day care (ADC) and adult day health (ADH) services are provided under multiple state programs, including two Medicaid 1915(c) waiver programs. The state does not license or certify ADC and ADH services providers; they are regulated through contracting requirements with the state agencies that administer ADC and ADH services programs.

ADC is provided under the Adult Protective Services Program, administered by the Alabama Department of Human Resources (DHR). The Department has established policies and procedures for a program of day care for adults, which prescribe minimum standards to be met by the centers that provide such care.

Alabama also provides ADC as a respite service through the Department of Senior Services Caregiver Support Program: Alabama CARES (Caregiver Assistance with Resources, Education, and Support). This program is funded under the Older Americans Act and implemented by Area Agencies on Aging through contracts with local providers.

ADH services are provided under the Alabama Community Transition (ACT) and Elderly and Disabled (E&D) waiver programs. To participate in the Alabama Medicaid program, providers must have a contractual agreement with Medicaid directly or through an Operating Agency (Alabama Department of Rehabilitative Services for the ACT waiver program or Alabama Department of Senior Services for the E&D waiver program) and meet the provider qualifications as outlined in the waiver document and provider manual for each waiver. The Medicaid requirements--which address services, staffing, and other topics--are described in this profile under the Adult Day Health heading.

No state agency other than those that administer the programs noted above regulates ADC and ADH providers.

Definitions

Adult day care as provided under Adult Protective Services is a program of care for a portion of a 24-hour day in a protective setting for eligible adults 18 years of age or older. This service is for adults who need care during the day and individuals who live alone and cannot manage totally on their own and who need meals and supervision. ADC enables families to maintain the adults at home. Its purpose is to prevent or remedy abuse, neglect, or exploitation, and to prevent unnecessary institutionalization.

Adult day care as provided under the CARES program is designed to meet the needs of adults with functional impairments through a structured and comprehensive program. A variety of health, social and related support services are offered in a supervised protective setting during some portion of a 24-hour day.

Adult day health is a service that provides Medicaid waiver participants with a variety of health, social, recreational, and support activities in a supervised group for 4 or more hours per day on a regular basis. The services furnished by ADH providers are based on the needs of individual participants. The objective of ADH services is to provide an organized program of rehabilitative, therapeutic, and supportive health and social services and activities to waiver program participants who are functionally impaired and who, because of the severity of their functional impairment, are not capable of living independently in the community.

Parameters for Who Can Be Served

The eligibility criteria for the various publicly-funded programs set the specific parameters for who can be served by ADC and ADH providers.

Adult day care is for adults who are 18 years of age or older who are at risk of abuse, neglect, or exploitation, or at risk of institutionalization, and certified as eligible for services by the appropriate County DHR. The CARES program serves frail adults aged 60 or older, or a person with Alzheimer's disease or other type of dementia regardless of age.

Adult day health services are for E&D waiver program participants 18 years of age or older, whose needs can be met in an outpatient setting that provides both health and social services needed to ensure optimal functioning. The ACT waiver program has no age requirement and will provide services to individuals with disabilities or long-term illnesses who currently live in a nursing facility and who desire to transition to a home and community setting. A second target population would be individuals currently served in one of Alabama's other waiver programs, whose condition is such that their current waiver program is not meeting their needs and admission to an institution would be imminent if the ACT waiver was not an option to meet their needs in the community.

Inspection and Monitoring

Adult Day Care. The state does not license or certify providers and thus, does not conduct inspections. The state fire marshal and the local health department conduct inspections prior to a program's operation to determine compliance with standards. ADC providers must meet all applicable Alabama health and fire safety standards. Recertification is required annually by the state fire marshal or local fire department and the local health department. Annual monitoring is conducted by DHR , Office of Resource Management to ensure that providers are in compliance with program requirements.

Adult Day Health. The state does not license or certify providers and thus, does not conduct inspections. The state fire marshal and the local health department conduct inspections prior to a program's operation to determine compliance with the standards. ADH providers must meet all applicable Alabama health and fire safety standards. Providers must be recertified annually to ensure continued compliance with standards.

Required and Optional Services

All ADC and ADH programs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

Required and Optional Services Adult Day Care Adult Day Health
  Required     Optional     Required     Optional  
ADL Assistance     X  
Health Education and Counseling     X  
Health Monitoring X   X  
Medication Administration     X  
Nursing Services     X  
Physical Therapy, Occupational Therapy, or Speech Therapy          
Skilled Nursing Services     X  
Social Services X   X  
Transportation   X X  

Medication Provisions

Adult day care. Program staff must not administer medications.

Adult day health. Unlicensed staff may not administer medications but can only assist or supervise participants who self-administer their medications, including reminding them to take medications. A registered nurse (RN) or licensed practical nurse (LPN) licensed by the Alabama Board of Nursing may administer medications from a container filled by a licensed pharmacist with a pharmacy label indicating physician instructions.

Staffing Requirements

Adult Day Care

Type of Staff. Each program must have a director. The director and at least one other staff person must be certified in cardiovascular pulmonary resuscitation (CPR) and first-aid. A registered nurse or licensed practical nurse must be available to provide a monthly health screening for participants.

Staffing Ratios. At least two staff members must be in the center when participants are present, and at least one of these must be CPR certified and trained in first-aid. In addition to the director, the program must, at a minimum, maintain the following number of staff who are directly involved with participants during hours of program operation: one staff member for 1-10 participants, two for 11-25 participants, three for 26-35 participants, four for 36-43 participants, and an additional staff member for each additional eight participants.

Staff whose primary responsibilities do not require direct involvement with participants will not be counted unless their job descriptions specify time periods when they have responsibility only for working with participants. Volunteers may be counted in the staff ratio if they meet the same qualifications as paid staff and are scheduled for the entire period that a paid worker would have worked.

Adult Day Health

Type of Staff. In addition to the director, there must be a designated person to serve as the center administrator, who does not have to be full-time, and a registered nurse or licensed practical nurse available at least 2 hours per week or 8 hours per month for consultation. ADH centers must maintain CPR and first-aid certification for at least two staff members at all times.

Staffing Ratios. At least two staff members (may be the director and another staff member, or two staff members) must be in the center when participants are present, and at least one of these must be CPR certified and trained in first-aid. At a minimum, the provider will maintain one staff member for 1-10 participants, two for 11-25 participants, three for 26-35 participants, four for 36-43 participants, and an additional staff member for each additional eight participants.

Training Requirements

Adult Day Care

Training must ensure that day care staff have sufficient knowledge of adults' mental, emotional, and physical processes to enable them to meet individual participant's needs. For staff who have no previous experience or training in ADC, the provider shall furnish an on-site orientation and a designated period of supervised training.

All staff must regularly (at least quarterly) participate in in-service training or other available training related to ADC. This shall include training on how to deal with participants with physical, mental, or emotional impairments. Staff must be trained to use Standard Universal Precautions.

Adult Day Health

The ADH provider must ensure that staff have sufficient knowledge of adults' mental, emotional, and physical processes to enable them to meet individual participant's needs. The training program must be approved by the relevant operating agency and the Alabama Medicaid Agency.

The ADH provider must ensure that staff who have had no previous experience or training working with adults who are elderly and disabled have an on-site orientation with a designated period of supervised training. The minimum training requirement must be completed prior to initiation of service with a participant. The ADH center is responsible for providing and/or conducting training.

The ADH provider must ensure that all ADH staff have at least 6 hours of in-service training annually in the following areas: behavior acceptance, accommodation, and intervention; providing care and supervision including safety and non-medical care; first-aid; documenting participant participation; fire and safety measures; confidentiality; participant rights; needs of the elderly and disabled population; basic infection control/universal standards; communication skills; and other areas of training as appropriate or as mandated by Medicaid and the operating agencies. Documentation of continuing education training required by the Alabama Board of Nursing may be accepted as in-service training for licensed nurses.

Location of Licensing, Certification, or Other Requirements

State of Alabama Department of Human Resources Minimum Standards for Adult Day Care Centers [November 2007] may be obtained by contacting aps@dhr.alabama.gov or by mail through Alabama Department of Human Resources, Adult Protective Services, 50 Ripley Street, Montgomery, AL 36130-4000.

Alabama Medicaid Agency Administrative Code, Chapter 36: Home and Community-Based Services for the Elderly and Disabled. [July 17, 2012]http://medicaid.alabama.gov/documents/5.0_Resources/5.2_Administrative_Code/Chapters_31_40/5.2_Adm_Code_Chap_36_HCBS_Elderly_and_Disabled_7-17-12.pdf

Alabama Medicaid Agency Administrative Code, Chapter 44: Home and Community-Based Services for the Alabama Community Transition Waiver. [July 17, 2012]http://medicaid.alabama.gov/documents/5.0_Resources/5.2_Administrative_Code/Chapters_41_50/5.2_Adm_Code_Chap_44_HCBS_ACT_Waver_7-17-12.pdf

Alabama Medicaid Provider Manual, Chapter 107: Waiver Services. [October 2013]http://medicaid.alabama.gov/documents/6.0_Providers/6.7_Manuals/6.7.7_Provider_Manuals_2013/6.7.7.4_October_2013/Oct13_107.pdf

Alabama Medicaid Adult Day Health Standards. [February 2014]http://medicaid.alabama.gov/documents/4.0_Programs/4.3_LTC_Services/4.3.1_HCBS_Waivers/4.3.1.1_E_and_D_Waiver/4.3.1.1_Adult_Day_Hlth_Stds.pdf

Information Sources

Doris BallDirectorAdult Protective ServicesDepartment of Human Resources

Monica S. AbronAssociate DirectorLong-Term Care Program Management UnitAlabama Medicaid Agency

ALASKA

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-alaska

Overview

Alaska has no licensure requirements for adult day services (ADS), but all providers must be certified by the Division of Senior and Disability Services (DSDS). ADS are provided under several Medicaid 1915(c) waiver programs. Residents of skilled nursing facilities or Pioneers' Homes (i.e., assisted living) are not eligible for ADS through a Medicaid waiver program. However, using other DSDS funding sources, individuals who are transitioning from a nursing facility or Pioneer Home to a home or community-based setting may receive ADS during the transition phase.

All provider agencies that furnish ADS using DSDS grant funds or under a Medicaid waiver must meet the minimum standards as stated in the ADS standards promulgated by DSDS and be certified as a Medicaid provider.

Definitions

Adult day services are defined as the provision of an organized program of services and activities during the day in a facility-based setting. The services and activities must be therapeutic and supportive for participants, and may include both individual and group activities. The program must provide supervision and a secure environment for participants to achieve goals identified in their individualized service plans.

ADS providers also furnish referrals to and assistance in using appropriate community resources. ADS help participants remain in their communities and allow families and other caregivers to continue caring for them at home. The program must operate for a minimum of 6 hours each day, not including transportation to and from the setting.

Medicaid defines ADS as health, social, and related support services, which are provided to older adults and adults with physical disabilities in a protective setting, other than a nursing facility, during any part of a day, but less than 24 hours per day. Recipients attend services on a planned basis during specified hours.

Parameters for Who Can Be Served

Individuals must be able to benefit from ADS. They may not be served if: (1) their medical condition is beyond the professional expertise of the staff; (2) they are bedfast or too weak to attend on a regular basis; (3) they are actively infected with a communicable disease; (4) they have emotional or behavioral disorders that include a pattern of disruptive behaviors that pose a danger to others; (5) they abuse alcohol and/or drugs; or (6) they are too independent to benefit from adult day activities.

Eligibility for ADS varies by public funding source. Depending on the program, providers may serve individuals age 55 or older or age 60 or older, or persons of any age who have Alzheimer's disease or another type of dementia.

Inspection and Monitoring

An on-site inspection is conducted as part of the initial certification process. Initial certification is for 1 year and renewal certification is for 2 years. An additional on-site visit is conducted during the certification period.

Required and Optional Services

All ADS programs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

Required and Optional Services Adult Day Services
  Required     Optional  
ADL Assistance X  
Health Education and Counseling    
Health Monitoring/Health-Related Services    
Medication Administration X  
Nursing Services   X
Physical Therapy, Occupational Therapy, or Speech Therapy      
Skilled Nursing Services   X
Social Services X  
Transportation X  

Medication Provisions

ADS providers must offer medication administration as an integral part of their services. This means the providers must have someone who is trained to administer medications--for example, a registered nurse--unless some other arrangement is made, such as: (1) a participant administers his or her own medications; (2) someone designated by a participant or a participant's representative comes to the facility to administer medications; or (3) a participant or participant's representative delegatesmedication administration.

Providers must have medication administration policies and procedures, specifying that participants who are able to keep their medicines shall keep them safely and that the program will keep medicines of participants who are unable keep them safely.

Participants may bring and take their own medications. Staff may supervise participants' self-administration of medications by: (1) reminding them to take medication; (2) opening bottle caps; (3) opening pre-packaged medication; (4) reading the medication labels to participants; (5) observing participants while they take medication; (6) checking the self-administered dosage against the label of the container; (7) reassuring participants that they have obtained and are taking the dosage as prescribed; and (8) directing or guiding the hand of a legally competent participant who is administering his or her own medications.

Staffing Requirements

Type of Staff. The provider must designate an ADS program administrator who is responsible for day-to-day management of the program. The provider may use a term other than program administrator for this position, for example, program director, program manager, or program supervisor.

Providers who serve Medicaid waiver participants may employ an individual to serve as program administrator for more than one home and community-based service if: (1) necessitated by the location of an agency office; and (2) given the size of the participant population served and the number of direct care workers employed by the provider, the administrator is capable of being actively engaged in the day-to-day management of each service. Whatever term is used to describe this position, the individual filling it must meet the requirements for program administrator that are specified in the Conditions of Participation for the services the provider offers.

The provider must appoint an activity coordinator or director who is responsible for planning and supervising activities for recipients. Direct care workers must be qualified through education or experience, and possess, or develop before providing services, the skills necessary to meet the needs of the participant population.

Program assistants, including volunteers, must meet the same requirements that direct care workers must meet. Substitute or volunteer staff may be used to provide care in the absence of regular staff. Two staff, one of whom may be a volunteer, must be present at all times during operation of the program. At least one staff person certified in cardiovascular pulmonary resuscitation (CPR)/first-aid must be on duty at all times.

Staffing Ratios. ADS providers must meet a minimum staff-to-participant ratio of 1:8, unless some participants have a diagnosis of Alzheimer's disease or another type of dementia, in which case the required ratio is 1:4. The provider must include only the staff and volunteers providing direct care services to participants when determining whether staffing ratio requirements are being met. If the provider bases the adequacy of the staff-to-participant ratio on volunteers, the volunteers must meet the same qualification and training requirements that direct care workers must meet.

Training Requirements

The provider must furnish an orientation for employees prior to service delivery, which transmits the agency's values, philosophy, and mission, and provides information about all laws, policies, procedures, and individual reporting responsibilities regarding participant abuse, neglect, and mistreatment. All paid and volunteer staff shall be provided general orientation to the facility (e.g., location, staff, and activities); information on fire and safety measures/codes; an overview of participants and activities; and information about other staff training opportunities. The agency shall periodically assess the need for specific staff training programs and shall comply with all mandatory personnel licensure and training schedules.

The provider must furnish training to direct care workers to ensure they are qualified to perform the services participants require, including the following topics, at a minimum:

  • Safety in the workplace and proper use of tools and equipment.

  • Maintenance of a clean, safe, and healthy workplace environment.

  • Universal precautions and basic infection control procedures.

  • CPR and first-aid.

  • Fall prevention, assistance with mobility, and body mechanics relating to safe transferring.

  • Understanding the needs of the population to be served, including the needs of individuals with dementia; nutrition, hydration, and special diet needs; and monitoring overall health and well-being.

Location of Licensing, Certification, or Other Requirements

Provider requirements and program standards are in the Home and Community-Based Waiver Services Certification Application Packet and in the chapter on Medical Assistance in the Alaska Administrative Code.

Alaska Administrative Code, Adult Day Services, Title 7, Health and Social Services. Rule 130.250. [July 1, 2013]http://www.legis.state.ak.us/basis/aac.asp#7.130.250

Home and Community-Based Waiver Services Certification Application Packet, Division of Senior and Disabilities Services. [February 12, 2004]http://dhss.alaska.gov/dsds/Documents/pca/CertAppPkt2ndEd42106(2)RegThirdEdition12-10.pdf

Adult Day Services Standards, Division of Senior and Disabilities Services. [July 1, 2003]http://dhss.alaska.gov/dsds/Documents/grantservices/PDFs/Adult_Day_Standards_2003%20%282%29.pdf

Adult Day Services, Conditions of Participation, Department of Health and Social Services, Division of Senior and Disabilities Services. [May 2, 2013]http://dhss.alaska.gov/dsds/Documents/regspackage/AdultDayServicesCOP.pdf

Frequently Asked Questions, HCBW Regulations 7AAC 130. [July 1, 2013]http://dhss.alaska.gov/dsds/Documents/regspackage/HCBWregulationsFY2013-FAQs.pdf

Information Sources

Angela SalernoManager, Policy UnitAlaska Health and Human Services

ARIZONA

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-arizona

Overview

The Arizona Department of Health Services licenses adult day health care (ADHC) facilities, which provide a medical model of care. Adult day care is a social model of care that is not licensed by the state and can serve only private pay participants.

The Arizona Long Term Care System (ALTCS) operates under an 1115 waiver program and covers services provided by licensed ADHC facilities. ALTCS has provider standards and requirements applicable to ALTCS contractors for the purpose of improving the quality of care and services provided to enrollees.

Definitions

Adult day health care services means a program that provides planned care supervision and activities, personal care, personal living skills training, meals, and health monitoring in a group setting during a portion of a continuous 24-hour period. Adult day health services (ADHS) may also include other health-related services such as preventive, therapeutic, and restorative health care services.

Adult day health care facility means a facility providing ADHS during a portion of a continuous 24-hour period for compensation on a regular basis for five or more adults not related to the proprietor.

Parameters for Who Can Be Served

Providers may not admit or retain participants if they require services not in the ADHC facility's scope of services or if their behavior is dangerous to self or interferes with the physical or psychological well-being of other participants.

Medicaid coverage of ADHS is available for participants who are either elderly and/or have physical disabilities, who need supervision, assistance in taking medication, recreation and socialization, or personal living skills training. Participants with developmental disabilities are not eligible for this service.

Inspection and Monitoring

The Department may conduct an on-site inspection as part of the substantive review for issuing an initial or renewal license. Initial and renewal licenses are issued for 1 year.

Required and Optional Services

All ADHC programs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

Required and Optional Services Adult Day Health Care
  Required     Optional  
ADL Assistance X  
Health Education and Counseling X  
Health Monitoring/Health-Related Services X  
Medication Administration X  
Nursing Services X  
Physical Therapy, Occupational Therapy, or Speech Therapy     X1
Skilled Nursing Services    
Social Services X  
Transportation   X
  1. Some providers offer restorative therapy overseen by physical therapists, occupational therapists, and speech-language therapists.

Medication Provisions

A registered nurse (RN) must be on the premises daily to administer medications and treatments, and to monitor participants' health status.

Training for a personnel member, other than a medical practitioner or RN, in assistance in the self-administration of medication must be provided by a medical practitioner or RN, or an individual trained by a medical practitioner or RN. Training must be completed before providing assistance with self-administration.

Staff may remind and supervise participants who are capable of self-administering medications. Supervision may include: (1) opening the medication container for the participant; (2) observing the participant while he or she removes the medication from the container; (3) verifying that the medication is taken as ordered by the participant's medical practitioner; and (4) observing the participant while she or he is taking the medication.

Providers must ensure that policies and procedures for assistance with self-administration of medication and medication administration are reviewed and approved by a pharmacist, medical practitioner, or RN.

Staffing Requirements

Type of Staff. An administrator has the authority and responsibility to operate the facility and manage ADHS. The administrator must remain on the premises, or ensure that a designee is present, whenever participants are present in the facility. The governing authority must designate, in writing, an acting administrator, with the same qualifications as the administrator, to act as administrator when the administrator is absent.

A registered nurse must manage the nursing services and provide direction for health-related services furnished by the ADHC facility.

The administrator must ensure that the qualifications, skills, and knowledge required for each type of personnel member include the specific skills and knowledge necessary for the personnel member to provide the expected physical health services and behavioral health services listed in the established job description.

Staffing Ratios. Sufficient personnel must be present on an ADHC facility's premises when participants are present and have the qualifications, skills, and knowledge necessary to: (1) provide the services in the ADHC facility's scope of services; (2) meet participants' needs; and (3) ensure the health and safety of participants.

At least two personnel members must be present on the premises whenever two or more participants are in the ADHC facility. At least one personnel member with cardiovascular pulmonary resuscitation (CPR) and first-aid certification must be on the premises at all times, and a nurse must be on the premises daily to administer medications and treatments and monitor participants' health status.

Training Requirements

The administrator must ensure that policies and procedures are established, documented, and implemented to cover orientation and in-service education for personnel, employees, volunteers, and students, and to cover certification in CPR and first-aid training.

Location of Licensing, Certification, or Other Requirements

Arizona Administrative Code, Title 9, Health Services, Chapter10: Health Care Institutions, Licensing, Article 11. Adult Day Health Care Facilities. Department of Health Services. [July 1, 2014] These new rules are titled "unofficial" because they have not yet been published by the Secretary of State's office.http://www.azdhs.gov/als/residential/documents/article-11.pdf

Information Sources

Jim TiffanyState Licensing Team LeaderArizona Bureau of Residential Facilities Licensing

Kim M. Elliott, Ph.D.AdministratorClinical Quality ManagementArizona Health Care Cost Containment System

Joanne ThomsonSenior Director of Day ServicesBenevilla Adult Day Centers

ARKANSAS

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-arkansas

Overview

The Arkansas Office of Long Term Care in the Department of Human Services licenses adult day care (ADC) and adult day health care (ADHC) under separate rules and regulations. The issuance of an ADC or ADHC facility license authorizes providers to operate an ADC or ADHC facility.

Arkansas provides ADC and ADHC under a Medicaid 1915(c) waiver program--ElderChoices. Medicaid providers must be licensed by the Office of Long Term Care and certified by the Division of Aging and Adult Services (DAAS) as having met all Centers for Medicare and Medicaid Services-approved provider criteria for the service(s) they wish to provide. ADC and ADHC providers must recertify with DAAS every 3 years; however, DAAS must maintain a copy of the agency's current ADC or ADHC annual license at all times.

DAAS may choose to certify providers in certain cities in states bordering Arkansas, which are licensed or certified by the appropriate agency in their state.

ElderChoices participants may receive ADC services or ADHC services for 4 or more hours per day but not to exceed 8 hours per day, when the services are prescribed by their attending physician and provided according to their written ElderChoices care plan. ADC and ADHC services of less than 4 hours per day are not reimbursable by Medicaid; the services may be utilized up to 40 hours per week, not to exceed 184 hours per month.

Definitions

Adult day care is a group program designed to provide care and supervision to meet the needs of four or more functionally impaired adults for periods of more than 2 hours but less than 24 hours per day, in a place other than the adults' own homes.

Adult day health care is a program that provides organized supportive health and social services and activities to meet the needs of four or more functionally impaired adults for periods of more than 2 hours but less than 24 hours per day, in a place other than the adults' own homes.

ADHC programs provide rehabilitative and health services directed toward meeting participants' health maintenance and restoration needs, which cannot be provided by ADC programs. ADHC is appropriate only for individuals whose facility-developed care plans specify one or more of the following health services:

  • Rehabilitative therapies (e.g., physical therapy, occupational therapy);
  • Pharmaceutical supervision;
  • Diagnostic evaluation; and
  • Health monitoring.

     

ADHC provides beneficiaries with needed rehabilitative, therapeutic, and supportive health and social services, as well as relief for caregivers. It differs from social ADC or community centers by its strong emphasis on holistic health care through the utilization of an interdisciplinary team, with the core team consisting of nursing, social work, medicine, rehabilitation, therapy, and activities coordination.

The goals of the ADHC program include the provision of therapy, a safe and supportive environment, crisis intervention, respite, family assistance and training, and restoring or maintaining optimal functioning of impaired adults through the provision of a defined range of specific services.

Parameters for Who Can Be Served

Adult day care may serve functionally impaired adults 18 years of age or older, who by reason of mental or physical disability require care and supervision. Participants will be deemed ineligible if they are bedfast, cannot self-administer their medication (facility staff cannot administer treatments and therapies), or have behavior problems that create a hazard to themselves or others. Participants may not be transferred or discharged except for medical reasons or to ensure their or other participants' welfare.

Adult day health care may serve functionally impaired older adults who need care and supervision to maintain their current level of functioning and to promote independence and self-esteem. Participants will be deemed ineligible if they are bedfast or have behavior problems that create a hazard to themselves or others. Participants may not be transferred or discharged except for medical reasons or to ensure their or other participants' welfare.

Inspection and Monitoring

Annual renewal is required for all ADC and ADHC facility licenses. Facilities must submit to regular unannounced inspection surveys and complaint investigations in order to receive or maintain a license. Providers are required to afford any authorized agents of the Department of Health Services, or their designee, full access at any time during normal business hours to participants, grounds, buildings, and files.

Required and Optional Services

All ADHC programs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

Required and Optional Services Adult Day Care Adult Day Health Care
  Required     Optional     Required     Optional  
ADL Assistance X   X  
Health Education and Counseling X   X  
Health Monitoring X   X  
Medication Administration     X  
Nursing Services     X  
Physical Therapy, Occupational Therapy, or Speech Therapy   X1   X1  
Skilled Nursing Services     X  
Social Services       X
Transportation   X   X
  1. Programs are required to facilitate the provision of these specialized services as needed by individual participants. They may be arranged for through community sources or provided through the program.

Medication Provisions

Adult Day Care. Participants must be able to self-administer their own medication. Facility staff may provide assistance to enable participants to self-administer medications. The facility must have a written and approved system for handling and storing participants' medications. In-service training on facility medication policies and procedures must be provided at least annually for all facility personnel, staff, employees, and volunteers supervising self-administration of medications.

Adult Day Health Care. Participants who are able to do so may keep and administer their own medicines while attending the ADHC program. They must be supervised as necessary in administering their medications. Facility staff must provide assistance to enable participants to self-administer medications. However, if participants are assessed as being unable to self-administer their medications, a registered nurse (RN) or licensed practical nurse (LPN) may administer their medications. The facility must provide for injection of insulin or other intramuscular or subcutaneous injections by licensed personnel for individual participants as ordered by the participant's physician. In-service training on facility medication policies and procedures must be provided at least annually for all facility personnel, staff, employees, and volunteers supervising or administering medications.

Staffing Requirements

Adult Day Care

Type of Staff. ADC facilities licensed for more than 15 participants must have a full-time director. Regardless of the number of participants, either the director or his/her designee must be present and in charge during all hours that participants are on the premises.

Staffing Ratios. The ADC program must provide a sufficient number of direct care staff on duty at all times to meet the needs of each participant and ensure that participants are never left unattended. At a minimum, there must be at least two direct care staff persons when 2-16 participants are present, and one additional direct care staff person for any number of up to eight additional participants. The Office of Long Term Care may require additional staff when it determines that participants' service needs are not being met.

In ADC programs where the executive director is responsible for more than day care services, he/she may not be counted as direct staff.

Trained volunteers at least 18 years of age may be counted in the direct care staff-to-participant ratio provided a volunteer program description is in writing and on file in the facility. The description must include the training to be provided and the system for ensuring the presence of scheduled volunteer help. When counted in the direct care staff-to-participant ratio, the volunteer must have the same qualifications as the staff position for which they are being substituted.

Universal Worker

Each staff person on duty may be counted as direct care staff even if they are currently involved in housekeeping, laundry, or dietary activities as long as universal precautions are followed.

In case of an emergency when a direct care staff must leave, one non-direct care staff person (which may include secretaries, cooks, accountants, and other non-direct care staff members) may count as direct care staff until the emergency has been resolved. Direct care staff must not be counted simultaneously to meet the required staffing ratios for multiple facilities operating in the same location.

Adult Day Health Care

Type of Staff. ADHC facilities licensed for more than 15 participants must have a full-time program director with the authority and responsibility for the management of activities and direction of staff, and who must ensure that activities and services are appropriate and in accordance with established policies.

An ADHC program must have a full-time health care coordinator to supervise the delivery of health care services. The health care coordinator must be either an RN or an LPN under the supervision of an RN.

In facilities licensed for 15 or fewer participants, a single individual may be both the full-time program director and the health care coordinator, provided that this individual meets all of the qualification of both positions, and the requirements for the staffing pattern are met.

Staffing Ratios. The staffing pattern must depend on the enrollment criteria and the particular needs of the participants to be served. The ADHC program must have sufficient staff responsible for personal care to comply with the rules and regulations for ADHC providers and the care requirements of the participants.

The ratio of paid staff to participants must be adequate to meet the goals and objectives of the program. The minimum ratios must be as follows: one paid full-time equivalent staff position with responsibility for direct care for each five participants. The Office of Long-Term Care may require additional staff when it is determined that the needs of the participants are not being met.

In ADHC programs where the executive director is responsible for more than ADHC services, he or she may not be counted as direct care staff. Secretaries, accountants, and other non-direct care staff must not be considered in the staffing ratio. In case of an emergency when a direct care staff must leave, one non-direct care staff may count as direct care staff until the emergency has been resolved.

Whenever paid staff are absent, substitutes must be used to maintain the staff-to-participant ratio and to ensure proper supervision and delivery of health care services. Such substitute staff must have the same qualifications, training, and personal credentials as the regular staff position for which they are substituting, and may be trained volunteers.

Universal Worker

Each staff person on duty may be counted as direct care staff even if they are currently involved in housekeeping, laundry, or dietary activities as long as universal precautions are followed.

Training Requirements

Adult Day Care. Both paid and volunteer direct care staff must be trained and oriented to perform the duties required by the written job description.

All staff, including non-direct care staff and direct care volunteers, must be given a general orientation to the program; its policies; and fire, safety and emergency procedures, prior to performing job responsibilities. Orientation documentation must be available for review by the Office of Long Term Care personnel.

  • In-service training sessions are required for all direct care staff: 4 hours per quarter for a total of 16 hours per year.

  • In-service training sessions for non-direct care staff are required at a minimum of 2 hours per quarter for a total of 8 hours per year.

  • In-service training sessions for part-time workers (20 hours or less per week) are required at a minimum of 2 hours per quarter for a total of 8 hours per year.

  • In-service training sessions are required for all volunteers and must total a minimum of 4 hours per quarter for full-time volunteers and 8 hours per year for part-time volunteers (less than 20 hours per week).

Adult Day Health Care. There must be an orientation program for new employees and volunteers and a program of ongoing staff development and in-service training.

  • In-service training sessions for direct care staff are required at a minimum of 4 hours per quarter for a total of 16 hours per year. Training must be appropriate to job function and must include but not be limited to: participant rights, safety standards, abuse reporting, normal signs of aging, health problems of aging, communications, and Alzheimer's or dementia training.

  • In-service training sessions for non-direct care staff are required at a minimum of 2 hours per quarter for a total of 8 hours per year.

  • In-services training sessions for part-time workers (20 hours or less per week) are required at a minimum of 2 hours per quarter for a total of 8 hours per year.

  • In-service training sessions are required for all volunteers and must total a minimum of 4 hours per quarter for full-time volunteers and 8 hours per year for part-time volunteers (less than 20 hours per week).

Location of Licensing, Certification, or Other Requirements

Rules and Regulations for Adult Day Care Providers in Arkansas. Arkansas Department of Health and Human Services. [April 15, 2006]http://humanservices.arkansas.gov/dms/oltcDocuments/adc.pdf

Rules and Regulations for Adult Day Health Care Providers in Arkansas. Arkansas Department of Human Services. [April 10, 2006]http://humanservices.arkansas.gov/dms/oltcDocuments/adhc.pdf

The Arkansas Medicaid Provider Manual, Section II, ElderChoices HCBS 2176 Waiver, Program Coverage. Arkansas Department of Human Services, Division of Medical Services. [January 1, 2013]https://www.medicaid.state.ar.us/InternetSolution/Provider/docs/elder.aspx

ElderChoices Adult Day Care Provider Application. Arkansas Department of Human Services. [November 2009]http://www.daas.ar.gov/pdf/Provider%20Certification/ADC%20Application%20...

ElderChoices Adult Day Health Care Provider Application. Arkansas Department of Human Services. [November 2009]http://www.daas.ar.gov/pdf/Provider%20Certification/ADHC%20Application%2...

Information Sources

Sherri Proffer, RNNurse Manager, Office of Long Term CareDivision of Medical ServicesArkansas Department of Human Services

Stephenie Blocker, RN-BCAssistant Director, Home and Community-Based ServicesArkansas Division of Aging and Adult Services

CALIFORNIA

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-california

Overview

The California Department of Social Services licenses adult day programs (ADPs) as community care facilities. ADP services are not covered by Medi-Cal--the name of California's Medicaid program. They receive funding from Area Agencies on Aging, private fees, and community donations. Applicants for an ADP center license must attend a mandatory orientation, which includes, but is not limited to a presentation on the scope of operation subject to the Department's regulation.

The California Department of Public Health licenses adult day health care (ADHC) centers as health facilities. Licensed ADHC centers may also operate an ADP.

In 2011, ADHC services were eliminated as an optional Medi-Cal State Plan benefit. A class action lawsuit challenged the elimination, and a Settlement Agreement was reached in March 2012. On April 1, 2012, Community-Based Adult Services became a mandated "long-term services and supports" (LTSS) benefit within California's 1115 Medi-Cal waiver program.8 To be a Medi-Cal provider, a licensed ADHC center must also be certified as a Community-Based Adult Services center by the California Department on Aging. Medicaid requirements for the Community-Based Adult Services have not yet been finalized.

Definitions

Adult day program means any community-based facility or program that provides care on a less than 24-hour basis to persons age 18 years or older who are in need of personal care services, supervision, or assistance essential to sustaining activities of daily living (ADLs), or for the protection of the individual.

Adult day health care means an organized day program of therapeutic, social, and health activities and services provided to elderly persons with functional impairments, either physical or mental, for the purpose of restoring or maintaining optimal capacity for self-care. Provided on a short-term basis, ADHC serves as a transition from a health facility or home health program to personal independence. Provided on a long-term basis, it serves as an alternative to institutionalization in a long-term health care facility when 24-hour skilled nursing care is not medically necessary or viewed as desirable by participants and their families.

Adult day health center or adult day health care center means a licensed and certified facility that provides ADHC, or a distinct portion of a licensed health facility in which such care is provided in a specialized unit under a special permit issued by the Department.

Alzheimer's day care resource center means a specialized program provided in either an ADP or ADHC setting that addresses the psychosocial, mental, functional, and cognitive needs of persons with dementia by assisting them to function at their highest level.

Community-based adult services means an outpatient, facility-based program that delivers skilled nursing care, social services, therapies, personal care, family/caregiver training and support, nutrition services, care coordination, and transportation to eligible Medicaid beneficiaries.

Parameters for Who Can Be Served

Both ADPs and ADHC centers may serve persons with Alzheimer's disease or other dementias, complex physical, mental or developmental disabilities, cognitive impairments, and other chronic disabling conditions. Community-Based Adult Services participants must meet Medicaid's medical necessity criteria, which is comparable to nursing facility level of care criteria.

Adult Day Program. Providers may not admit and must discharge individuals whose needs cannot be met. Immediate discharge is allowed if a participant's condition has suddenly changed and remaining in the day program is likely to cause danger to the participant or others. Individuals may not be admitted or retained if they require health services or have a health condition including, but not limited to:

  • naso-gastric and naso-duodenal tubes;
  • active, communicable TB;
  • conditions that require 24-hour nursing care and/or monitoring;
  • Stage 3 and 4 pressure sores (dermal ulcers); and
  • any other condition or care requirements that would require the day program to be licensed as a health facility.

ADPs may accept or retain participants who have certain health conditions only if the participant is under the medical care of a licensed professional and the medical condition is chronic and stable, or is temporary in nature and expected to return to a condition normal for the participant.9 These conditions include:

  • use of inhalation-assistive devices;
  • colostomy/ileostomies;
  • requirement for fecal impaction removal, enemas, and suppositories;
  • use of catheters;
  • staph or other serious, communicable infections;
  • insulin-dependent diabetes;
  • Stage 1 and 2 pressure sores (dermal ulcers);
  • wounds; and
  • gastrostomies and tracheostomies.

To admit or retain participants with these conditions, the program must meet all general and condition-specific requirements regarding the provision of incidental medical services, including: (1) ensuring that program staff who will participate in meeting a participant's specialized care needs complete training provided by a licensed professional, sufficient to meet those needs; and (2) providing care for these conditions as specified in the regulations.

Adult Day Health Care. ADHC facilities may serve adults of all ages who are chronically ill or impaired and would benefit from ADHC services. Providers may not admit individuals for whom, in their clinical judgment, they cannot appropriately care. They may serve persons with dementia and other special needs populations, such as persons with developmental disabilities or persons with mental disabilities. Providers may discharge participants if they are unable or unwilling to use the prescribed services and ADHC staff have made every effort to remove possible obstacles.

Inspection and Monitoring

Adult Day Program. As part of the application review process, the licensing agency conducts a site visit to the proposed day program. Within 90 days after a license has been issued, the Department inspects the facility. Unannounced visits may be made to determine compliance with applicable laws and regulations--as often as deemed necessary. The Department conducts random unannounced visits to no less than 10 percent of facilities each year. Under no circumstances does the Department visit a facility less often than once every 5 years.

Adult Day Health Care. As resources permit, an inspection may be conducted prior to--as well as within the first 90 days of--ADHC center operation. Inspections are conducted annually or at least every 2 years, and as often as necessary to ensure the quality of care being provided. An inspection may occur without notice at any time, to secure compliance with--or to prevent a violation of--any regulation.

If an ADHC center or an applicant for a license has not been previously licensed, the Department may only issue a provisional license to the center. A provisional license to operate an ADHC center expires 1 year from the date of issuance, or at an earlier time, as determined by the Department at the time of issuance. Within 30 days prior to the expiration of a provisional license, the Department conducts a full and complete inspection of the ADHC center. If the ADHC center meets all licensure requirements, a regular license is issued for 1 year and must be renewed each year.

Required and Optional Services

All adult day and ADHC programs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

Required and Optional Services Adult Day Care Adult Day Health Care
  Required     Optional     Required1     Optional2  
ADL Assistance X   X  
Health Education and Counseling X   X  
Health Monitoring/Health-Related Services X   X  
Medication Administration   X X  
Nursing Services   X X  
Physical Therapy, Occupational Therapy, or Speech Therapy       X  
Skilled Nursing Services   X X  
Social Services X   X  
Transportation X3   X4  
  1. Medical and psychiatric or psychological services are also required.
  2. Additional optional services are podiatric services, optometric screening, and dental screening.
  3. Providers must furnish or arrange transportation, or assist in the transportation of participants to and from the program.
  4. Providers must either furnish or arrange transportation.

Medication Provisions

Adult Day Program. Participants must be assisted as needed with self-administration of prescription and non-prescription medications. Program staff who receive training from a licensed professional may assist participants with metered-dose inhalers and dry powder inhalers if requirements regarding training, supervision, and documentation are met.

Program staff, except those authorized by law, may not administer injections, but staff designated by the licensee are authorized to assist participants with self-administration of injections, as needed.

Assistance with self-administration does not include forcing a participant to take medications, hiding or camouflaging medications in other substances without the participant's knowledge and consent, or otherwise infringing upon a participant's right to refuse to take a medication.

If the participant's physician has stated in writing that he or she is able to determine and communicate his/her need for a prescription or non-prescription PRN (i.e., as needed) medication, program staff are permitted to assist the participant with self-administration of PRN medications.

If the participant's physician has stated in writing that the participant is unable to determine his/her own need for non-prescription PRN medication, but can clearly communicate his/her symptoms, program staff designated by the licensee are permitted to assist the participant with self-administration, provided all requirements relating to physicians' orders and medication record-keeping are met.

If the participant is unable to determine his/her own need for a prescription or non-prescription PRN medication, and is unable to communicate his/her symptoms clearly, program staff designated by the licensee are permitted to assist the participant with medication self-administration, provided all requirements regarding physician/nurse practitioner notification/orders and medication record-keeping are met.

Adult Day Health Care. Each participant's health record must include a drug history that lists all medications currently being taken by the participant and any medications to which the participant is allergic. Medications must be administered only by licensed medical or licensed nursing personnel. Self-administration of medications is permitted only under the following conditions: (1) the center has approved policies permitting self-administration of medications when approved by the multidisciplinary team; (2) training in self-administration of medications is provided to all participants based on the recommendation of the multidisciplinary team; and (3) the health record of each participant who is capable of self-medication names all drugs that are to be self-administered.

Staffing Requirements

Adult Day Program

Type of Staff. All ADPs must have an administrator who will be responsible for carrying out program responsibilities, supervising the program's operation, coordinating all activities and services, and providing staff orientation and training. The administrator must be at the program site the number of hours necessary to manage and administer the program in compliance with applicable laws and regulations.

When the administrator is absent from the ADP site, a substitute staff person with the required qualifications must assume his/her responsibilities. If an administrator is responsible for two or more ADPs, each site must have an employee who is responsible for the program's day-to-day operation. The licensing agency may require that the administrator increase his/her time spent at the facility if it is determined that his/her absence has a detrimental effect on the facility.

Direct care staff are responsible for participants' care and supervision. Care staff must not be assigned to any support staff duties, such as housekeeping, cooking, or office work, unless participants' care and supervision needs have been met. During the performance of support staff duties, a direct care staff member must not be counted in the required staff-to-participant ratio. Volunteers may be utilized only if they are supervised and are not included in the staffing plan. When regular staff members are absent, coverage must be provided by personnel capable of performing assigned tasks as evidenced by on-the-job performance.

All personnel must be competent to provide the services necessary to meet individual participant's needs and must at all times be employed in numbers necessary to meet such needs. The licensing agency has the authority to require any licensee to provide additional staff whenever the licensing agency determines and documents that additional staff are required for the provision of services necessary to meet participant needs.

Staffing Ratios. At least two persons must be on duty at all times when two or more participants are present in the day program; at least one of the two must be a direct care staff member. The licensee must provide for an overlap of staff at each shift change to ensure continuity of care.

The direct care staff-to-participant ratio must not be less than 1:8 (or fraction thereof). Whenever a participant who relies upon others to perform all ADLs is present, the staff-to-participant ratio must be no less than 1:4. Volunteers may be included in the staff-to-participant ratio if they meet the direct care staff requirements.

Adult Day Health Care

Type of Staff. Each center must have an administrator. The administrator must have the responsibility and authority to carry out the licensee's policies. Each center must provide for continuity of operation and assumption of the administrator's responsibilities during his/her absence. The administrator must not be responsible for more than three centers without prior written approval by the Department. In this circumstance, there must be one or more assistant administrators for every three additional centers.

Each center must have a full-time program director. The program director must be on the premises and available to participants, employees, and relatives. When the program director is temporarily absent, another adult staff member must be designated to serve as the acting program director. Centers with a capacity of 50 and over must have both an administrator and a full-time program director.

The program director of centers whose average daily attendance is 20 or fewer may also serve as the registered nurse (RN), social worker, occupational therapist, physical therapist, speech therapist, or dietitian, provided that the program director has the professional qualifications for that position and the program director and the administrator are not the same person. Program aides must be employed in a sufficient number to meet participants' needs and staffing requirements of the Department.

The program director, a RN with a public health background, a medical social worker, a program aide, and an activity coordinator must be on duty during the hours the center offers basic services. Other staff must be employed in sufficient numbers to provide services as prescribed in the individual care plans in accordance with minimal requirements determined by each center's average daily attendance (based on the previous quarter's experience). Medical services must be provided to each participant by a personal or a staff physician.

Occupational, physical, and speech therapy services staff must work the hours necessary to meet the needs of each participant as specified in the individual care plan and in accordance with the Department's staffing requirements.

For the provision of psychiatric or psychological services, the center must have consultant staff available a minimum of 3 hours per month consisting of a psychiatrist, clinical psychologist, psychiatric social worker, or psychiatric nurse. Consultant staff must spend a sufficient number of hours in the center to meet the needs of each participant and the Department's staffing requirements.

Program aides must be employed in sufficient numbers to meet participants' needs and the Department's staffing requirements. Volunteers may provide services but must not be used to replace required employees. Each volunteer must receive orientation, training, and supervision.

Staffing Ratios. There must be one program aide for every 16 participants during the hours of operation. An additional half-time social work assistant and an additional half-time licensed vocational nurse must be on-site for each increment of ten participants in average daily attendance exceeding 40.

Training Requirements

Adult Day Program. The administrator must have a minimum of 30 hours of continuing education every 24 months of employment, which includes the completion of courses workshops, seminars, and academic classes related to the roles and responsibilities of the administrator position.

The licensee must develop, maintain, and implement a written plan for the orientation, continuing education, on-the-job training and development, supervision, and evaluation of all direct care staff. Direct care staff must receive a minimum of 8 hours of documented training each year.

All personnel must be given on-the-job training or must have related experience that provides knowledge of and skill in the following areas, as appropriate to the job assigned, and as evidenced by safe and effective job performance: (1) principles of nutrition, food preparation and storage, and menu planning; (2) housekeeping and sanitation principles; (3) provision of participant care and supervision, including communication; (4) assistance with prescribed medications that are self-administered; (5) recognition of early signs of illness and the need for professional assistance; (6) availability of community services and resources; (7) universal precautions; (8) emergency procedures; and (9) mandated reporting requirements for dependent adult and elder abuse.

The licensee must ensure that program staff who will participate in meeting the specialized care needs for restricted conditions complete training provided by a licensed professional sufficient to meet those needs. Training must include hands-on instruction in both general procedures and participant-specific procedures.

Adult Day Health Care. A planned in-service education program, including orientation, skill training, and continuing education, must be provided for employees. All staff members must receive in-service training in first-aid and cardiovascular pulmonary resuscitation within the first 6 months of employment. An ADHC center that provides care for adults with Alzheimer's disease and other dementias must provide staff training regarding the use and operation of the center's egress control devices (i.e., those precluding the use of exits); the protection of participants' personal rights; wandering behavior and acceptable methods of redirection; and emergency evacuation procedures for persons with dementia.

Location of Licensing, Certification, or Other Requirements

Manual of Policies and Procedures, Community Care Licensing Division, Title 22, Chapter 3: Adult Day Program. State of California Health and Human Services Agency, Department of Social Services. [January 12, 2007]http://www.dss.cahwnet.gov/getinfo/pdf/adpman.PDF

California Law website, Health and Safety Code, Division 2--Licensing Provisions, Chapter 3.3: California Adult Day Health Care Act. [September 2012]http://ca.regstoday.com/law/hsc/ca.regstoday.com/laws/hsc/calaw-hsc_DIVISION2_CHAPTER3p3.aspx#1

Medi-Cal Certification and Licensing Regulations, Title 22, Chapter 10: Adult Day Health Care. California Department of Social Services.http://www.cdss.ca.gov/shd/res/pdf/54001.pdf

Information Sources

Lydia Missaelides, MHAExecutive DirectorCalifornia Association for Adult Day Services

COLORADO

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-colorado

Overview

Colorado has two types of adult day services: basic adult day services (ADS) and specialized adult day services (SADS). Neither type require licensure but to receive Medicaid reimbursement, ADS centers and SADS centers have to meet state certification standards. The Department of Health Care Policy and Financing administers the Medicaid program and oversees Medicaid ADS and SADS providers.

This profile presents the certification standards for both ADS and SADS Medicaid providers. The state has multiple 1915(c) waiver programs, which may have additional standards for SADS providers depending on the populations they serve, such as persons with mental illness, persons with AIDS, and persons with a brain injury. For example, the Brain Injury Waiver program has additional training requirements to address the unique needs of its participants.

ADS and SADS centers that do not participate in Medicaid do not have to meet certification standards.

Definitions

Adult day services meanshealth and social services and individual therapeutic and psychological activities furnished on a regularly scheduled basis in an ADS center, as an alternative to long-term nursing facility care.

Basic adult day services center means a community-based entity that conforms to all state-established requirements.

Specialized adult day services center means a community-based entity determined by the state to be providing intensive health supportive services for participants with a primary diagnosis of Alzheimer's disease or other type of dementia, multiple sclerosis, brain injury, chronic mental illness, or developmental disability; or post-stroke participants who require extensive rehabilitative therapies. To be considered a specialized center, two-thirds of an ADS center's population must be participants whose physician has verified one of the above diagnoses and recommended the appropriate specialized services.

Parameters for Who Can Be Served

Providers may serve only individuals whose needs can be met by the ADS center within its certification category.

Inspection and Monitoring

To determine if a provider meets certification standards, the Department of Health Care Policy and Financing or its designee reviews a provider's application and the Department of Health conducts an on-site survey. The Department or its designee conducts an annual on-site survey of ADS and SADS centers.

Required and Optional Services

All ADS programs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

Required and Optional Services Basic Adult Day Services Specialized Adult Day Services
  Required     Optional     Required     Optional  
ADL Assistance X   X  
Health Education and Counseling     X  
Health Monitoring/Health-Related Services     X  
Medication Administration X   X  
Nursing Services X   X  
Physical Therapy, Occupational Therapy, or Speech Therapy     X1 X  
Skilled Nursing Services   X X2  
Social Services        
Transportation        
  1. These services are provided only if they are prescribed by the participant's physician, documented in the participant's care plan, and are not being provided in the participant's home.
  2. Although not stated in the Code of Colorado Regulations, skilled nursing services are required if needed to meet participants' needs.

Medication Provisions

ADS and SADS centers must provide nursing services necessary to supervise the administration of medications by trained medication aides. Provisions regarding medication administration must be included in an ADS center's written operation policies. ADS centers providing medication administration as a service must have qualified persons on their staff who have been trained in accordance with state law regarding qualified medication administration.

Staffing Requirements

Type of Staff. ADS and SADS center requirements for licensed staff are based on their participants' level of need. All ADS centers must provide nursing services for regular monitoring of participants' ongoing medical needs and the supervision of medication administration. These services must be available a minimum of 2 hours daily and must be provided by a registered nurse (RN) or a licensed practical nurse (LPN). Certified nursing assistants (CNAs) may provide these services under the direction of an RN or an LPN. Supervision of CNAs must include consultation and oversight on a weekly basis or more according to participants' needs.

Staffing Ratios. All ADS centers must maintain a staff-to-participant ratio of 1:8 or fewer participants to meet the needs of the population served. SADS centers providing a restorative model of care shall have sufficient staff to provide the following: (1) nursing services during all hours of operation provided by a licensed RN or LPN or by a CNA under the supervision of an RN or LPN; and (2) therapies to meet participants' restorative needs.

Training Requirements

All staff must be trained in the use of universal precautions for infection control. The operator and staff must provide training specific to the needs of the populations served (e.g., elderly, blind, and disabled). All staff and volunteers must be trained to handle emergencies, and providers must have written procedures for staff to meet medical crises.

Location of Licensing, Certification, or Other Requirements

Department of Health Care Policy and Financing website: LTSS Services and Special Programs, Adult Day Services.http://www.colorado.gov/cs/Satellite/HCPF/HCPF/1218102955170

Code of Colorado Regulations. Medical Assistance, Section 8.400: Long Term Care, 8.491, Adult Day Services. The Department of Health Care Policy and Financing. [May 30, 2014]http://www.sos.state.co.us/CCR/GenerateRulePdf.do?ruleVersionId=5709&fileName=10%20CCR%202505-10%208.400

Instructions for Providers: How to Get Licensed or Certified, Flowchart.http://www.colorado.gov/cs/Satellite?blobcol=urldata&blobheadername1=Con...

Colorado's 1915(c) HCBS Waiver Services, Service Descriptions for Waiver Modernization Sub-Group. [December 27, 2012]http://www.colorado.gov/cs/Satellite?blobcol=urldata&blobheader=applicat...

Information Sources

Colin LaughlinHome and Community-Based Services Adult Waiver Specialist LeadLong Term Services and Supports DivisionDepartment of Health Care Policy and Financing

CONNECTICUT

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-connecticut

Overview

The state has two models of adult day care (ADC): the social model and the medical model. The social model is designed for individuals who need supervision and activities but not extensive personal care and medical monitoring. The medical model provides more extensive personal care, medical monitoring, and rehabilitative services in addition to structured and stimulating activities. Both the social and medical model arecalled adult day care (or adult day health services [ADHS] in Connecticut's Home Care Program for Elders).

The state does not license ADC centers. But to be reimbursed by the state for participants who meet income and medical eligibility criteria for state assistance, adult day centers must meet the Connecticut Association of Adult Day Centers standards for certification, developed in cooperation with the Department of Social Services. An adult day center may provide both models of care; however, each model requires separate certification. Centers that do not receive state funds do not need certification, but may choose to be certified.

In order to receive payment for ADHS provided under a Medicaid 1915(c) waiver program, an ADHS provider must meet all applicable state and local requirements including zoning, licensing, sanitation, fire and safety requirements. In addition, any facility located and operating within the State of Connecticut or located and operating outside the State of Connecticut, in a bordering state, must be certified by the Connecticut Association of Adult Day Centers, its successor agency or a Department designee.

A facility located and operating outside the State of Connecticut in a bordering state must also be licensed or certified by its respective state and comply at all times with all pertinent licensure or certification requirements in addition to the approved standards for certification by the Connecticut Department of Social Services.

The Connecticut Home Care Program for Elders also covers adult day services. This program has a three-tiered structure through which individuals can receive home care services in amounts corresponding to their financial means and functional dependence. Two categories within the program are funded primarily with state-only funds; the third category is funded by several Medicaid 1915(c) waiver programs (Acquired Brain Injury, Elderly, Mental Health, or Personal Care Assistant). Each category has its own eligibility requirements.

Definitions

The term adult day care (or adult day health services as it is called in Connecticut's Home Care Program for Elders) is used for both the social and the medical model. ADC is provided to meet the needs of cognitively and physically impaired adults through a structured, comprehensive program that furnishes a variety of health, social, and related support services, including but not limited to socialization, supervision and monitoring, personal care, and nutrition, in a protective setting during any part of a day.

Parameters for Who Can Be Served

The parameters for who can be served are stated generally in the definition of ADC as individuals with cognitive or physical impairments who need health, personal care, nutrition, and social services. Providers are required to have a written case-mix policy that specifies any limits they place on the number of persons with a specified condition they will serve at any one time. Because providers may serve Medicaid waiver participants, they can serve individuals who meet the state's nursing home level of care criteria. Individual centers may serve special needs groups through their case-mix policy.

Inspection and Monitoring

The Connecticut Association of Adult Day Centers is authorized by the Connecticut Department of Social Services to conduct and administer a program of peer review. This is the key mechanism through which quality standards are ensured. Adult day centers are required to have a written plan for an annual self-evaluation of the center's operation and services. The self-evaluation is surveyed by the peer review team of the Connecticut Association of Adult Day Centers for the purpose of recertification.

Required and Optional Services

All ADC or ADHS programs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

Required and Optional Services Social Model Medical Model
  Required     Optional     Required     Optional  
ADL Assistance X1   X  
Health Education and Counseling   X   X
Health Monitoring X1   X  
Medication Administration X1   X  
Nursing Services X1   X  
Physical Therapy, Occupational Therapy, or Speech Therapy   X1   X2  
Skilled Nursing Services     X  
Social Services X   X  
Transportation X   X  
  1. These services are required only if they are specified in a participant's care plan.
  2. The adult day center must have the capacity to provide such services on site; this requirement must not preclude the provider from also arranging to provide therapeutic and rehabilitation services at other locations in order to meet individual participant needs.

Medication Provisions

Each physician's assessment of participants must include a record of current medications and indicate those that need to be administered at the adult day center. The program nurse is responsible for administering medications as needed.

Staffing Requirements

Type of Staff. Providers are required to have staff to meet participants' needs. An administrator/director must be responsible for the daily operation of the center. In the absence of the director an on-site staff member must be designated to supervise the program and staff.

Full-time or full-time equivalent direct care staff are those who spend 70 percent of their time providing direct service to participants. Personal care services must be provided by trained staff as specified in the individual care plan.

The activity director must develop planned individual and group activities suited to participants' needs and abilities, as determined in their individual care plans.

Social services, including counseling, information, and referral, must be available to each participant on site. Providers may either employ an individual to fill the social services position or contract with one.

Providers that furnish nursing services must either employ or contract with registered nurses (RNs) or licensed practical nurses (LPNs) licensed in the State of Connecticut.

Centers offering the medical model of care must meet the following additional staffing requirements: a program nurse must be available on site for not less than 50 percent of each operating day. The program nurse is responsible for administering medications as needed and ensuring that participants' nursing services are coordinated with other services provided in the adult day center and other health and social services received--whether at home, by existing community health agencies, or by personal physicians.

The program nurse must be a RN, except that a program nurse may be a LPN if the program is located in a hospital or long-term care facility licensed by the Department of Public Health with ready access to a RN from such hospital or long-term care facility; or the program nurse is supervised by a RN who can be reached by telephone at any time during the operating day and who can be called to the center if needed within one-half hour of the request.

Staffing Ratios. The direct care staff-to-participant ratio must be a minimum of 1:7. Volunteers can be counted as direct care staff only when they conform to the same standards and meet the same requirements as paid staff. Staffing must meet participants' needs.

Training Requirements

Providers must furnish orientation for new employees and volunteers within 6 weeks of employment. General orientation to the program and facility must include, but not be limited to, the mission and goals of ADC, the center's policies and procedures, roles and responsibilities of other staff, standard precautions, fire and safety methods and codes, and participants' rights.

All staff and volunteers must receive regular in-service training that meets their individual training needs. All staff must participate in at least four annual training sessions, including, but not limited to, Occupational Safety and Health Administration regulations on universal precautions and infection control, emergency training, and fire and safety codes.

In addition to the above requirements, providers who contract with the Home Care Program for Elders must make available regular and ongoing staff training about key specialty areas such as physical therapy, occupational therapy, speech therapy, and training in techniques for recognizing when to arrange or refer participants for such services.

Location of Licensing, Certification, or Other Requirements

Services Covered under the Connecticut Home Care Program for Elders (Section 17b-342-2(b) Adult Day Health Services). Department of Social Services. [September 17, 2010]http://www.ct.gov/dss/lib/dss/pdfs/chcpe_regs_post-lco_report_with_corrections_to_send_to_colp_9_17_10.pdf

Standards for Adult Day Care Centers in Connecticut, Connecticut Association of Adult Day Centers, Inc. [April 19, 2005]. Request through the Association's website.http://www.leadingagect.org/adult-day-centers

Information Sources

Maureen Dolin, RNPresidentConnecticut Association of Adult Day Care Centers

Kathy Bruni, MPA, LCSWManager, Alternate Care UnitDepartment of Social Services

DELAWARE

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-delaware

Overview

The Department of Health and Social Services (DHSS) establishes standards for the regulation of adult day care (ADC) facilities and grants licenses for such facilities to persons, associations, or organizations that have been approved in accordance with the state's regulations for ADC facilities. The regulations apply to any program that provides health, social, and related support services as described in the regulations for four or more functionally impaired adults who reside in the community and are in need of these services as determined by a pre-admission assessment.

The state covers medical and social ADC under its Medicaid 1915(c) Elderly and Disabled (E&D) waiver program. The program requires providers to agree to all terms and conditions listed in the Delaware Medical Assistance Program contract and the policies and procedures listed in the E&D waiver program provider-specific policy manual. In addition, the Division of Services for Aging and Adults with Physical Disabilities operates one adult day center, New Horizon, which is located in the Delaware Hospital for the Chronically Ill.

ADC programs are also funded through the following public funding sources: Older Americans Act, Social Services Block Grant, and Medicaid Managed Long-Term Care. All Medicaid ADC programs are funded through two managed care organizations.

Definitions

Adult day care is defined as a therapeutic program for four or more community-living adults with functional and/or cognitive impairments provided in a protective non-residential setting whose needs cannot be appropriately met in other settings such as sheltered workshops, supported employment, or unsupervised senior centers. Such adults are not capable of full-time independent living but with certain activities can become more self-sufficient in the community. Services are provided to adults for a period of less than 12 hours during the day and are provided in a setting other than a participant's home or the residence of the facility operator.

Parameters for Who Can Be Served

The ADC facility may admit only those individuals whose needs it can meet. No participant may be discharged from an ADC facility except for the following reasons: the program can no longer meet the participant's needs; medical reasons; non-participation in the care plan or non-compliance with the written admission agreement; or the participant's or other participants' welfare.

To be eligible for ADC in a Medicaid waiver program, individuals must meet the state's nursing home level of care criteria. To be eligible for ADC--called adult day services (ADS)--through a non-Medicaid program administered by the Division of Services for Aging and Adults with Physical Disabilities, individuals must: (1) be able to benefit from the program; (2) be unable to be left alone at home; (3) live with a caregiver who either works outside the home or needs temporary relief from caregiving; and (4) must be assessed as requiring intermediate care (i.e., needing assistance with activities of daily living [ADLs] and/or assistance with prescribed medications).

Individuals receiving ADS through Older Americans Act Title III funding must be 60 years of age or older; individuals receiving ADS through the Social Services Block Grant, must be18 years of age or older.

Inspection and Monitoring

Every licensed ADC facility must be periodically inspected by a representative of DHSS at least once every 3 years.

Required and Optional Services

All ADC programs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

Required and Optional Services Adult Day Care
  Required     Optional  
ADL Assistance X  
Health Education and Counseling    
Health Monitoring/Health-Related Services X  
Medication Administration X  
Nursing Services   X
Physical Therapy, Occupational Therapy, or Speech Therapy     X
Skilled Nursing Services   X
Social Services X  
Transportation   X

Medication Provisions

Medications may be self-administered or administered in accordance with all state and federal laws, including the State of Delaware Nurse Practice Act. Those participants who, upon admission, are incapable of self-administration or who become incapable of self-administration must have their medications administered according to the provisions of the Nurse Practice Act. Medication must not be administered to a participant unless prescribed by a licensed practitioner with independent prescriptive authority as provided by Delaware Code.

Staffing Requirements

Adult Day Care

Type of Staff. There must be an activities coordinator who will plan group activities for all participants and personalized options for individuals with varying interests and needs.

The director/administrator or designee responsible for the management of the ADC program must be present and in charge during all hours that participants are on the premises. There must be at least one registered nurse or licensed practical nurse on the premises at all times when participants are present for those facilities serving participants requiring nursing services.

There must be at least one employee certified in cardiovascular pulmonary resuscitation on the premises at all times when participants are present.

Staffing Ratios. There must be at least two ADC facility staff on duty at all times when participants are present. If a facility has separate physical areas in which ADC is provided, each area must be treated as independent for meeting staffing requirements. The minimum staffing requirements must not include volunteers or employees who have not yet completed the required orientation program.

For facilities with more than 16 participants, there must be a minimum of one adult staff person on duty for each eight participants. Facilities may not use rounding in determining staffing requirements (i.e., for 17-24 participants at least three staff members would be required, for 25-32 participants at least four staff members, and so on). As the number or dysfunction of participants with functional and cognitive impairments increases, the staff-to-participant ratio must be adjusted accordingly to meet their needs.

Programs serving mainly participants with severe cognitive or physical disabilities must have a staff-to-participant ratio of at least 1:4 for all severely disabled participants.

Training Requirements

Prior to assuming job responsibilities, all personnel must receive training in fire safety; first-aid; emergency procedures; infection control; and special needs of the elderly and persons with cognitive or other disabilities, including the specific needs of the participants being served.

Aide orientation and training must include at least 40 hours of instruction and supervised practicum and address the following topics: (1) the aide's role as a member of the ADC team; (2) personal care services; (3) principles of good nutrition; (4) the process of growth, development, and aging; (5) principles of infection control; (6) observation, reporting, and documentation of participant status; (7) maintaining a clean, safe, and healthy environment; (8) maintaining a least restrictive environment; (9) verbal/non-verbal communication skills; and (10) principles of body mechanics.

Ongoing staff development is required to maintain and improve the skills of the ADC team and should include: (1) the needs of the elderly and persons with disabilities; (2) assisting participants to achieve maximum self-reliance through re-learning and modifying ADLs; (3) physical restraint and the use of less restrictive alternatives; (4) maintaining an environment that encourages morale building and self-help; (5) review of participant care policies and procedures; (6) prevention and control of infection; (7) confidentiality of participant information; and (8) the rights of participants.

Personnel who are primarily responsible for the direct care of participants must attend at least 12 hours annually of staff development activities, which must consist of in-service training programs, workshops, or conferences related to ADC or the specific needs of participants.

An ADC facility that provides direct health care services to persons diagnosed as having Alzheimer's disease or other forms of dementia must provide dementia-specific training annually to health care providers (other than physicians) who must participate in continuing education. Mandatory training must include: communicating with persons diagnosed as having Alzheimer's disease or other forms of dementia; the psychological, social, and physical needs of these persons; and safety measures which need to be taken with these persons.

Location of Licensing, Certification, or Other Requirements

State of Delaware Regulations for Adult Day Care Facilities. Department of Health and Social Services. [February 3, 2014]http://regulations.delaware.gov/register/april2002/proposed/5%20DE%20Reg%201879%2004-01-02.htm

Delaware Administrative Code, Title 16, Health and Social Services: Regulations for Adult Day Care Facilities. Department of Health and Social Services.http://regulations.delaware.gov/AdminCode/title16/Department%20of%20Health%20and%20Social%20Services/Division%20of%20Public%20Health/Health%20Systems%20Protection%20%28HSP%29/4402.pdf

Elderly and Disabled Waiver Provider Specific Policy Manual, Delaware Health and Social Services, Division of Medicaid and Medical Assistance.[April 16, 2012]http://www.dmap.state.de.us/downloads/manuals/elderly.disabled.waiver.provider.specific.pdf

Service Specification, Social Services Block Grant Adult Day Services. Delaware Health and Social Services [April 26, 2009]http://dhss.delaware.gov/dsaapd/files/adult_day.pdf

Final Health Systems Protections Order to add provisions to require certain persons to receive dementia-specific training. Delaware Department of Health and Social Services, Division of Public Health. [August 11, 2011]http://regulations.delaware.gov/register/august2011/final/15%20DE%20Reg%20220%2008-01-11.pdf

Information Sources

Tom BarlowVice President for Senior ServicesEaster Seals Delaware

Frank JonesDepartment of Health and Social ServicesDivision of Services for Aging and Adults with Physical Disabilities

DISTRICT OF COLUMBIA

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-district-columbia

Overview

The District of Columbia (DC) does not license or certify adult day care (ADC) providers who offer a social model of care.

DC provides a medical model of ADC, also called geriatric day care, through the DC Office on Aging (DCOA) grants. These grants are issued under the DC State Plan on Aging to providers who are governed by geriatric day care requirements issued and administered by the DCOA. These requirements are described in this profile.

No fee is charged for geriatric day care but participants, family members, and/or caretakers must be informed of the cost of the services and offered the opportunity to make voluntary contributions to help defray the cost, thereby making additional service available to others.

Definitions

Geriatric day care is a therapeutic service provided to functionally impaired DC residents age 60 years or older to avoid or forestall institutionalization. Geriatric day care involves care and supervision provided during the day by professionally qualified personnel in a suitable facility. Geriatric day care is a more intense level of care than center-based social and recreation services.

Parameters for Who Can Be Served

Adult day care is for seniors and persons with disabilities who are not homebound but who have chronic health care needs and require assistance during the day in order to avoid or delay nursing facility placement. Many ADC participants have physical or cognitive impairments related to heart disease, stroke, diabetes, or hypertension.

Inspection and Monitoring

The DCOA Program Monitor conducts quarterly compliance monitoring of ADC sites in addition to unannounced visits as needed.

Required and Optional Services

All ADC programs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

Required and Optional Services Adult Day Care
  Required     Optional  
ADL Assistance X  
Health Education and Counseling X  
Health Monitoring/Health-Related Services    
Medication Administration X  
Nursing Services X  
Physical Therapy, Occupational Therapy, or Speech Therapy     X1
Skilled Nursing Services X  
Social Services X  
Transportation X  
  1. As necessary or as required by the participant's care plan.

Medication Provisions

Nursing services such as injections and drug supervision must be provided only by a qualified and licensed professional.

Staffing Requirements

Type of Staff. Fully trained and professional staff are required, including, but not limited to, a licensed social worker, a registered nurse or licensed practical nurse, and various therapists.

Staffing Ratios. The required staff ratio is one staff member for every six participants.

Training Requirements

All staff providing services must be fully trained. The agency providing ADC must maintain, follow, and continually update a training and supervision program to ensure that ADC staff arefully trained and familiar with agency procedures.

Location of Licensing, Certification, or Other Requirements

Required standards are on file at the Grantee Office, Licensing Agency, and the DCOA for professional staff.

Information Sources

Aurora Delespin-JonesProgram AnalystProgram and Grants AdministrationDistrict of Columbia Office on Aging

Sally WhiteExecutive DirectorIona Senior Services

Claudia Schlosberg, J.D.Acting Director, MedicaidHealth Care Policy and Research AdministrationDepartment of Health Care Finance

FLORIDA

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-florida

Overview

The Florida Agency for Health Care Administration, Division of Health Quality Assurance, Health Facility Regulation, licenses all adult day care (ADC) centers. Licenses are issued for a two-year period. The Department of Elderly Affairs, in conjunction with the Agency, adopts rules to implement the statutory provisions for ADC centers. A specialty license is needed to provide services as a Specialized Alzheimer's Services Adult Day Care Center. An ADC center can be a freestanding program or services can be offered through a nursing home, assisted living facility, or hospital.

Adult day health care (ADHC) is not a specific licensing category; however, it is a service that can be provided in an ADC center. ADC centers may choose to be ADHC providers. If so, they must furnish additional services, such as nursing and rehabilitative therapies, and meet related staffing requirements. ADHC is covered in the state's Medicaid Managed Long-Term Care Program, which has replaced six 1915(c) waiver programs that formerly served the aged and disabled populations.

All Medicaid providers must be licensed but if they contract directly with one of the state's managed care organizations they do not have to become a Medicaid-contracted provider. Managed long-term care plans may limit the providers in their networks based on credentials, quality indicators, and price, but they must include a minimum number of providers of all covered services.

Licensed assisted living facilities, licensed hospitals, and licensed nursing home facilities that provide ADC services to adults who are not residents are exempt from licensure as an ADC center, providing they do not hold themselves out to the public as one.

Definitions

Adult day care is a program of therapeutic social and health services as well as activities for adults who have functional impairments, furnished in a protective environment that provides as non-institutional an environment as possible. Participants may utilize a variety of services offered during any part of a day, but for less than a 24-hour period.

Adult day care center or center means any building, buildings, or part of a building, whether operated for profit or not, in which its owner or management provides for part of a day, basic services to three or more persons who are 18 years of age or older, who are not related to the owner or operator by blood or marriage, and who require such services. Any facility that comes within the definition of an ADC center must be licensed as such.

Parameters for Who Can Be Served

No participant may be admitted or retained in a center if the services required exceed those that the center is licensed to provide. Admission is limited to adults with functional impairments in need of a protective environment and a program of therapeutic social and health activities and services.

No participant who requires medication during the time spent at the center and who is incapable of self-administration may be admitted or retained unless there is a person licensed according to Florida law to administer medications who will provide this service.

Any participant who is diagnosed as having a communicable disease must be excluded from participation until deemed non-infectious. However, participants who have HIV infection may be admitted to the center, provided that they would otherwise be eligible.

Centers are not required to accept or retain any applicant or participant whose behavior and physical limitations are deemed hazardous to the safety of the individual or other participants, and such conditions shall constitute a basis for termination of center participation.

Inspection and Monitoring

An on-site inspection is conducted after an initial application for licensure is submitted to verify the information submitted on or in connection with the application. Subsequently, the Agency can conduct an on-site inspection at any reasonable time to determine compliance with licensing requirements. Any subsequent inspections are unannounced.

Licensed assisted living facilities, licensed hospitals, and licensed nursing home facilities that provide ADC services to adults who are not residents are monitored during their regular inspection and at least biennially to ensure adequate space and sufficient staff.

Required and Optional Services

All ADC programs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

Required and Optional Services Adult Day Care
  Required     Optional1  
ADL Assistance2    
Health Education and Counseling   X*
Health Monitoring/Health-Related Services   X*
Medication Administration   X*
Nursing Services   X*
Physical Therapy, Occupational Therapy, or Speech Therapy     X
Skilled Nursing Services    
Social Services X  
Transportation   X*
  1. All ADC providers may choose to offer optional services. If furnished, such services must be administered by staff qualified to provide them. To be considered an ADHC center, providers must offer services indicated with an asterisk (*), as well as medical screening, and other medical services. ADHC providers must furnish services for a minimum of 5 hours per day, 5 days per week.
  2. Assistance with activities of daily living (ADLs) is not specified as a basic service; however, providers must be able to provide the appropriate level of care and service to all participants.

Medication Provisions

"Supervision of self-administered medication" means reminding participants to take medication at the time indicated on the prescription; opening or closing medication container(s) or assisting in the opening of pre-packaged medication; reading the medication label to participants; observing participants while they take medication; checking the self-administered dosage against the label of the container; reassuring participants that they have obtained and are taking the dosage as prescribed; keeping daily records of when participants received supervision; and immediately reporting apparent adverse effects on a participant's condition to the participant's physician and responsible person. Supervision of self-administered medication must not be construed to mean that a center shall provide such supervision to participants who are capable of administering their own medication.

No participant who requires medication during the time spent at the center and who is incapable of self-administration can be admitted or retained unless there is a person licensed according to Florida law to administer medications. A physician, advanced registered nurse (RN) practitioner, dentist, licensed practical nurse (LPN), RN, or physician's assistant can administer medications.

Staffing Requirements

Type of Staff. The center must employ qualified staff to provide the services, personal assistance, and safety measures required by participants. The owner or operator may serve in a dual capacity as an RN, occupational therapist, physical therapist, speech-language pathologist, or social worker, if licensed as required by Florida law and qualified to provide such services. The owner or operator may be counted as one of the required staff members, provided the owner or operator provides direct services and is included in the center's work schedule. The designated responsible person must be on the premises during the center's hours of operation.

If centers provide adult day health care, the following staff members are required: (1) a registered nurse or licensed practical nurse on site during the primary hours of program operation and on call during all hours the center is open; all LPNs must be supervised by an RN; (2) a social worker or case manager to provide and supervise the provision of social services, including counseling for participants' families and caregivers and compilation of a social history and psychosocial assessment of formal and informal support systems, and mental and emotional status; and (3) an activity director or recreation therapist, who may be retained as a consultant. All services provided by program aides must be directly supervised by the activity director or recreation therapist.

Staffing Ratios. At all times, staffing must be maintained to meet participants' needs as required by the participant file, including centers that serve persons with Alzheimer's disease and other types of dementia, persons with physical handicaps, or other special target populations.

  • A minimum staff ratio of one staff member who provides direct services for every six participants must be present in the center at all times.

  • If licensed as a specialized Alzheimer's services ADC center, the minimum staff-to-participant ratio is one staff member who provides direct services for every five participants with Alzheimer's disease or other dementia.

  • No fewer than two staff, one of whom has a certification in an approved first-aid course and cardiovascular pulmonary resuscitation, must be present in the center at all times.

  • The owner or operator may be counted as one of the required staff members if he or she provides direct services and is included in the center's work schedule. However, the owner or operator must not be counted more than once in the staff-to-participant ratio, calculated on the basis of daily census.

Training Requirements

Upon beginning employment with the facility, each employee must receive basic written information about interacting with participants who have Alzheimer's disease or other dementias.

In addition, newly hired ADC center personnel who are expected to--or whose responsibilities require them to have direct contact with participants with Alzheimer's disease or other dementias--must complete initial training of at least 1 hour within the first 3 months after beginning employment. The training must include information to provide an understanding of Alzheimer's disease and other dementias, their characteristics, and how to communicate with participants who have these conditions.

Employees who will be providing direct care to a participant who has Alzheimer's disease or other dementia must complete an additional 3 hours of training within 9 months after beginning employment. This training must address the following topics as they apply to Alzheimer's disease and other dementias, including but not limited to: (1) the management of problem behaviors; (2) assistance with ADLs to promote participants' independence; (3) activities for participants; (4) stress management for caregivers; (5) family issues; (6) the participant's environment; and (7) ethical issues.

For certified nursing assistants, the required 4 hours of training must be part of the total hours of training required annually.

Location of Licensing, Certification, or Other Requirements

Florida Administrative Register and Florida Administrative Code. Rule Chapter 58A-6: Adult Day Care.https://www.flrules.org/gateway/ChapterHome.asp?Chapter=58A-6

Florida Agency for Health Care Administration website. Adult Day Care Statutes/Rule Authority; Survey Guidelines; Notices and Updates; Applications and Forms; and Resources.http://ahca.myflorida.com/MCHQ/Health_Facility_Regulation/Assisted_Living/adcc.shtml

Florida Agency for Health Care Administration website. Inspection Reports for Health Care Providers.http://ahca.myflorida.com/MCHQ/WebDmHelp/

2014 Florida Statutes. Title XXX, Chapter 429.905 Exemptions: monitoring of adult day care center programs co-located with assisted living facilities or licensed nursing home facilities.http://www.leg.state.fl.us/statutes/index.cfm?mode=View%20Statutes&SubMenu=1&App_mode=Display_Statute&Search_String=adult+day+care&URL=0400-0499/0429/Sections/0429.905.html

2014 Florida Statutes. Title XXX, Chapter 429.917: Patients with Alzheimer's disease or other related disorders; staff training requirements for Specialized Alzheimer's Services, Adult Day Care Centers.http://www.leg.state.fl.us/statutes/index.cfm?mode=View%20Statutes&SubMenu=1&App_mode=Display_Statute&Search_String=adult+day+care&URL=0400-0499/0429/Sections/0429.917.html

Florida Agency for Health Care Administration website. Home and Community-Based Services Waivers.http://www.fdhc.state.fl.us/Medicaid/hcbs_waivers/

Information Sources

Christine PowersPresidentFlorida Adult Day Services Association     andChairFlorida Alzheimer's Advisory Committee

Catherine Anne AveryUnit ManagerAgency for Health Care AdministrationBureau of Health Facility Regulation

Devona PickleAdministratorAgency for Health Care Administration

GEORGIA

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-georgia

Overview

The Healthcare Facility Regulation Division in the Georgia Department of Community Health Licensing oversees the licensing of adult day centers. Licensing was mandated in January 2015.

Adult day centers can provide adult day care (ADC) services and/or adult day health services (ADHS) to three or more adults. The state covers ADHS under two Medicaid 1915(c) waiver programs: the Community Care Services Program (CCSP)--also referred to as the Elderly and Disabled Waiver--and the Service Options Using Resources in a Community Environment program, which also serves elderly persons and younger adults with disabilities. To continue serving Medicaid program participants, ADHS providers enrolled with the State Department of Community Health as Medicaid providers must submit a copy of their license by July 31, 2015. New providers must be licensed to enroll as a Medicaid provider. Medicaid providers of ADHS are required to follow specific Medicaid-only requirements for their provision.

CCSP ADHS providers may offer adult day health services-mobile (ADH-M) in rural and other underserved areas. The ADH-M site can be located no more than 100 miles from the primary ADH facility. Participants who attend ADH-M receive the same services offered at the primary ADH facility. Medicaid pays for a full day of service (a minimum of 5 hours per day, excluding transportation time) and a part day of service (from 3-5 hours per day). Transportation time may not exceed 1 hour each way and is not used to determine the number of hours a participant attends the ADH center each day.

The ADH-M shares staff and supplies with the primary ADH facility. Staff are mobile, traveling from the primary location (the CCSP-approved ADH facility) to the rural or underserved area, transporting needed supplies and materials with them. Depending on the needs of the area, each ADH-M site is open for 5-6 hours per day, 1-3 days per week. ADH-M services are provided in existing facilities (e.g., senior centers, churches) that are accessible and meet all applicable fire/safety and building codes.

Definitions

Adult day care (ADC) means the provision of a comprehensive plan of services that meets the needs of aging adults under a social model of care. A social model program addresses primarily the basic social and recreational activities needed to be provided to aging adults, but also provides, as required, limited personal care assistance, supervision, or assistance essential for sustaining the activities of daily living (ADLs). Such programs of care shall be based on individual plans of care and shall be provided for less than 24 hours per day.

Adult day health services (ADHS) means the provision of a comprehensive plan of services that meets the needs of aging adults under a medical model of care. A medical model means a comprehensive program that provides adults with the basic social, rehabilitative, health and personal care services needed to sustain the essential ADLs and to restore or maintain optimal capacity for self-care. Such a program of care must be based on individual plans of care and be provided for less than 24 hours per day.

An adult day center means a facility serving aging adults that provides ADC or ADHS for compensation to three or more persons. Adult day centers may operate in more than one location if classified and approved by the department as a mobile adult day center.

A mobile adult day center means a program of services offered by an ADC which utilizes designated staff that travel from one central location to off-site locations to provide adult day services. The services offered by a mobile adult day center may either be ADC services or ADHS, or both, and are offered 4 days per week or less at any one location. Each license issued to a mobile adult day center shall enable the licensee to provide services at no more than five off-site locations.

Parameters for Who Can Be Served

Adult day centers must admit individuals based on their comprehensive description of the types of services they will provide and must only admit and retain individuals whose needs they can meet. Centers have the right to not accept or to discharge an individual who refuses assistance with medications if the center reasonably feels that the participant cannot safely possess and control his/her medications.

ADHS are provided at two levels that indicate the intensity of care required by individual CCSP participants, which is determined during an initial assessment or reassessment. ADH centers serve individuals with varying degrees of functional limitations and may not choose to serve only participants at one level.

Participants may be discharged immediately if they endanger their or others safety and welfare.

Inspection and Monitoring

Prior to licensure and periodically thereafter, the department inspects each adult day center to ensure that it is providing adequate care to its participants and is in compliance with all applicable rules and regulations. The department also conducts complaint investigations and periodic on-site inspections of any center when determined necessary.

The department may exempt a center from periodic inspections if such center has been certified or accredited by an entity recognized and approved by the department if such entity uses standards that are substantially similar to those established by the department.

In addition, a Georgia Division of Aging Services (DAS) CCSP provider specialist performs a site visit to an ADH provider before they recommend approval for a Medicaid provider identification number. DAS/CCSP performs another site inspection if a facility relocates or if it receives reports of compliance issues.

DAS and care coordination staff make site visits to existing facilities where ADHS-M are being provided, to ensure compliance with Medicaid's physical environment standards.

Required and Optional Services

All adult day health (ADH) programs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

Required and Optional Services Adult Day Care   Adult Day Health Services  
  Required     Optional     Required     Optional  
ADL Assistance     X  
Health Education and Counseling     X  
Health Monitoring     X  
Medication Administration   X1 X  
Nursing Services     X  
Physical Therapy, Occupational Therapy, or Speech Therapy       X  
Skilled Nursing Services     X  
Social Services        
Transportation   X   X
  1. Assistance with self-administration only is permitted.

Medication Provisions

Registered nurses (RNs), licensed practical nurses (LPNs), and proxy caregivers must administer medications in accordance with all applicable laws and regulations. A "proxy caregiver" is an unlicensed person who has been determined qualified to have the necessary knowledge and skills acquired through training by a licensed health care professional to perform documented health maintenance activities, including medication administration, for an individual with a disability who has delegated to the designated proxy caregiver the performance of such health maintenance activities through execution of a written informed consent by the individual with a disability or a person legally authorized to act on behalf of such individual with a disability.

All medications required by a participant in an adult day center that does not employ a licensed RN, LPN, or proxy caregiver must be self-administered by the participant.

Staff in centers that provide assistance with medication without employing a licensed RN, LPN, or proxy caregiver may: (1) remind participants of the time to take medication; (2) check the dosage according to the container label; and (3) physically assist a participant in opening or pouring the medication.

Unlicensed staff who are assisting with or supervising medication self-administration by capable participants must receive medication training.

This training must be conducted with an appropriate curriculum for providing medication assistance and include at least the following topics:

  • The center's medication policy and procedures, including actions to take if concerns regarding participant's capacity to self-administer medications are identified.

  • How to read prescription labels including common abbreviations.

  • Providing the right medication to the right participant at the right time in the right amount and the right way including how to measure various medications.

  • Actions to take when concerns regarding medications are identified.

  • Infection control procedures relative to providing assistance with medications.

  • Proper medication storage and disposal.

  • Recognition of side effects and adverse reactions for the specific medications.

  • Understanding the common classifications of medications, typical side effects and adverse reactions, and medications for which unlicensed staff may never provide assistance with, or supervision of self-administration.

  • Proper documentation and record-keeping using the Medication Assistance Record.

Staffing Requirements

Adult Day Care

Type of Staff. Each center must have a director who is responsible for day-to-day operations, and in the absence of the director, a staff member must be designated to supervise the center. Each center must have at least one staff member who has current certification in first-aid and cardiovascular pulmonary resuscitation (CPR) that shall be in the center at all times.

Staffing Ratios. Each center must have appropriately qualified staff and/or volunteers on duty at all times to properly safeguard participants' health, safety, and welfare, and in a sufficient number to meet participants' needs and implement their individual plan of care. At a minimum, adult day centers must provide a staff and/or volunteer-to-participant ratio of no less than 1:8. The staffing ratio refers to the staff providing direct services to participants and excludes such employees as clerical or office workers and maintenance or food service staff.

Each center must ensure sufficient staffing to promptly and safely evacuate all participants in the event of an emergency. The center must adjust staffing as necessary based on the number of non-ambulatory participants at the center.

Adult Day Health Services

Type of Staff. In addition to meeting the staffing requirements for ADC, ADH centers must also hire a registered nurse to assess participants' physical and mental health needs and to develop, and supervise participants' individual plan of care. If the center employs the services of a licensed practical nurse, the licensed practical nurse must be supervised by an RN. The LPN shall be available by phone, pager and/or e-mail when not on site at the center.

ADH centers must also have appropriately qualified staff to perform physical therapy, occupational therapy, and speech therapy, as identified in the participant's individual plan of care. Each center must also identify which staff person is responsible for directing activities for the center.

Staff Ratios. Medicaid requires the ADH center director to develop a staffing pattern that meets participants' needs as determined by the number of participants and their functional level. A minimum ratio of staff-to-participants is used to determine adequate staff coverage when participants are in attendance. Staff ratio refers to the staff providing direct services to participants and excludes clerical, food service, and office staff. For participants receiving Level I care, the staff-to-participant ratio is 1:8. For those receiving Level II care, the ratio is 1:4.

Training Requirements

The director is responsible for ensuring that any person working in the center as an employee or under contract receives work-related training acceptable to the department within the first 90 days of employment. The center must ensure that at least one staff member who has completed the minimum training requirements be present in the center at all times.

Work-related training for employees must at a minimum include the following topics:

  • Orientation to licensing rules and regulations and to the center's policies and procedures.

  • Standard precautions, infection control, and latex safety.

  • Identification of potential victims of elder abuse or self-neglect.

  • Participants' rights including the prevention and reporting of suspected abuse, neglect, or exploitation.

  • Protecting the confidentiality of participant information and records.

  • Influenza and the role of vaccination in controlling its spread.

  • Diversity and cultural sensitivity.

  • Alzheimer's disease and other dementias including communication and responding to behavior techniques.

In addition to the training requirements above, centers that provide ADHS must provide training on the laws governing administration of prescribed medications.

The director is responsible for ensuring that all volunteers receive training in accordance with the services they provide in the center. At a minimum, all volunteers must receive training in identifying abuse, neglect, and exploitation, and the applicable reporting requirements; and participants' rights.

All ADH staff, subcontractors, and volunteers who interact with participants must complete an orientation within the first 2 weeks of employment. In addition, the ADH provider must make available annual in-service training to all staff on the following topics: (1) an overview of Alzheimer's disease; (2) understanding communication techniques; (3) understanding common behaviors and appropriate interventions of participants with Alzheimer's disease (i.e., wandering, agitation, redirecting, cuing); (4) care and management skills; (5) activities appropriate for aging or chronically ill participants; (6) safety and accident prevention (risk management); (7) medications and side effects; (8) elder abuse reporting; (9) advance directives; and (10) nutrition care, food safety, and safe feeding.

All ADH staff, subcontractors, and volunteers must complete a minimum of 12 hours of continuing education annually on topics related to their job responsibilities and the participant population.

The RN, LPN, and any ADH staff providing direct care to participants are required to have current certifications in CPR and first-aid.

Location of Licensing, Certification, or Other Requirements

Rules of Department of Community Health, Chapter 111-8, Healthcare Facility Regulation, 111-8-1, Rules and Regulations for Adult Day Centers.http://dch.georgia.gov/sites/dch.georgia.gov/files/Adult_Day_Center_Rules_Initial_Adoption_100314.pdf

Georgia Department of Community Health website, Georgia Medicaid Management Information System.https://dch.georgia.gov/medicaid-management-information-system-mmis

Medicaid Manual, Part II, Chapter 1100: Policies and Procedures for Adult Day Health Services. Georgia Department of Community Health, Division of Medical Assistance.[July 1, 2010]http://ftp.floydcountyga.org/pub/purchasing/2011%20&%20Prior/Mercy%20Senior%20Center/2010-07_CCSP_ADH_v4.pdf

Information Sources

Tom UnderwoodCCSP Program SpecialistGeorgia Department of Community HealthMedicaid Division

Georgia GunterPresidentGeorgia Adult Day Services Association

HAWAII

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-hawaii

Overview

The Department of Health licenses both adult day care (ADC) centers and freestanding adult day health (ADH) centers. To obtain licensure as a freestanding ADH center, a provider must first obtain an approved Certificate of Need from the Hawaii Health Planning and Development Agency.

Hawaii has implemented the QUEST Expanded Access (QExA) Medicaid program, which is a managed care program for Medicaid-eligible persons aged 65 years or older and for working-age adults with disabilities. QExA covers both ADC and adult day health care (ADHC) and requires all providers to be licensed in accordance with state law. QExA replaced two 1915(c) waivers serving the aged and disabled population: the Residential Alternative Community Care Program and Nursing Home Without Walls program.

Nursing facilities may also provide ADHC services. A nursing facility-based ADH center is licensed under the state administrative rules for nursing facilities. Nursing facilities must ensure that the space and staffing requirements for ADH center activities do not reduce the space and staff requirements of the nursing facility, and that medical records of nursing facility residents and ADH center participants are filed separately.

Definitions

Adult day care center means a licensed facility maintained and operated for the purpose of providing regular care, which includes supportive care to four or more disabled adults. The purpose of ADC services is to provide disabled adults a sheltered setting and specified activities to support and promote their level of functioning and ability to remain or be maintained safely in the community outside institutions and other care facilities.

Adult day health care means an organized day program of therapeutic, social, and health services provided to adults with physical impairments or mental impairments, or both, which require nursing oversight or care, for the purpose of restoring or maintaining, to the fullest extent possible, their optimal capacity for self-care.

Parameters for Who Can Be Served

Adult Day Care. Providers may serve individuals who need the services offered in order to maintain their current level of social, emotional, or physical functioning; have a physical or mental disability suitable to the day care program as verified by a medical or psychological report; and desire and are capable of participating in a day care program.

Providers may not serve participants whose condition deteriorates to the point that enrollment is unsuitable; if the participant is unwilling or unable to make constructive use of the service and continuation of the service is contrary to the overall service plan for the participant; or if services are no longer appropriate.

Adult Day Health Care. The definition of ADHC (above) provides general information regarding who can be served in these programs. Medicaid rules state that providers may serve individuals who need health, nursing, therapeutic, or social services in order to reach or maintain their highest degree of functional status practicable. Medicaid waiver program participants generally have functional limitations and/or medical and nursing needs because they must meet the state's nursing home level of care criteria.

Inspection and Monitoring

Adult Day Care. The Department of Health contracts with Community Ties of America to perform the licensing and certification activities for ADC centers. Community Ties of America is an organization that provides long-term care consulting and services to multiple states. Centers are inspected to determine compliance with applicable building and fire codes and licensing standards. Licenses are issued for 1 year and providers are inspected annually.

Adult Day Health Care. Licenses are issued for 1 year. The director of the Department of Health or an authorized representative must inspect each licensed freestanding ADH center at least once annually. Notice of the approximate time for the annual inspection visits may be given to the center. In addition to performing annual inspection visits, the director--or his or her authorized representative--without prior notice, may enter the center at any reasonable time for the purposes of confirming correction of deficiencies, investigation of complaints, or both.

Required and Optional Services

All ADC and ADHC programs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

Required and Optional Services Adult Day Care Adult Day Health Care1
  Required     Optional     Required     Optional  
ADL Assistance X2   X  
Health Education and Counseling     X  
Health Monitoring/Health-Related Services X   X  
Medication Administration   X X  
Nursing Services     X  
Physical Therapy, Occupational Therapy, or Speech Therapy       X  
Skilled Nursing Services     X  
Social Services X   X  
Transportation   X   X
  1. ADHC providers must also provide medical services, psychiatric or psychological services, and must develop a care plan that includes provisions for arranging any needed services that are not routinely available at the center.
  2. Some facilities do not have a physical plant that allows for assistance with bathing.

Medication Provisions

Adult Day Care. Medication may be administered by staff members licensed by the state as a licensed practical nurse (LPN) or registered nurse (RN), or by unlicensed assistive personnel delegated the task by an LPN, with a signed authorization from the participant's physician. However, providers are not required to hire or contract with an LPN or RN. If licensed personnel are not available, then ADC staff can only give reminders to take a medication to participants, or if a physician orders it, the staff may assist with self-administration.

Adult Day Health Care. Only appropriately licensed and trained staff are allowed to administer drugs and they must be responsible for proper recording of medication administration, including its route.

Staffing Requirements

Adult Day Care

Type of Staff. Each ADC center must have a director responsible for the center's total program, who must designate a staff member to be responsible for center administration whenever he or she is absent. Each center must always have staff members who are capable of providing supervision to the participants at the center.

Staffing Ratios. The staff-to-participant ratio must be one regular staff member to six participants. This ratio may include the center director. At least one staff member currently certified in first-aid and cardiovascular pulmonary resuscitation (CPR) must be present at the center while participants are present and must accompany participants on field trips.

Adult Day Health Care

Type of Staff. Each ADH center must have an administrator, and centers with a capacity of 50 or more participants must also have a separate full-time program director. An individual may be an administrator of no more than three centers. A program director of a center whose average daily attendance is fewer than 20 participants, may also serve as the RN, social worker, occupational therapist, physical therapist, activity coordinator, speech therapist, or dietitian, provided that the program director is qualified and is not also the administrator.

In addition, the regulations state that each center must have the following staff and services.

  • A sufficient number of employees qualified and competent to provide the services for which the center is licensed.

  • Available appropriate consultant staff trained in psychiatric care when there is a participant requiring the services while at the center.

  • Social services, which include an initial and continuing assessment by a social worker.

  • Nursing staff sufficient in number and qualifications to meet the needs of the participants. A registered nurse must be employed and a licensed nurse--either an registered nurse or an licensed practical nurse--must be on-site whenever participants are present. Nursing services must be provided under the supervision of a RN.

  • An activity coordinator to provide a program of social and recreational activities to meet the needs and interests of each participant.

  • Aides sufficient in number to perform the necessary duties. Volunteers may be utilized but not to replace required professionally qualified employees unless they are so qualified. Each volunteer must receive orientation, training, and supervision.

Staffing Ratios. Employees must be sufficient in number to provide the services for which the center is licensed. Each program must have nursing staff sufficient in number to meet the needs of participants. At least one staff person trained and certified in CPR and basic first-aid must be present at all times.

Training Requirements

Adult Day Care. No requirements identified.

Adult Day Health Care. Staff must be provided an in-service education program that includes orientation to the program's philosophy, organization, policies, procedures, practices, and goals. Initial and ongoing training must be provided for employees who have not achieved the desired level of competence, and to update and improve the skills and competencies of all employees.

Annual or more frequent training must include, but not be limited to, prevention and control of infections; fire prevention and safety; accident prevention; participants' rights; and the problems and needs of the aged, ill, and disabled. Provision must be made for training appropriate personnel in CPR and appropriate first-aid techniques.

Location of Licensing, Certification, or Other Requirements

Hawaii Administrative Rules, Title 11, Chapter 96: Freestanding Adult Day Health Centers. Department of Health. [May 31, 1991]http://gen.doh.hawaii.gov/sites/har/admrules1/11-96.pdf

Hawaii Administrative Rules, Title 17, Subtitle 9 Community Long-Term Care Programs, Chapter 1417: Adult Day Care Services. Department of Human Services. [June 29, 1992; some rules amended April 17, 1995 and October 28, 1995]http://humanservices.hawaii.gov/wp-content/uploads/2013/01/17-1417-Adult-Day-Care.pdf

Hawaii Administrative Rules, Title 17, Subtitle 9 Adult and Community Care Programs, Chapter 1424: Licensing of Adult Day Care Centers. Department of Human Services. [October 4, 2001]http://www.comties.com/HIforms/HAR%2017-1424.pdf

Hawaii Administrative Rules, Title 17, Subtitle 12 Med-Quest Division. Chapter 1720: Benefits Package. Department of Human Services. [September 30, 2013]http://humanservices.hawaii.gov/wp-content/uploads/2013/10/HAR-17-1720-BENEFITS-Final-9-5-13.pdf

Hawaii Administrative Rules, Title 11, Chapter 94: Skilled Nursing/Intermediate Care Facilities, §11-94-5 Adult day health center. Department of Health. [April 22, 1985]http://gen.doh.hawaii.gov/sites/har/admrules1/11-94.pdf

Information Sources

David Ayling, RNCompliance ManagerCommunity Ties of America, Inc.State Contractor for Certifying Adult Day Care Centers

Patti BazinAdministratorHealth Care Services BranchDepartment of Human ServicesMed-QUEST Division

IDAHO

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-idaho

Overview

Adult Day Care (ADC) in Idaho is regulated for persons served by the Commission on Aging Senior Services Program under the Rules Governing Senior Services Programs. The rules state that ADC programs must operate under guidelines established by the Idaho Commission on Aging that are in accordance with the standards developed by the National Council on Aging, National Institute on Adult Day Care (now known as the National Adult Day Services Association). The ADC service is funded under Title III-B and III-E.

Adult Day Health (ADH) services are provided under two Medicaid 1915(c) waivers: the Aged and Disabled Waiver and the Adult Developmental Disabilities (DD) Waiver. Waiver services providers are governed by the Department of Health and Welfare, Division of Medicaid and must meet standards described in the Medicaid provider manual as well as additional terms to the Medicaid provider agreement.10

The building standards in the additional terms agreement apply to freestanding structures that provide only ADH services. Such facilities must meet the building and health standards identified in the Idaho Code relating to DD agencies. In addition to freestanding ADH facilities and DD agencies, ADH services may also be provided in certified family homes and licensed residential and assisted living facilities. All entities must meet their certification or licensure requirements when providing ADH services.

The sources of information in this profile include the Idaho administrative code rules for governing the Senior Services program and Medicaid enhanced plan benefits, the Idaho Medicaid provider manual, and the Idaho Medicaid provider agreement's additional terms for ADC.

Definitions

Adult day care is a comprehensive program that provides individually planned care, supervision, social interaction, and supportive services for frail older persons in a protective group setting other than the participants' homes during any part of a day, but for less than 24 hours. It is designed to meet the needs of eligible participants whose functional or cognitive abilities have deteriorated and is intended to provide relief and support for family caregivers.

Adult day health is a supervised, structured service generally furnished 4 or more hours per day on a regularly scheduled basis, for 1 or more days per week. It is provided outside the participant's home in a non-institutional, community-based setting, and encompasses health services, social services, recreation, supervision for safety, and assistance with activities of daily living (ADLs) needed to ensure the optimal functioning of the participant.

Aged and Disabled Waiver program participants may receive adult health services for any part of a day but not more than 12 hours in any 24-hour period.

Parameters for Who Can Be Served

Adult Day Care. Persons eligible to receive services must be 60 years of age or older. Functionally or cognitively impaired adults under age 60 living in the home of a caregiver who is age 60 or older are exempt from this requirement. In those instances the caregiver is considered to be the participant. Providers may serve individuals who have physical or cognitive disabilities affecting ADLs or instrumental ADLs, and are capable of being transported, of benefiting from socialization and structured and supervised group-oriented programs, and of self-care with supervision or cueing.

Adult Day Health. Centers may accept waiver program participants who do not have: (1) pressure ulcers, open wounds, or draining wounds that cannot be contained; or (2) who require continuous nursing assessment and intervention. Providers may accept participants only when they are able to provide the type or level of service the participant requires and have an adequate number of skilled and/or licensed staff on site to deliver the service. No participant may be enrolled whose physical, emotional, or social needs are not compatible with the other participants in the facility.

Inspection and Monitoring

Adult Day Care. The Idaho Commission on Aging contracts with six Area Agencies on Aging (AAAs) to provide ADC services.The AAAs subcontract with local providers and monitor their performance.

Adult Day Health. Idaho Medicaid conducts a review of all provider agencies every 2 years to ensure rule compliance and best practices. Agencies are contacted at least 30 days prior to a review. Providers conduct a quality assurance program consisting of: (1) sufficient training sessions to ensure staff qualifications and competence, and participant satisfaction; and (2) an annual competency review. Providers must implement a quality improvement plan for any deficiencies noted.

Required and Optional Services

All ADC and ADH programs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

Required and Optional Services Adult Day Care Adult Day Health
  Required     Optional     Required     Optional  
ADL Assistance X   X  
Health Education and Counseling        
Health Monitoring        
Medication Administration       X
Nursing Services     X  
Physical Therapy, Occupational Therapy, or Speech Therapy          
Skilled Nursing Services        
Social Services        
Transportation       X

Medication Provisions

Adult Day Care. Service workers must not administer medications. A service worker may remind a participant to take medications, assist with removing the cap from a multi-dose or bubble pack container, and observe the participant taking medications.

Adult Day Health. Medications may be administered only by licensed nurses. Any staff member who assists with medications must be licensed to do so or must successfully complete a Board of Nursing-approved course on assistance with medication, as the delegate of a licensed nurse.

Staffing Requirements

Adult Day Care

Type of Staff. Staff must be adequate in numbers and skill to provide essential services.

If the site administrator is responsible for more than one site or has duties not directly related to ADC, a program manager must be designated for each site. If the ADC program is provided in other than a freestanding facility, such as in a nursing facility or assisted living facility, the rules governing that facility must also be followed.

Staffing Ratios. At least two responsible persons must be at the center at all times when participants are in attendance. One must be a paid staff member. The staff-to-participant ratio must be increased appropriately if the number of participants in day care increases or if the degree of severity of participants' functional or cognitive impairment increases. Staff persons counted in the staff-to-participant ratio must be those who spend the major part of their work time in direct service to participants. Volunteers may be included in the staff ratio only when they conform to the same standards and requirements as paid staff.

Adult Day Health

Type of Staff. The provider must employ sufficient personnel to ensure the safe and proper care of the participants.

Staffing Ratios. The staff-to-participant ratio must be a minimum of one staff to six participants. As the number of participants and the severity of participant functional impairments increases, the staff-to-participant ratio must be adjusted accordingly. Programs serving a high percentage of participants who are severely impaired must have a staff-to-participant ratio of 1:4.

Training Requirements

Adult Day Care

All service workers must receive an employee orientation from the provider before performing any services. Orientation must include the purpose and philosophy of the services, review of pertinent skills, program regulations, policies and procedures, proper conduct in relating to participants, and handling of confidential and emergency situations involving a participant.

Service workers must complete cardiovascular pulmonary resuscitation (CPR) training within 3 months of hire and must maintain certification thereafter. Providers must annually provide service workers with a minimum of 10 hours training, including CPR, for the purpose of upgrading their skills and knowledge. Providers must ensure that service workers who assist participants with bathing or hair washing receive specific training in performing these services prior to being assigned to a participant.

Adult Day Health

Providers must meet, either by formal training or demonstrated competency, the training requirements contained in the Aged and Disabled Waiver program's provider training matrix and the standards for direct care staff and allowable tasks or activities. The provider must ensure that staff have sufficient training to maintain qualifications and competence. At a minimum, providers must have training in infection control, CPR, and first-aid.

Location of Licensing, Certification, or Other Requirements

Idaho Administrative Code, IDAPA 15, Office of the Governor: Rules Governing Senior Services Program. Idaho Commission on Aging.[Various dates, latest is April 6, 2005]http://adminrules.idaho.gov/rules/current/15/0101.pdf

Idaho Administrative Code, IDAPA 16: Medicaid Enhanced Plan Benefits. Department of Health and Welfare. [Various dates, latest is April 4, 2013]http://adminrules.idaho.gov/rules/current/16/0310.pdf

Idaho Medicaid Provider Manual 2014. Idaho Department of Health and Welfare.http://www.qualishealth.org/sites/default/files/private/ID-Medicaid-Provider-Manual.pdf

State of Idaho Medicaid Provider Agreement Additional Terms--Adult Day Care [February 1, 2012]https://www.idmedicaid.com/Provider%20Enrollment%20Paper%20Maintenance%2...

Information Sources

Pam Catt-OliasonProgram SpecialistIdaho Commission on Aging

Mark WassermanAlternative Care CoordinatorBureau of Long Term CareDivision of MedicaidDepartment of Health and Welfare\

ILLINOIS

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-illinois

Overview

Illinois does not require licensing for adult day services (ADS). However, providers that want to serve participants in the Illinois Department on Aging (IDOA) Community Care Program (CCP) or the Department of Human Services/Office of Rehabilitation Services (DHS/ORS) Home Services Program11 must be certified with IDOA. The services are funded under a 1915(c) Medicaid waiver program. Providers may also contract with the Veteran's Administration to provide ADS, and although it is not compulsory, they are generally required to be certified by the IDOA.12 Providers serving only private pay participants are not regulated in any way.

IDOA promulgates ADS standards through the state's administrative rules, which are the basis for the regulations described in this profile. Only ADS providers with an IDOA or a DHS/ORS contract are required to comply with these standards. The Illinois Adult Day Service Association offers training on the IDOA standards, which provides guidelines for new providers.

Definitions

Adult day services as provided under CCP are defined as the direct care and supervision of adults 60 years of age and over in a community-based setting for the purpose of providing personal attention, and promoting social, physical, and emotional well-being in a structured setting. The service is called adult day care (ADC) in the Home Services Program and is defined as the direct care and supervision of people with severe disabilities under age 60 in a community-based setting to promote their social, physical, and emotional well-being.

Parameters for Who Can Be Served

An ADS provider must furnish services to all CCP participants referred by the Case Coordination Unit except: (1) for participants who do not meet the ADS provider's admission criteria, or current participants whose condition warrants discharge under the ADS provider's discharge criteria; (2) if the CCP care plan is determined to be inappropriate in the provider's professional judgment of the provider; or (3) if the provider requests from IDOA a cap on the number of participants to be served.

Inspection and Monitoring

For the CCP, IDOA--or its designee--conducts recertification of each provider agency no less frequently than every 3 years to determine continued compliance with qualifications for the applicable service. Before recertifying a service provider, the department will conduct a performance review.

For the Home Services Program, the DHS/ORS completes a review of each ADC provider at least every 2 years, to ensure compliance with the criteria set forth in the state's administrative rules. The review consists of an on-site assessment conducted by Home Services Program staff.

Required and Optional Services

All ADS programs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

Required and Optional Services Adult Day Services
  Required     Optional1  
ADL Assistance X  
Health Education and Counseling X  
Health Monitoring X  
Medication Administration X  
Nursing Services X  
Physical Therapy, Occupational Therapy, or Speech Therapy     X
Skilled Nursing Services   X
Social Services X  
Transportation X  
  1. Shopping assistance and escort to medical and social services are also optional services. Reimbursement for costs of optional services is not included in the unit rate paid by the departments.

Medication Provisions

An ADS provider must have on file and utilize written procedures to manage storage and administration of medications, including ensuring that prescribed medication is administered by an appropriately licensed professional to those ADS participants who are determined unable to self-administer medications. Judgment of a participant's inability to self-administer medications must be documented by a physician's order or the Case Coordination Unit care plan and/or the ADS care plan by the program nurse.

Staffing Requirements

Type of Staff. An ADS facility must have a program administrator. The administrator's responsibilities may be performed by the program coordinator/director. If so, only the qualification requirements for program coordinator/director apply. The program coordinator/director must be on duty full-time when participants are in attendance or have a qualified substitute.

Each ADS provider must have adequate personnel in skill and number (a minimum of two staff persons) at the ADS site to provide for program and fiscal administration, nursing and personal care services, nutritional services, planned therapeutic/recreational activities, and to provide or arrange transportation to and from the ADS site. At least two program ADS staff must be certified in cardiovascular pulmonary resuscitation (CPR) and trained in first-aid, and at least one trained staff member must be on-site when participants are present.

A program nurse must be a registered nurse (RN) licensed by the state or a licensed practical nurse (LPN) licensed by the state under the supervision of an RN. (The RN may be contractual and must meet with the LPN at least monthly to review care plans and medication administration records, and be available to provide direction as needed.) The program nurse: (1) must be on duty at least one-half of a full-time work period each day when participants are in attendance, either as staff person or on a contractual basis; (2) must be full-time if also serving as the program administrator or program coordinator/director; and (3) must meet the qualifications for a program nurse and fulfill responsibilities for all assigned positions.

Nutrition staff (provider-employed or contractual) must include at least one staff member who meets the requirements of the Food Service Sanitation Code and a nutrition consultant/dietitian, either paid or in-kind, who must be licensed by the Department of Financial and Professional Regulation, with experience in an agency setting and who must approve menus for ADS providers to meet requirements stated in the ADS standards.

The ADS team consisting of program coordinator/director and program nurse may include other staff at the option of the program coordinator/director. The following optional staff, either contractual or employed by an ADS provider, must meet the specified qualifications:

  • A social service worker must be under the direction of the program coordinator/director; if the social service worker function is performed by the program administrator or program coordinator/director, that person must be full-time, and must meet the qualifications for a social worker and fulfill responsibilities for all assigned positions.

  • A medical consultant must be a physician licensed to practice medicine by the State of Illinois.

  • A rehabilitation consultant must be licensed, registered, or certified by the Department of Financial and Professional Regulation in a discipline that relates to rehabilitation.

Substitutes for staff positions and/or regularly scheduled volunteers/students/student interns utilized by an ADS provider must have the same personal, health, administrative and professional qualifications as are required of staff for whom they act as substitutes.

Staffing Ratios. The minimum ratio of full-time or full-time equivalent staff (qualified ADS staff, trained volunteers, or substitutes) present at the ADS site must be two staff for 1-12 participants, three staff for 13-20 participants, four staff for 21-28 participants, five staff for 29-35 participants, six staff for 36-45 participants, and one additional staff person for each seven additional participants.

Fifty percent or more of a staff member's time must be spent in direct service or supervision on behalf of one or more participants in order to be counted in the ratio. Staff included in the staff-to-participant ratio must include only those who work on-site, are actively involved with participants, and are immediately available in the activity area to meet participants' needs, except during participant drop-off and pick-up times in normal business hours.

Training Requirements

Adult day services management staff are required to complete ADS management training prior to the award of a CCP ADS contract from the Department of Aging. At a minimum, the provider program administrator, or program coordinator/director--if also functioning as the program administrator--must complete this training.

Each ADS provider is responsible for monitoring and meeting staff training needs. Pre-service training totaling a minimum of 24 hours is required within the first week of employment (exclusive of orientation). A worker may be exempted from pre-service training by the ADS provider if the worker: (1) has had previous documented training equivalent to 24 hours with another CCP agency or in a related field within the past 2 years prior to current employment; or (2) holds a valid, active certified nursing assistant (CNA), RN, or LPN license, and/or has a BA, BS, BSW, or higher degree. Pre-service training must include at least 18 hours of training selected from the following topics:

  • Purpose and goals of ADS.

  • Facility, environmental, and safety considerations.

  • Assistance with activities of daily living.

  • Basic principles of personal care.

  • Dealing with adverse behaviors: wandering, aggression, mental illness and depression.

  • Promoting participant dignity, independence, self-determination, privacy, choice and rights.

  • Understanding aging and functionally impaired persons.

  • Recognizing participant abuse, neglect and/or exploitation; abuse and neglect prevention and reporting requirements.

  • Confidentiality of participant information.

  • Communication/interaction skills.

  • Universal precautions, blood-borne pathogens and infection control.

  • Fire and life safety, including emergency procedures to be implemented under the agency's all hazards disaster operations plan.

  • Family dynamics.

  • Understanding Alzheimer's disease and dementia.

  • Body mechanics and normal range of motion, transfer techniques, and positioning.

  • Cultural diversity.

  • Recognizing changes in bodily functions that should be reported to the supervisor.

  • Nutrition and safe food handling.

  • CPR and first-aid.

  • Participant activities.

  • Respiratory services.

  • Use of seclusion and restraints.

A minimum of 12 hours in-service training for continuing education per year is mandatory for all ADS employees, including at least 9 hours of training selected from the pre-service training topics above and the following additional topics:

  • Responding to emergency situations, including, but not limited to, site-related emergencies (e.g., late pick-up of participants), participant-related emergencies (e.g., participants leaving the site unattended), choking prevention, and intervention techniques.

  • Appropriate and safe techniques in providing assistance with personal care.

  • Developing and improving participant-centered activities.

  • Modification of the environment to support engagement/well-being.

  • Special characteristics of the elderly population; participants' physical, emotional and developmental.

  • Chronic illness, death, and dying.

  • Medicaid fraud and abuse.

  • Understanding advance directives.

  • Nutrition and safe food handling.

Pre-service training must fulfill the continuing education requirement for new employees for the first year. Progress toward certification in a related field (e.g., CNA) may be used for up to 3 hours of in-service training per calendar year. Substitutes and volunteers/students/student interns who are not used to meet program requirements are exempt from pre-service and in-service training requirements.

Location of Licensing, Certification, or Other Requirements

Administrative Code, Title 89 Social Services, Chapter II: Illinois Department on Aging, Part 240 Community Care Program. Joint Committee on Administrative Rules. [June 25, 2014]http://www.ilga.gov/commission/jcar/admincode/089/08900240sections.html

Administrative Code, Title 89 Social Services, Chapter IV: Department of Human Services, Subchapter d: Home Services Program, Part 686 Provider Requirements, Types of Services, Rates of Payment. Joint Committee on Administrative Rules. [June 25, 2014]http://www.ilga.gov/commission/jcar/admincode/089/08900686sections.html

Information Sources

Staff MemberIllinois Department on Aging

Kerri PendleyRegional CoordinatorIllinois Adult Day Service Association     andRegional Director of Adult Day ServicesAddus HealthCare, Inc.

INDIANA

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-indiana

Overview

Indiana does not have licensing or certification requirements for adult day services (ADS). The Indiana Family and Social Services Administration, Division of Aging is responsible for approval of the ADS programs it administers--through the Medicaid 1915(c) Aged and Disabled Waiver and Traumatic Brain Injury Waiver programs, and the non-Medicaid CHOICE (Community and Home Options to Institutional Care for the Elderly and Disabled) program.

To serve participants in all publicly-funded programs, ADS providers must meet Medicaid waiver standards and guidelines, which are described in this profile.

Definitions

Adult day services are community-based group programs designed to meet the needs of adults with impairments through individual care plans. These structured, comprehensive, non-residential programs provide health, social, recreational, and therapeutic activities, supervision, support services, and personal care. By supporting families and other caregivers, ADS enable participants to live in the community.

ADS must be provided in a congregate, protective setting. Participants attend on a planned basis--from a minimum of 3 hours to a maximum of 10 hours per day. Services are offered at three levels, which are determined by the extent of services needed: Basic (level 1), Enhanced (level 2), and Intensive (level 3).

Parameters for Who Can Be Served

Participants in publicly-funded programs must meet the eligibility criteria for those programs. The CHOICE program serves adults who have a disability due to a mental or physical impairment, and are at risk of losing independence. Medicaid waiver program participants must meet nursing home level of care eligibility criteria.

Inspection and Monitoring

The Division of Aging conducts an on-site inspection before an ADS provider is enrolled as a provider in one or more of its programs. On-site inspections are conducted every 3 years thereafter to ensure continued compliance with standards and guidelines. Medicaid also conducts surveys to ensure compliance with program requirements every 3 years.

Required and Optional Services

All ADS programs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

Required and Optional Services Adult Day Services
  Required     Optional  
ADL Assistance X  
Health Education and Counseling X  
Health Monitoring X  
Medication Administration X  
Nursing Services X  
Physical Therapy, Occupational Therapy, or Speech Therapy   X1  
Skilled Nursing Services X1  
Social Services X  
Transportation   X
  1. Services required only for level 3 participants.

Medication Provisions

The provider and direct care staff should demonstrate an understanding of each participant's medication administration regimen, including the reason the medication is used, medication actions, specific instructions, and common side effects.

Participants must have a physician/nurse practitioner's written order approving self-medication. For "as needed" or "PRN" medications, the prescriber's orders must be followed exactly as they are written; specifically, when, how much, and how often a medication may be administered. For some participants, provider assistance and oversight of their self-medication may be needed.

Staffing Requirements

Type of Staff. The administrator or program director must appoint a staff person to supervise the program during the director's absence. Staff must be adequate in number and skills to provide essential services.

Basic (level 1). A registered nurse (RN) or licensed practical nurse (LPN) with RN oversight must be available as a consultant and for health education needs, assessments, medication oversight or administration, health promotion, prevention of illness, and health screening.

Enhanced (level 2). An LPN must be on staff full-time with monthly documented RN supervision or an RN half-time to provide health assessment upon admission and ongoing at least every 6 months, dispense or supervise the dispensing of medication, administer or oversee treatments, and maintain medical information for each participant. Personal care must be provided by the nurse or personal care attendants who are certified ADS program assistants, certified nursing assistants, qualified medication aides, or home health aides. A degreed social worker, certified therapist, or related professional must be available for monthly consultation and documentation regarding participants' psychosocial needs.

Intensive (level 3). An LPN must be on staff full-time with monthly documented RN supervision or an RN half-time who must be available for all hours of the program and available to fulfill all duties as noted for nurses in the Basic and Enhanced levels. An LPN or RN will provide more intensive nursing interventions as appropriate and/or prescribed, such as colostomy care, tube feeding, injections, dressing changes, catheter care, blood sugar checks, etc. Full-time, qualified staff must be available to attend to participants' psychosocial needs with monthly documented supervision by a licensed social worker, certified therapist, or a related professional.

Staffing Ratios. If the ADS program is housed in a building with other services or programs, or is part of a larger organization, the program must have separate identifiable staff available during operational hours. If volunteers are included in the staff ratio they must be professionally trained, certified, and oriented as staff members.

Basic (level 1). The staff-to-participant ratio must be a minimum of 1:8.

Enhanced (level 2). The staff-to-participant ratio must be a minimum of 1:6.

Intensive (level 3). The staff-to-participant ratio must be a minimum of 1:4.

At least two paid staff members must be in the facility and available at all times when more than one participant is present. Volunteers are not included in the staff ratio unless they are professionally trained and/or certified in a health occupation, and oriented and trained as staff members.

Training Requirements

All staff must receive orientation prior to providing ADS. Topics must include program policies and procedures, participants' rights, evacuation procedures, location of participants' records, emergency contact numbers, and the location of the medication cabinet and key. If volunteers are used as staff, their orientation and training requirements must be the same as paid staff.

Basic (level 1). Training is required for all direct care and administrative staff and includes, but is not limited to, the following topics: (1) basic first-aid (medical personnel such as an RN or physician are excluded as this is within their scope of practice); (2) cardiovascular pulmonary resuscitation; (3) working with aged and/or disabled participants; (4) basic information concerning medical treatments, age-related diseases, illnesses, drug interactions, medical terms, functional and behavioral issues, nutrition, and end of life issues; (5) cognitive impairment or other special needs of the population served; and (6) how to lead therapeutic group activities that meet the needs of participants and maximize their independence (for staff providing or assisting with activities).

Enhanced (level 2). The training requirements for direct care and administrative staff (if administrative staff are secondary staff available at times or are included in staff-to-participant ratios) include all of the level 1 topics, plus training in personal care services. Personal care assistants must maintain the continuing education requirements unique to their certification and maintain current certificates. Centers providing services to individuals with mild to moderate cognitive impairment must provide training in dementia-specific care to all staff involved with activities programming, and personal care.

Intensive (level 3). The training requirements for direct care and administrative staff (if administrative staff are secondary staff available at times or are included in staff-to-participant ratios) include all of the level 1 and level 2 topics, plus the following: (1) in-service training regarding special care needs of populations served, such as appropriate two-person assistance for transfers, moderate to severe cognitive impairments that put participants at high risk of elopement, choking or outbursts, or multiple vital signs monitoring more than once a day; (2) in-service training for personal care assistants on the special care needs of the population served, such as colostomy skin care, enema administration, and tube feeding, commensurate with level of professional training or certification of each assistant; and (3) training for activities staff in modification of therapeutic activities to meet the specialized needs of participants with moderate to severe cognitive impairment and/or higher physical acuity needs.

Location of Licensing, Certification, or Other Requirements

Division of Disability and Rehabilitative Services 2012 Waiver Manual. Indiana Family and Social Services Administration. [October 30, 2012]http://www.in.gov/fssa/files/DDRS_Waiver_Manual_Fall_2012.pdf

Provider Approval Request for Agency Providers of Adult Day Services. Indiana Family and Social Services Administration, Division of Aging. [August 15, 2014]http://www.in.gov/fssa/files/ADS_Survey_Tool_Final.pdf

Home and Community-Based Services Waiver Provider Manual. Indiana Family and Social Services Administration, Division of Aging. [August 5, 2014]http://provider.indianamedicaid.com/ihcp/manuals/DA%20HCBS%20Waiver%20Provider%20Manual.pdf

Aged and Disabled and Traumatic Brain Injury Waiver: Provider Certification--Required Documents. Indiana Family and Social Services Administrationhttp://www.in.gov/fssa/files/Provider_Matrix.PDF

Information Sources

Debbie PiersonAssistant DirectorHCBS and Medicaid WaiverDivision of AgingFamily and Social Services Administration

IOWA

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-iowa

Overview

All adult day services (ADS) providers in the state must be certified by the Iowa Department of Inspections and Appeals and are required to meet the provisions for ADS in the state's administrative code, which are described in this profile. Certification is equivalent to licensure. In addition, a program may be voluntarily accredited by the Department's designated accreditation entity--the Commission on Accreditation of Rehabilitation Facilities. Certification standards are different for accredited and non-accredited providers.

Iowa provides ADS--called adult day care--under several Medicaid 1915(c) waiver programs administered by the Iowa Department of Human Services, including the Health and Disability waiver, the Elderly waiver, the AIDS/HIV waiver, and the Brain Injury waiver. Medicaid providers must be certified by the Department of Inspections and Appeals and comply with additional requirements in the Medicaid provider manual.

Definitions

Adult day services mean an organized program providing a variety of health-related care, social services, and other support services for up to 16 hours in a 24-hour period to two or more persons with a functional impairment on a regularly scheduled, contractual basis. Functional impairment means a psychological, cognitive, or physical impairment that creates an inability to perform personal and instrumental activities of daily living (ADLs) and associated tasks and that necessitates some form of supervision or assistance or both. ADS programs may provide dementia-specific ADS.

Dementia-specific adult day services means a certified program that: (1) serves fewer than 55 participants and has five or more participants who have dementia between Stages 4 and 7 on the Global Deterioration Scale; (2) serves 55 or more participants and 10 percent or more of the participants have dementia between Stages 4 and 7 on the Global Deterioration Scale; or (3) holds itself out as providing specialized care for persons with a cognitive disorder or dementia, such as Alzheimer's disease, in a dedicated setting.

Parameters for Who Can Be Served

Programs may not knowingly admit or retain an individual who: (1) is under age 18; (2) is bedfast; (3) requires routine three-person assistance with standing, transfer, or evacuation; (4) requires more than part-time or intermittent health-related care; (5) has unmanageable incontinence on a regular basis; or (6) is dangerous to self or others.

An individual who is dangerous to self or others includes, but is not limited to, an individual who: (1) despite intervention, chronically elopes, is sexually or physically aggressive or abusive, or displays unmanageable verbal abuse; or (2) is in an acute stage of alcoholism, drug addiction, or uncontrolled mental illness.

Inspection and Monitoring

Within 180 calendar days following the issuance of provisional certification, the Department of Inspections and Appeals must conduct on-site monitoring to determine the program's compliance with applicable requirements. The Department must make a final certification decision based on the results of the monitoring and a review of an acceptable plan of correction if needed. If the decision is to continue certification, the Department must issue a full 2-year certification effective from the date of the original provisional certification.

The Department may conduct an on-site monitoring evaluation within 90 days following a change in ownership or management to ensure that the program continues to comply with requirements.

Required and Optional Services

All ADS programs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

Required and Optional Services Adult Day Services
  Required     Optional  
ADL Assistance X  
Health Education and Counseling    
Health Monitoring   X
Medication Administration   X
Nursing Services   X
Physical Therapy, Occupational Therapy, or Speech Therapy      
Skilled Nursing Services   X
Social Services    
Transportation   X

Medication Provisions

Each program must have a written medication policy. Participants may self-administer medications unless: (1) the prescription states that the participant is not to self-administer the medication; or (2) the participant or, if applicable, the legal representative, delegates administration to the program by contractual agreement or signed service plan. The program may not prohibit a participant from self-administering medications.

An ADS program may provide for medication setup if requested by a participant or the participant's legal representative. If medication setup is provided following such request, the program must be responsible for the specific task requested and the participant must retain responsibility for those tasks not requested to be provided.

If administration of medications is delegated to the program by the participant or the participant's legal representative, the medications may be administered by a registered nurse (RN), licensed practical nurse, or advanced RN practitioner licensed or registered in Iowa, or by the individual to whom such licensed or registered individuals may properly delegate administration of medications.

If medication setup is provided by the program at the request of the participant or the participant's legal representative, or if medication administration is delegated to the program by the participant or the participant's legal representative, appropriate staff of the program may transfer the medications in the participant's presence from the original prescription container to medication dispensing containers, reminder containers, or medication cups.

Staffing Requirements

Type of Staff. A program that administers prescription medications or provides professionally-directed health care or health-related care must have a registered nurse. All personnel of a program must be able to implement the program's accident, fire safety, and emergency procedures. A program that serves one or more participants with cognitive disorders or dementia must have written procedures that address how the program will respond to the emergency needs of the participants.

Staffing Ratios. Sufficient trained staff must be available at all times to fully meet participants' identified needs. No fewer than two staff persons who monitor participants as indicated in each participant's service plan must be awake and on duty during all hours of operations when two or more participants are present.

Training Requirements

The owner or management of the program is responsible for ensuring that all personnel employed by or contracting with the program receive training appropriate to their assigned tasks and the needs of the target population. Personnel who are employed by or contract with the program and who are responsible for food preparation and/or service must have an orientation on sanitation and safe food handling prior to handling food and must have annual in-service training on food protection.

All personnel employed by or contracting with a dementia-specific program must receive a minimum of 8 hours of dementia-specific education and training prior to--or within 30 days of--employment or the beginning date of the contract. The dementia-specific education or training must include, at a minimum, the following topics: (1) an explanation of Alzheimer's disease and other types of dementias; (2) the program's specialized dementia care philosophy and program; (3) skills for communicating with persons with dementia; (4) skills for communicating with family and friends of persons with dementia; (5) an explanation of family issues such as role reversal, grief and loss, guilt, relinquishing the caregiving role, and family dynamics; (6) the importance of planned and spontaneous activities; (7) skills in providing assistance with ADLs; (8) the importance of the care plan and social history information; (9) skills in working with challenging participants; (10) techniques for simplifying, cueing, and redirecting; and (11) staff support and stress reduction.

An employee or contractor who provides documentation of the completion of a dementia-specific education or training program within the past 12 months is exempt from the education and training requirements listed above.

All personnel employed by or contracting with a dementia-specific program must receive a minimum of 2 hours of dementia-specific continuing education annually direct contact personnel must receive a minimum of 8 hours of dementia-specific continuing education annually.

Location of Licensing, Certification, or Other Requirements

Iowa Administrative Codes and Rules, Chapter 481.70: Adult Day Services. [September 3, 2014]https://www.legis.iowa.gov/law/administrativeRules/rules?agency=481&chapter=70&pubDate=09-03-2014

Iowa Legislature, website, Adult Day Services: Medication Set Up--Administration and Storage of Medicationshttps://www.legis.iowa.gov/publications/search/document?fq=id:188450&q=A...

Home and Community-Based Services Provider Manual, Chapter III: Provider-Specific Policies. Iowa Department of Human Services. [August 1, 2014]https://dhs.iowa.gov/sites/default/files/private/HCBS.pdf

Information Sources

Amber FranzenDirectorIowa Adult Day Services Association

Leann HowlandMedicaidIowa Department of Human Services

KANSAS

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-kansas

Overview

The Kansas Department on Aging licenses adult day care (ADC) facilities. Some licensing requirements for adult care homes apply to ADC providers. Kansas covers ADC provided by licensed providers through its Medicaid 1915(c) Frail Elderly Waiver program.

Definitions

Adult day care means any adult care home operating less than 24 hours a day caring for individuals not related within the third degree of relationship to the operator or owner by blood or marriage and who, due to functional impairment, need supervision or assistance with activities of daily living.

The state's definition of "adult care home'' encompasses a wide range of settings, including nursing facilities, intermediate care facilities for persons with intellectual and other types of developmental disabilities, assisted living facilities, residential health care facilities, boarding care homes, and ADC facilities.

Parameters for Who Can Be Served

ADC providers cannot serve persons in need of specialized services for mental illness unless they can provide appropriate treatment. Individuals must be admitted under the care of a physician. The Medicaid Frail Elderly Waiver program serves participants 65 years of age or older who would be institutionalized without these services.

Providers may define the target population they wish to serve but cannot admit individuals who:

  • are incontinent and will not participate in the management of their incontinence;
  • are immobile;
  • have any condition requiring a two-person transfer;
  • have any behavior symptom that are not manageable; or
  • have a clinical condition that requires the use of physical restraints.

Individuals with any of the conditions listed above can be admitted only if their negotiated service agreement includes resources to meet their needs.

Providers may discharge individuals if necessary for their welfare, if their needs cannot be met in the current setting, or if they endanger the safety or health of other individuals.

Inspection and Monitoring

ADC facilities must provide immediate access to a representative of the Secretary of the Kansas Department of Health and Environment or the Kansas Department of Social and Rehabilitation Services. The representative must conduct at least one unannounced inspection of each ADC facility within 15 months of any prior inspection for the purpose of determining whether the adult care facility is complying with applicable statutes, rules, and regulations relating to the health and safety of participants. Surveyors from the Department of Aging and Disability Services must conduct a site visit every 15 months to ensure that a facility complies with construction standards.

Required and Optional Services

All ADC programs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

Required and Optional Services Adult Day Care
  Required     Optional  
ADL Assistance X  
Health Education and Counseling   X
Health Monitoring X  
Medication Administration X  
Nursing Services X  
Physical Therapy, Occupational Therapy, or Speech Therapy     X
Skilled Nursing Services X  
Social Services   X
Transportation   X

Medication Provisions

Self-Administration of Medications. Participants may self-administer and manage medications independently if a licensed nurse has performed an assessment and determined that a participant can safely and accurately do so without staff assistance. Participants who self-administer their medications can use a medication container or syringe pre-filled by a licensed nurse or pharmacist, or by a family member or friend who has provided this service without charge.

An assessment must be completed before a participant initially begins self-administration, annually, and when the participant experiences a significant change of condition. Each assessment must include an evaluation of the participant's physical, cognitive, and functional ability to safely and accurately self-administer and manage medications independently or use a pre-filled medication container or pre-filled syringe.

Self-Administration of Medications with Assistance. Any participant who self-administers medication can select some medications to be administered by a licensed nurse or medication aide. If a facility is responsible for the administration of a participant's medications, the administrator or operator must ensure that all medications and biologicals are administered to that participant in accordance with a medical care provider's written order, professional standards of practice, and each manufacturer's recommendations. Only licensed nurses and medication aides may administer medications for which the facility has responsibility.

Staffing Requirements

Type of Staff. Each ADC facility must have an administrator or operator who may supervise more than one facility if: (1) each facility is located within a proximate geographical location; (2) the combined participant capacity does not exceed 100 participants; and (3) the administrator or operator ensures that the lack of full-time, on-site supervision of the facility will not adversely affect the health and welfare of participants. The administrator's or operator's responsibilities include the following:

  • Planning, organizing, and directing the facility.

  • Implementing operational policies and procedures for the facility.

  • Authorizing, in writing, a responsible employee who is 18 years old or older to act on the administrator's or operator's behalf in his or her absence.

Each facility must be responsible for ensuring that a licensed nurse is available on-site or by telephone to provide immediate direction to medication aides and nurse aides for participants who have unscheduled needs. The licensed nurse may be employed by the facility or by a home health agency or a hospice. A registered nurse must be available to supervise licensed practical nurses.

Staffing Ratios. The administrator or operator of each ADC facility must ensure the provision of a sufficient number of qualified personnel to provide each participant with services and care in accordance with each participant's functional capacity, health care service plan, and negotiated service agreement.

Training Requirements

Each ADC facility will provide orientation to new employees and regular in-service education for all employees to ensure that the services provided assist participants to attain and maintain their individuality, autonomy, dignity, independence, and ability to make choices. Subjects for in-service education must include: principles of ADC, fire safety, disaster procedures, accident prevention, participant rights, infection control, and prevention of abuse. Facilities admitting participants with dementia must provide in-service education on the treatment of behavioral symptoms.

Location of Licensing, Certification, or Other Requirements

Kansas Medical Assistance Program Provider Manual, Home and Community-Based Services Frail Elderly Waiver Program: Adult Day Care Benefits and Limitations. [November 2012]https://www.kmap-state-ks.us/Documents/Content/Provider%20Manuals/HCBS%20FE%2011072012_12111.pdf

Statutes and Regulations for the Licensure and Operation of Adult Day Care Facilities. Kansas Department on Aging. [May 29, 2009]http://www.aging.ks.gov/PolicyInfo_and_Regs/ACH_Current_Regs/ADC_Regs_Complete.pdf

Information Sources

Patty BrownRegional ManagerState License FacilitiesKansas Department for Aging and Disability Services

KENTUCKY

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-kentucky

Overview

The Kentucky Cabinet for Health and Family Services certifies adult day care (ADC), which is a social model, and licenses adult day health care (ADHC), which is a medical model, and promulgates administrative regulations to establish health, safety, and treatment requirements for both models.

ADC certification and associated regulations apply to the publicly-funded Adult Day and Alzheimer's Respite program and the private pay Adult Day and Alzheimer's Respite program. Apart from parameters for who can be served, the requirements described in this profile are the same for both the publicly-funded and private pay programs.

The Cabinet for Health and Family Services pays for ADC services and Alzheimer's respite care in as many Area Development Districts as funding permits through state general funds, such as the Older Americans Act program. Voluntary contributions to cover costs are encouraged and a sliding scale for cost-sharing is used. However, services are not withheld from otherwise eligible individuals who do not voluntarily contribute to their cost.

The Department for Medicaid Services pays for ADHC services under several 1915(c) waiver programs. In addition to licensure, if providers are reimbursed through a waiver program, they must be certified under the provider enrollment process for Medicaid contracting purposes.

All certified ADC centers, whether funded publicly or paid for privately, may also be licensed as ADHC centers.

Definitions

Adult day care is a supportive and therapeutic social program of supervision and care provided to an eligible adult during a part of the day, but for less than 24 hours.

Alzheimer's respite is a program of supervision and care provided to a person with Alzheimer's disease or another type of dementia to give caregivers temporary relief from caregiving duties.

All ADC and Alzheimer's respite programs offer help with self-administration of medications, personal care services, self-care training, social activities, and recreation.

Adult day health care is a licensed program that provides organized health care for individuals of all ages during specified daytime hours, which may include: (1) continuous supervision to ensure that health care needs are being met; (2) supervision of self-administration of medications; (3) nursing services that include medication administration for participants who are unable to self-administer; (4) provision of personal care services; (5) self-care training; and (6) social and recreational activities.

Parameters for Who Can Be Served

Adult Day and Alzheimer's Respite Program. Participants must be able to respond and participate in program activities without creating health and safety problems for themselves or others. Providers may serve individuals who are age 60 or older and: (1) physically disabled or frail as a result of medical condition or age and need care during part of the day; (2) mentally confused and in need of supervision to prevent injury and ensure proper nutrition and medication use; or (3) who, due to emotional or social needs, may benefit from the individualized attention and social structure these programs offer, which are not otherwise available. Participants may be of any age if they have a diagnosis of probable Alzheimer's disease or another type of dementia, as confirmed by a written statement from a physician.

Only a case manager or participant may decide to terminate adult day and Alzheimer's respite services. The services may be reduced if the participant's condition or support system improves; or a determination that the plan of care specified in the administrative regulation cannot be followed.

Private Pay Adult Day and Alzheimer's Respite Program. Participants must meet the age requirements specified in a private pay ADC center's policies and procedures, but must be at least 18 years of age and able to participate in and respond to program activities without creating health and safety risks to themselves or others. A private pay ADC center or participant may decide to terminate ADC and Alzheimer's respite services. Upon discovery of a participant being ineligible for services due to health or safety risks as specified in the administrative regulation, the private pay ADC center must assist in making a referral to another agency, if requested.

Adult Day Health Care. These programs may serve aged or disabled persons who are 21 years of age or older, who meet Medicaid's eligibility criteria for waiver program services, and who, without these services, would be admitted to a nursing facility.

Should an ADHC participant's condition become such that a different type of care would be more beneficial, the ADHC provider must make the necessary transfer or referral and advise the Medicaid waiver program of the referral or transfer.

Inspection and Monitoring

The regional offices of the Division of Health Care are responsible for conducting on-site visits of all health care facilities in the state to determine compliance with applicable licensing regulations and Medicare/Medicaid certification requirements. All inspections of ADC centers are unannounced. Certification renewals of ADC are made every 2 years while licensure renewals for ADHC are made annually.

In addition, the Department for Medicaid Services has contracted with Carewise Health to perform an annual monitoring survey of ADHC centers. Carewise Health sends a monitoring review packet to ADHC providers scheduled for review, which contains the information required during the review to allow providers time to obtain the information needed for a complete documentation record.

Required and Optional Services

All ADC and ADHC programs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

Required and Optional Services Adult Day Care Adult Day Health Care
  Required     Optional     Required     Optional  
ADL Assistance X   X  
Health Education and Counseling        
Health Monitoring/Health-Related Services     X  
Medication Administration     X  
Nursing Services     X  
Physical Therapy, Occupational Therapy, or Speech Therapy       X  
Skilled Nursing Services     X  
Social Services X      
Transportation X1   X2  
  1. Providers of ADC are required to assist the family in arranging transportation but do not have to furnish it themselves.
  2. ADHC providers are required to furnish transportation only for physician's appointments and medical emergencies.

Medication Provisions

Adult Day Care. A service provider may allow staff to assist participants in self-administration of medications by: (1) reminding a participant when to take medications and observing to ensure that the participant takes the medication as directed; (2) handing the participant's medication to the participant, or if it is difficult for the participant or if the participant requests assistance, opening the unit dose or medication organizer, removing the medication from a medication organizer or unit dose container, closing the medication organizer, placing the dose in a container, and placing the medication or the container in the participants hand; (3) steadying or guiding a participant's hand while the participant is self-administering medications; or (4) applying non-prescription topical ointments and lotions.

Adult Day Health Care. Basic services include monitoring and supervision of self-administered medications. Drugs and treatments must be administered by ADHC staff only as ordered by the physician. ADHC staff must evaluate and monitor all patient medications for possible adverse reactions, significant side effects, drug allergies, and contraindications.

Staffing Requirements

Adult Day Care

Type of Staff. Trained and experienced staff must be present each day of operation.

Staffing Ratios. Staffing ratios must be one staff member for each five participants. At least two responsible persons must be at the center, one of whom must be a paid staff member, whenever there is more than one participant in attendance. Whenever participants are at the center, at least one staff member who has completed first-aid training and is currently certified by the American Heart Association or the American Red Cross to perform cardiovascular pulmonary resuscitation (CPR) must be present.

Adult Day Health Care

Type of Staff. An ADHC program must have an administrator who is responsible for the operation of the facility and delegates such responsibility in his/her absence. An ADHC program must employ or have access to a sufficient number of qualified personnel as may be required to provide the services mandated by the administrative regulation and indicated by the needs of the program's participants. The administrator must designate the person who must be primarily responsible for the coordination and provision of a dietary and activity services. An employee of the program who has direct patient care responsibilities must have current CPR certification from either the American Heart Association or the American Red Cross. The ADHC program may provide required therapy services through a contractual arrangement with a qualified therapist.

Staffing Ratios. None identified.

Training Requirements

Adult Day Care. Staff training must be provided by appropriate qualified professionals. Prior to assuming duties, paid and volunteer personnel must receive a minimum of 6 hours of orientation to the program and center on the following topics: (1) program objectives; (2) program policies and procedures; (3) health, sanitation, emergency and safety codes and procedures; (4) participant confidentiality; and (5) personnel policies and procedures. Policies and procedures must be provided in writing and explained verbally.

Within 1 month of employment, staff must become certified in CPR. Within 3 months of employment, personnel must be provided a minimum of 34 hours of basic training that includes: (1) the aging process; (2) interpersonal communication; (3) personal care; (4) first-aid; (5) identifying and reporting health problems; (6) stress management; (7) recognizing and reporting suspected adult abuse, neglect, or exploitation; and (8) universal blood and body fluid precautions.

In addition to basic training, Alzheimer's respite personnel must be provided training in: (1) dementia; (2) causes and manifestations of dementia; (3) managing the participant with dementia; (4) crisis intervention with combative participants; and (5) effects of dementia on the caregiver. A minimum of 8 hours of annual training to review and update knowledge and skills must be provided.

Adult Day Health Care. An ADHC program must conduct an orientation for new employees. The administrator must attend educational programs appropriate to the responsibilities of the position and arrange for other professional personnel to attend appropriate educational programs about supervision and topics related to personal care, activities, nutrition, and other pertinent subjects.

ADHC providers must ensure agency staff are trained in the prevention, identification, and reporting of abuse, neglect, and exploitation. A planned in-service training program must be provided to employees covering policies and procedures pertinent to their roles within the program.

Location of Licensing, Certification, or Other Requirements

Program and certification requirements for the Private Pay Adult Day and Alzheimer's Respite Program. Kentucky Administrative Regulations 910 KAR 1:150. [March 5, 2010]http://www.lrc.ky.gov/kar/910/001/150.htm

Program and certification requirements for the Adult Day and Alzheimer's Respite Program.Kentucky Administrative Regulations 910 KAR 1:160. [March 5, 2010]http://www.lrc.ky.gov/kar/910/001/160.htm

Adult Day and Alzheimer's Respite Program Standard Operating Procedures. Department of Aging and Independent Living. [March 5, 2010]http://chfs.ky.gov/NR/rdonlyres/CF2B2278-BB6A-4FF5-9899-5C9DB717BBC5/0/DAILSOPCH2ADCALZRESPITECombined.pdf

Certification of Adult Day Care Centers. Kentucky Revised Statutes 205.950. [June 20, 2005]http://www.lrc.ky.gov/Statutes/statute.aspx?id=7878

Unannounced Inspection of Adult Day Care Centers. Kentucky Revised Statutes 205.955. [July 14, 1992]http://www.lrc.ky.gov/Statutes/statute.aspx?id=7879

Adult Day Health Care Services Manual. Department for Medicaid Services.Transmittal #1. [May 2005]http://chfs.ky.gov/NR/rdonlyres/154BF44E-EF73-4B88-8DD1-14F47BE945E1/0/ADHCManual2005.pdf

Technical Amendment. Reimbursement for Home and Community-Based Waiver Services. Kentucky Administrative Regulations 907 KAR 1:170. [July 16, 2013]http://www.lrc.state.ky.us/kar/907/001/170.htm

Operation and Services; Adult Day Health Care Programs. Kentucky Administrative Regulations 902 KAR 20:066. [June 8, 2001]http://www.lrc.ky.gov/kar/902/020/066.htm

Skilled Nursing Services Provided to Medicaid Recipients by Adult Day Health Care Programs. Kentucky Revised Statutes 205.635. [April 9, 2002]http://www.lrc.ky.gov/Statutes/statute.aspx?id=7776

Cabinet to License and Regulate Adult Day Care Health Programs.Kentucky Revised Statutes 216B.0441. [June 2005]http://www.lrc.ky.gov/Statutes/statute.aspx?id=9194

Home and Community-Based Waiver Services. Kentucky Administrative Regulations 907 KAR 1:160. [July 7, 2008]http://www.lrc.ky.gov/kar/907/001/160.htm

General Administration, Programs for the Elderly. Kentucky Administrative Regulations 910 KAR 1:220. [June 14, 2013]http://www.lrc.ky.gov/kar/910/001/220.htm

Information Sources

Deana HuffSocial Services SpecialistDepartment for Aging and Independent LivingConstituent Services Branch

Jennifer L. Smith, RNNurse Consultant/InspectorHome and Community-Based Waiver ServicesDepartment for Medicaid Services

Marilyn Ferguson, RNNurse Consultant/InspectorHome and Community-Based Waiver ServicesDepartment for Medicaid Services

Tracy Steinberg, MS, LSWChief Program OfficerGuardiaCare Services, Inc.

Kelly UpchurchPresidentKentucky Association of Adult Day Centers     andStaff MemberOffice of Inspector GeneralCabinet for Health and Family Services

LOUISIANA

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-louisiana

Overview

The Louisiana Department of Health and Hospitals, Health Standards Section licenses adult day health care (ADHC) providers. No ADHC provider may be licensed to operate unless the Facility Need Review Program has granted approval for the issuance of an ADHC provider license.

Licensed ADHC providers may serve participants in two 1915(c) Medicaid waiver programs--Community Choices and the Adult Day Health Care waiver program--and other publicly-funded programs. They may also serve private pay participants.

Adult day care (ADC) is a licensed service for adults with developmental disabilities, which is funded through the New Opportunities waiver program. Because the focus of this regulatory review is on programs that serve older persons, licensing regulations for ADC are not included in this profile.

Definitions

Adult day health care is a program that provides medical, nursing, social, and personal care services for a portion of the day to adults who have physical, mental, or functional impairments. Such services are rendered by utilizing licensed professionals in a community-based nursing center, and provide an alternative to--or a possible prevention or delay of--24-hour institutional care.

Adult day health care center is any place owned or operated for profit or non-profit by a person, society, agency, corporation, institution, or any group wherein two or more functionally impaired adults who are not related to the owner or operator of such agency are provided with ADHC services. An ADHC center must be operational for at least 5 hours each day of operation and at least 5 days per week.

Parameters for Who Can Be Served

Providers may not admit participants whose presence would pose a documented health and safety risk to themselves or other ADHC participants. The Medicaid provider manual states that a participant can be discharged under the following circumstances:

  • The health and welfare of the individual cannot be reasonably ensured through the provision of the ADHC waiver services within the individual's cost cap.

  • It is not cost-effective to serve the individual in the ADHC waiver program.

  • For the medical protection or the well-being of the participant or others.

  • In an emergency situation (i.e., fire-related or weather-related damage).

  • The health or welfare of the recipient is threatened.

  • The ADHC provider is unable to furnish the services indicated in the recipient's Plan of Care after documented reasonable accommodations have failed.

Inspection and Monitoring

ADHC providers must submit an initial licensing application packet of required information. Once approved by the Department of Health And Hospitals, the applicant must attend a mandatory preparatory training class conducted quarterly by the Department's Health Standards Section before the initial licensure survey will be conducted. Once the provider has successfully completed the class, the provider will be sent written notification with instructions for requesting the announced initial licensing survey.

Prior to the initial license being issued, an initial licensing survey is conducted on-site at the ADHC center to ensure compliance with ADHC licensing standards. If the initial licensing survey finds that the ADHC center is compliant with all licensing laws and regulations, and is compliant with all other required statutes, laws, ordinances, rules, regulations, and fees, the Department issues a full license for 1 year. The license is valid until the expiration date shown on the license, unless the license is modified, revoked, suspended, or terminated. The Department also may perform an on-site survey and inspection upon annual renewal of a license.

The initial licensing survey of an ADHC provider is an announced survey. Follow-up surveys to the initial licensing surveys are not announced. Once an ADHC provider has been issued an initial license, the Department conducts unannounced surveys at intervals it deems necessary to investigate complaints, to determine compliance with licensing regulations, and to ensure that any previously identified deficient practices have been corrected.

Medicaid Requirements

Services offered through the ADHC waiver program are closely monitored to ensure compliance with Medicaid policy as well as applicable state and federal regulations. Medicaid's Health Standards Section staff conducts on-site reviews of each provider agency. These reviews are conducted to monitor the provider agency's compliance with Medicaid's provider enrollment participation requirements, continued capacity for service delivery, quality, and appropriateness of service provision to the waiver population, and the presence of the personal outcomes defined and prioritized by the participants.

The reviews include an examination of administrative records, personnel records, and a sample of participants' records to ensure that appropriate services are delivered and documented. In addition, provider agencies are monitored with respect to:

  • Recipient access to needed services identified in the Plan of Care and Individualized Service Plan.

  • Quality of assessment and service planning.

  • Appropriateness of services provided including content, intensity, frequency, and recipient input and satisfaction.

  • The presence of the personal outcomes as defined and prioritized by the recipient/guardian.

  • Internal quality improvement.

On-site reviews are unannounced and conducted by Health Standards Section staff to ensure compliance with program requirements, and ensure that services provided are appropriate to meet participants' needs.

Required and Optional Services

All ADHC programs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

Required and Optional Services Adult Day Health Care
  Required     Optional  
ADL Assistance X  
Health Education and Counseling X  
Health Monitoring/Health-Related Services X  
Medication Administration X  
Nursing Services X  
Physical Therapy, Occupational Therapy, or Speech Therapy      
Skilled Nursing Services    
Social Services X  
Transportation X1  
  1. Centers are expected to provide transportation to any client within their licensed region, but no participant, regardless of their region of origin, may be in transport for more than 1 hour on any single trip.

Medication Provisions

A registered nurse (RN) must serve on the interdisciplinary team and monitor participants' overall health needs. The RN serves as a liaison between the participant and medical resources, including the treating physician. The RN's responsibilities include medication review for each participant at least monthly and, when there is a change in the medication regime, to:

  • determine the appropriateness of the medication regime;
  • evaluate contraindications;
  • evaluate the need for lab monitoring;
  • make referrals to the primary care physician for needed monitoring tests;
  • report the efficacy of the medications prescribed; and
  • determine if medications are being administered properly in the center.

The RN must supervise medication administration to participants (both self-administration and staff administration) and approve the method of medication storage and record-keeping.

Staffing Requirements

Type of Staff. A full-time director is required to manage the center and ensure that all services provided are consistent with accepted standards of practice and that center policies are executed. The director must be accessible to center staff or to any representative of the Department of Health and Hospitals conducting an audit, survey, monitoring activity, or research and quality assurance.

Facilities are required to hire a registered nurse to provide medical care and supervision services for all participants but the RN does not have to be a full-time employee. Facilities are also required to hire a program manager to carry out the center's individualized program for each participant, and a social service designee/social worker to arrange medical and/or social services for participants. The social service designee/social worker and the program manager must be employed at least 10 hours a week in their respective capacities.

The latter three positions are considered to be "key staff," any one of whom may also serve as the director. Centers with a licensed capacity of 15 or fewer participants may designate one full-time staff person or full-time equivalent person to fill up to three "key staff" positions, and must employ at least one full-time person or full-time equivalent to fulfill key staff requirements.

Centers with a licensed capacity to serve 16-30 participants must employ at least two full-time persons or full-time equivalents to fulfill key staff requirements, and may designate one full-time staff person or full-time equivalent person to fill up to, but no more than, two "key staff" positions.

Centers with a licensed capacity to serve more than 30 participants must employ at least three full-time persons or full-time equivalents to fill key staff positions. Each key staff position must be filled with a full-time person or full-time equivalent.

The center must also designate one staff member who is employed at least 10 hours per week as a food service supervisor who is responsible for meal preparation and/or serving. A direct service worker is an unlicensed staff person who has face-to-face direct contact with participants and provides personal care or other services and support to them to enhance their well-being.

Volunteers and student interns are considered a supplement to the required staffing component and must be directly supervised by a paid staff member. They must also receive orientation and ongoing in-service training at least quarterly.

The Medicaid ADHC waiver program further requires that an adequate number of qualified direct service staff arepresent to ensure participants' health, safety, and well-being, and that staff possess direct care abilities, skills, and knowledge to adequately perform care and assistance as required by waiver program participants. Regardless of the program's licensed capacity, Medicaid requires that the RN or licensed practical nurse (LPN), the social service designee/social worker, the program manager, and the food service supervisor, all be full-time positions that cannot be occupied by one person.

Staffing Ratios. The direct service worker-to-participant ratio is a minimum of one full-time direct service worker to every nine participants.

As described above, center staffing requirements must be based on licensed capacity; however, the center must ensure that the following requirements are met regardless of the licensed capacity of the center:

  • The RN or LPN must be on the premises daily for at least 8 hours, the number of hours the center is open, or during the time participants are present at the center, whichever is less.

  • If the RN or LPN has been on duty at least 8 hours and participants are still present in the center, the RN or LPN may be relieved of duty; however, at least one key staff person must remain on duty at the center--either the social service designee/social worker or the program manager.

  • A staff member certified in cardiovascular pulmonary resuscitation must be on the premises at all times while participants are present.

Training Requirements

An ADHC center's orientation program must provide training for new employees to acquaint them with the center's philosophy, organization, program, practices, and goals. The orientation must also include instruction in safety and emergency procedures as well as the specific responsibilities of the employee's job. A center must document that all employees receive training on an annual basis in:

  • the principles and practices of participant care;
  • the center's administrative procedures and programmatic goals;
  • emergency and safety procedures;
  • protecting the participant's rights;
  • procedures and legal requirements concerning the reporting of abuse and neglect;
  • acceptable behavior management techniques;
  • crisis management; and
  • use of restraints (manual method, mechanical, or physical devices).

A center must ensure that each direct care staff person completes no less than 20 hours of face-to-face training per year. Orientation and normal supervision will not be considered to meet this requirement.

The Medicaid ADHC waiver program requires that the center's RN provides in-service training to both staff and participants on health-related matters.

Location of Licensing, Certification, or Other Requirements

Department of Health and Hospitals website: Licensing, Regulations, Policies, and Procedures for Adult Day Health Care Centershttp://new.dhh.louisiana.gov/index.cfm/newsroom/detail/1657

Adult Day Health Care Waiver Provider Manual, Chapter Nine of the Medicaid Services Manual. Department of Health and Hospitals, Medicaid. [December 1, 2010]http://new.dhh.louisiana.gov/assets/docs/OAAS/Manuals/ADHCManual.pdf

Information Sources

Christopher Vincent, RN, BSNMedical Certification Program ManagerHealth Standards SectionDepartment of Health and Hospitals

MAINE

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-maine

Overview

All adult day services (ADS) providers, whether publicly-funded or serving only private pay participants, are required to be licensed by the Maine Department of Health and Human Services (DHHS) Division of Licensing and Certification. DHHS promulgates regulations governing the licensing and functioning of ADS programs. This profile summarizes these regulations, which are applicable to all types of ADS programs.

Maine recognizes three types of ADS programs: adult day health services (ADHS) and social ADS, which differ in scope and intensity of service delivery, and a night program that provides ADS to persons with dementia. Providers may be licensed to offer more than one program, as long as record-keeping is distinct. All licenses are renewed annually.

All types of ADS programs are eligible for reimbursement under MaineCare, the state's Medicaid program, and through non-Medicaid programs.13 ADHS provided under the Medicaid State Plan program have the same or similar additional requirements as for the 1915(c) Elderly and Adults with Disabilities Waiver program, which are described in this profile.

Definitions

Adult day services is a group program designed to meet the needs of adults who, through an assessment and service plan, are determined to need therapeutic activities, socialization, supervision, support services, assistance with activities of daily living (ADLs), and/or health monitoring. The program is maintained or carried out on a regular basis by a person or persons in a private dwelling or other facility, for any part of a day, for at least 2 hours a day, for more than two adults 19 years of age or older who are not blood relatives and are coming to the facility for up to 7 days a week for the express purpose of participating in the program.

Adult day health services is an ADS program that provides health monitoring and personal care services in addition to a group program of care, therapeutic activities, and supervision. Therapeutic activities means restorative activities designed to maintain or improve the quality of life or delay skill deterioration. Examples of therapeutic activities include those aimed at improving or maintaining gross motor activities, social activities, sensory enhancement activities, crafts, outdoor activities, spiritual activities, and extensive ADL assistance.

The 1915(c) Elderly and Adults with Disabilities Waiver program defines ADHS as health and social services provided to promote the optimal functioning of MaineCare participants. Services are delivered according to an individual care plan at an adult day health (ADH) site for 4 or more hours per day, on a regularly scheduled basis, up to 7 days a week. The hours spent in ADHS count as personal care services.14

Social adult day services are designed to meet the social and supportive service needs of individuals attending the program. This may include socialization, supervision, supportive services and/or limited ADL assistance.

Night programs15 are ADS programs staffed by awake staff and delivered between the hours of 5:00pm and 7:00am to persons with dementia who are awake and participating in activities during some of those hours. A night program may be offered by either a social ADS program or an ADHS program, but it must have applied for--and received--a license to provide a night program. Requirements are the same as for programs offered between 7:00am and 5:00pm.

A participant may attend a night program up to seven times per week if he or she is not attending the daytime program for either ADH or social ADS. Participants in both a daytime program and a night program are limited to seven dates of participation in a 7-day period. At no time should an ADS program provide 24-consecutive-hour services to a participant.

Parameters for Who Can Be Served

The definitions of ADS, ADHS and social ADS above and the list of services provided indicate the parameters for who can be served in these programs. Providers may discharge participants if they endanger the safety and/or health of other program participants.

In addition, to be eligible for the three non-Medicaid programs and for MaineCare, individuals must have a recognized or diagnosed need verified through a standard functional assessment (Medical Eligibility Determination Form).

Inspection and Monitoring

DHHS is responsible for evaluating the adequacy of care provided and the adequacy of the site. The Department may make unannounced visits to evaluate compliance with regulations and to talk privately with participants.

Medicaid requires ongoing monitoring by the DHHS, Office of Aging and Disability Services, which includes site visits to the Assessing Services Agency (ASA)16 and the Service Coordination Agency (SCA)17 and visits to a sample of participants. The Department monitors the ASA's and SCA's compliance with the waiver program document, regulations, and contract performance.

Required and Optional Services

All ADS programs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

Required and Optional Services Adult Day Services   Adult Day Health Services  
  Required     Optional     Required     Optional  
ADL Assistance X1   X2  
Health Education and Counseling       X
Health Monitoring/Health-Related Services     X  
Medication Administration   X X  
Nursing Services     X  
Physical Therapy, Occupational Therapy, or Speech Therapy         X
Skilled Nursing Services     X  
Social Services       X
Transportation        
  1. Limited assistance.
  2. Extensive assistance.

Optional services, if required by the participant's authorized care plan, can be reimbursed by various payers. For example, for participants dually-eligible for Medicare and Medicaid, Medicare--as first payer--could pay for the various therapies, counseling, and social services. Otherwise, under the Medicaid waiver program, participants can choose from a menu of services up to the amount of their waiver cost cap. These services are organized by a SCA that is not a provider of direct service.

Medication Provisions

Participants may keep medications that they self-administer as long as they can self-administer appropriately and their possession of medications poses no danger to other participants.

Providers may assist with medication if requested in writing by participants or their designated representative on a form approved by the DHHS. No medication may be administered without a written order signed by a duly authorized practitioner or person licensed to prescribe medications. A person qualified to administer medications must be on site at the facility whenever a participant has medications prescribed "as needed" if this medication is not self-administered.

Unlicensed employees who are certified as residential medication aides may administer medications only if: (1) they have completed, at a minimum, the certified residential medication aide (CRMA) training curriculum within the previous 12 months; or (2) were employed in a health care setting during the previous 12 months where medication administration was part of their responsibilities. All certified assistive personnel administering medications and/or treatments must complete a DHHS-approved 8-hour refresher course every 2 years for recertification within 2 years of the original certification.

No injectable medications may be administered by an unlicensed person, with the exception of bee sting kits and insulin. Before administration of injectable bee sting kits or insulin, unlicensed persons must be trained by a registered nurse (RN). The training that is required is an in-service training delivered to unlicensed staff previously trained through the CRMA training curriculum, also delivered by an RN. Documentation of the training must be included in the employee's record.

Staffing Requirements

Type of Staff. The program administrator is responsible for the development, coordination, supervision, fiscal management, and evaluation of services provided at the ADS program. When the administrator is not on site for at least 50 percent of the hours of operation, the administrator must appoint an individual to be responsible for site operation and management during those hours of operation. The program must employ the number of persons needed to carry out regulatory requirements.

Medicaid mandates that ADHS be provided by the following qualified professional staff in accordance with the individual written care plan: registered nurse, practical nurse, social worker, physical therapist, occupational therapist (registered), and speech-language pathologist. These staff may be employees or consultants. Other qualified staff may include certified nursing assistants and other service aides and assistants who provide services appropriate to their level of training under the supervision of a licensed professional, who may be a consultant.

Staffing Ratios. ADS programs must maintain a minimum staff-to-participant ratio of 1:6 at all times when participants are present. Programs with 3-6 participants must maintain a second staff person to be on call and available for emergencies at all times that participants are present. DHHS may require additional staff based on participants' needs. Volunteers may be included in the staff ratio only when they conform to the same standards and requirements as paid staff, meet the job qualifications, and have designated responsibilities.

Training Requirements

There must be an orientation program for all new employees and volunteers that includes a review of applicable program policies, participant rights, emergency procedures and fire safety, job description and related responsibilities, confidentiality, communication skills, needs of the population served, elder abuse reporting, standard precautions, and licensing regulations.

The program must provide annually at least 6 hours of education and training for part-time (20 hours or less a week) staff and volunteers, and 12 hours for full-time staff and volunteers who meet the job qualification standards and have designated responsibilities for 21 hours a week or more. Required topics include participant rights, emergency preparedness, body mechanics, choking prevention and intervention techniques, workplace safety, basic nutrition and food safety, first-aid, and behavioral interventions and specific training for services related to participants with cognitive impairments and other diagnosed conditions (e.g., Parkinson's disease).

Location of Licensing, Certification, or Other Requirements

Maine.gov website: Licensing Rules. Select Adult Day Service Programs for Regulations Governing the Licensing and Functioning of Adult Day Services Programs, 10-144, Chapter 117. DHHS, Division of Licensing and Certification, Community Services Programs. [January 4, 2006]http://www.maine.gov/dhhs/dlrs/licensing-rules.html

MaineCare Benefits Manual, Chapter II, Section 19: Home and Community Benefits for the Elderly and for Adults with Disabilities. DHHS, Bureau of Medical Services. [August 8, 2013]http://www.maine.gov/sos/cec/rules/10/ch101.htm

MaineCare Benefits Manual, Chapter II, Section 26: Day Health Services. DHHS, Bureau of Medical Services. [August 5, 2005]http://www.maine.gov/dhhs/audit/rate-setting/documents/S26P08052005.pdf

Section 61: Adult Day Services. Bureau of Elder and Adult Services Policy Manual. [November 1, 1997]http://www.maine.gov/sos/cec/rules/10/149/149c5-61.doc

Section 63: In-home and Community Support Services. 10-149, Chapter V: Office of Elder Services Policy Manual.http://www.maine.gov/sos/cec/rules/10/149/149c5-63.doc

Section 68: Respite Care for Adults with Alzheimer's Disease or Related Disorders. Office of Elder Services Policy Manual. [February 1, 2009]http://www.maine.gov/sos/cec/rules/10/149/149c5-68.doc

Department of Health and Human Services website, Licensing and Regulatory Services: Certified Residential Medication Aide (CRMA)https://gateway.maine.gov/dhhs-apps/assisted/crma_overview.asp

Information Sources

David D. BerryCommunity Support Specialist, Long-Term CareDHHS Office of Aging and Disability Services

MARYLAND

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-maryland

Overview

Maryland licenses two types of adult day services--adult day care (ADC) and medical day care--through the Office of Health Care Quality in the Department of Health and Mental Hygiene. ADC services are offered and managed by the Department's Office of Health Services through state-funded contracts.

Maryland provides medical day care under the Medicaid State Plan and under the Home and Community-Based Options waiver program. In addition to meeting the same licensing requirements as day care providers, medical day care providers must meet the general requirements for participation in the Medicaid program and the specific requirements for Medicaid's medical day care program.

This profile describes both ADC and medical day care licensing requirements.

The Maryland Department of Aging (MDoA) also offers a small social ADC program called Senior Center Plus--a program of structured group activities and enhanced socialization designed for older adults with mild physical or cognitive impairments. Senior Center Plus providers do not have to be licensed but must meet MDoA certification requirements for zoning and planning, and Medicaid standards if serving waiver participants. Providers licensed to furnish medical day care may also provide Senior Center Plus services.

The level of personal support provided by the Senior Center Plus program is less intensive than medical ADC and no medical care is provided. Currently, the Senior Center Plus program has 32 sites.

Definitions

Adult Day Care

Day care center for adults means a place operated to provide, with or without charge, care for adults with a medical disability. Centers are designated as group day care for four or more adults or as a family home that provides day care for 2-3 adults.

Day care center for the elderly means a place that is operated to provide, with or without charge, care for elderly individuals. Centers are designated as group day care for at least four elderly individuals or as a family home that provides day care for 2-3 elderly individuals.

Elderly individual means an individual who is age 55 years or older who lives alone or with a spouse, relative, or friend; needs temporary care and supervision during part of a day in a protective group setting; and has a disability that prevents gainful employment or the accomplishment of a routine of normal daily activities without assistance, or has a permanent or recurring mental impairment.

Adult with a medical disability means an individual age 16 years or older who lives alone or with a spouse, relative, or friend; has a physical impairment that prevents gainful employment or the accomplishment of a routine of normal daily activities outside an institutional or sheltered environment; or has a permanent or recurring mental impairment that requires domiciliary or institutional care in a sheltered environment.

Medical Day Care

Medical day care means a program of medically supervised, health-related services provided in an ambulatory setting to adults with a medical disability, who due to their degree of impairment, need health maintenance and restorative services to support community living.

Medical day care center means a facility operated for the purpose of providing medical day care services in an ambulatory care setting to adults with a medical disability who do not require 24-hour inpatient care but, due to their degree of impairment, are not capable of full-time independent living.

Waiver participant means a health-impaired adult who is certified by the Department as requiring nursing facility services, but whose illness or disability does not require 24-hour inpatient care, unless medical day care services are not available; and whose disabilities and needs cannot be satisfactorily and totally met in an episodic ambulatory care setting, but require participation at least 1 day a week in a day-long rehabilitative or maintenance ambulatory care program that provides a mix of medical and social services.

Parameters for Who Can Be Served

The target populations include elderly and working-age adults with a medical disability. Parameters for individuals who can be served are specified generally in the definitions of ADC and medical day care (above). Providers may not serve individuals whose needs they cannot realistically meet.

Private pay participants are not required to need a nursing home level of care.

Inspection and Monitoring

Upon application for a license, the Department's authorized representative inspects the proposed facility. A re-inspection is made for license renewal and periodic re-inspections may be conducted by the Department at any time. The Department monitors or inspects ADC and medical day care facilities at least once every 2 years to ensure compliance with the licensing requirements.

Required and Optional Services

All ADC and medical day care programs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

Required and Optional Services Adult Day Care Medical Day Care
  Required     Optional     Required     Optional  
ADL Assistance X   X  
Health Education and Counseling   X X  
Health Monitoring X   X  
Medication Administration X   X  
Nursing Services X   X  
Physical Therapy, Occupational Therapy, or Speech Therapy     X X1  
Skilled Nursing Services     X  
Social Services   X X  
Transportation X   X  
  1. Required if specified in an individual's care plan.

Medication Provisions

Providers must have written policies specifying the individual authorized to procure, receive, control, and manage the facility's medication program. Participants who are independently responsible for taking their own medication at home are permitted, if authorized by their physician, to continue to be responsible for taking their own medications during the hours spent in the facility. If any participant requires supervision of medication administration, all federal, state, and local laws, ordinances, standards, and codes must be followed. Staff supervising participants who are self-administering medications must have appropriate training.

Only licensed nurses may give injectable medications. For participants not capable of self-medicating, the individual who is assigned the responsibility of administering medications must prepare the dosage, observe the participant swallowing the oral medication, and document that the participant has taken the medication.

Staffing Requirements

Adult Day Care

Type of Staff. Required staff includea full-time director, who may work half-time in each of two facilities if the employing organization operates more than one facility; a half-time registered nurse (RN); and a full- or half-time activities coordinator. A full-time center director who is a RN may also serve as the RN. If an ADC center is part of another facility, the center must have its own full-time director and program staff.

At least one staff member who is trained in first-aid and cardiovascular pulmonary resuscitation (CPR) must be present at all times at the center, during outings, or during transportation of participants.

Staffing Ratios. The staff-to-participant ratio must be 1:7 exclusive of the director, volunteers, and consultants. Any staff member who does not provide direct care to participants may not be counted when computing the staff ratio.

The Senior Center Plus program requires one staff member to eight participants.

Medical Day Care

Type of Staff. The medical day care center must have adequate staff capability to monitor and appropriately serve participants at all times. At a minimum, the medical day care center must have a full-time registered nurse, an activities coordinator (full-time or part-time), a medical social worker (full-time or part-time), and a staff physician (full-time, part-time, or contractual). Additional nursing staff may be required based on the number of participants and their level of impairment.

The provider must designate a program director and a health director. The program director must be full-time and have either a bachelor's degree or be a RN. The health director may be the RN or the staff physician, if the staff physician is required to be present at least half of the hours the medical day care center is open. Medical services must be supervised by the staff physician.

The composition of the staff depends in part on the number and needs of the participants the program serves. When regular employment--full-time or part-time--is not justified by participants' needs, contractual employees may be used to meet their needs. For mandatory services that the required staff cannot perform, such as physical therapy, occupational therapy, and nutrition, the medical day care center has the option of adding staff or establishing written agreements with licensed specialists.

At least one staff member trained in first-aid and certified in CPR must be on the premises at all times that participants are in attendance.

Staffing Ratios. The medical day care center must have adequate staff capability to monitor and appropriately serve the participants at all times. The staff-to-participant ratio at each center must be a minimum of 1:7.

Training Requirements

The program director must ensure that staff and volunteers receive orientation and training and that an ongoing educational program is planned and conducted for the development and improvement of all personnel's skills, including training related to problems and needs of the elderly--both health-impaired and disabled.

The center must provide a minimum of eight in-service training sessions annually, which must include at least the following topics: (1) prevention and control of infections; (2) fire prevention and emergency safety procedures; (3) accident prevention; (4) care of persons with Alzheimer's disease or other dementias; and (5) recognition and reporting of abuse. When job duties involve the provision of individual care services, employees must receive a minimum of 2 hours of training on cognitive impairment and mental illness within the first 90 days of employment.

First-aid training must be taken from the American Red Cross or another approved comparable source. At a minimum, training must be taken every 3 years. Recertification in CPR must be obtained annually.

Location of Licensing, Certification, or Other Requirements

Annotated Code of Maryland, Title 10, Subtitle 09, Chapter7: Medical Day Care Services. Department of Health and Mental Hygiene Regulations.http://www.dsd.state.md.us/comar/SubtitleSearch.aspx?search=10.09.07

Annotated Code of Maryland, Title 10, Subtitle 12, Chapter4: Day Care for the Elderly and Adults with a Medical Disability. Department of Health and Mental Hygiene Regulations.http://www.dsd.state.md.us/comar/SubtitleSearch.aspx?search=10.12.04

Annotated Code of Maryland, Title 10, Subtitle 09, Chapter 54: Home and Community-Based Services Options Waiver: Specific Conditions for Provider Participation--Senior Center Plus. Department of Health and Mental Hygiene Regulations.http://www.dsd.state.md.us/comar/getfile.aspx?file=10.09.54.07.htm

FAQs for Adult Medical Care License, Department of Health and Mental Hygiene Regulations.http://dhmh.maryland.gov/ohcq/AMDC/docs/AMDC%20-%20License%20FAQ.pdf

Checklist for Opening an Adult Medical Day Care Center. Department of Health and Mental Hygiene Regulations.http://dhmh.maryland.gov/ohcq/AMDC/docs/Checklist%20for%20opening%20an%20Adult%20Medical%20Day%20Care%20Center.pdf

Information Sources

Victoria JohnsonAdult Waiver ProgramDepartment of AgingOffice of Health and Mental Hygiene

MASSACHUSETTS

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-massachusetts

Overview

Massachusetts offers three models of adult day services: adult day health (ADH), dementia day services, and supportive day programs--also called social day programs. Beginning May 2015, Massachusetts required licensure for all ADH programs. Licensure is not required for dementia day services and supportive day programs. The licensing rules include suitability requirements and standards for maintenance and operation. Licensing is overseen by the Massachusetts Department of Public Health (DPH).

ADH providers who are reimbursed through the state's Medicaid program--called MassHealth--are additionally regulated and overseen by MassHealth Office of Long-Term Services and Supports. Licensed ADH programs can also provide dementia day programs.

MassHealth reimburses adult day health services (ADHS) providers through the Medicaid State Plan and through the 1915(c) Frail Elder Home and Community-Based Services Waiver program. Services are governed by regulations published in the ADH manual under a contract between MassHealth and the provider. Programs serving participants with cognitive impairments, dementia, or Alzheimer's disease needing complex level of care services must provide the additional services and meet the requirements listed in Appendix D of the ADH manual.

Providers offering dementia day services and supportive day programs can be reimbursed through non-Medicaid public programs that are operated in accordance with program standards issued by the Massachusetts Executive Office of Elder Affairs.18 Providers must agree to the standards as part of their provider agreement.

The Executive Office of Elder Affairs provides ADH, dementia day and supportive day services as part of the Aging Services non-Medicaid Home Care Program and the Enhanced Community Options Program (ECOP). Both the Home Care Program and ECOP offer care and non-care supports to individuals in their homes but ECOP is targeted for individuals with higher level of care needs. To qualify, eligible seniors must have a need for support services.

Most adult day programs (ADPs) accept private payment as well as payment from MassHealth, the Home Care Program and ECOP, the Department of Veterans Affairs, and long-term care insurance. As well as the new licensing requirements for ADH programs, the requirements described in this profile include both Medicaid requirements and the standards for supportive day programs issued by the Executive Office of Elder Affairs. (Revisions to the Medicaid/MassHealth Adult Day Health Program regulations are pending, but not available as of May 15, 2015.)

Definitions

Adult day programs provide daytime supervision and care for adults in a group setting in the community. They help frail seniors, adults with physical or mental disabilities, and other adults who want or need a structured day program. Different types of ADPs offer different levels of care as described below.

Adult day health programs: (1) provide nursing care, supervision, and health-related support services in a structured group setting to persons 18 years of age or older who have physical, cognitive, or behavioral health impairments; and (2) support families and other caregivers thereby enabling participants to live in the community.

MassHealth further defines three levels of care: Health Promotion and Prevention,19 Basic Level of Care, and Complex Level of Care. The level of care provided is based on the participant's care needs. Providers must operate their ADH programs at least Monday through Friday for 8 hours a day. Some programs also operate on weekends. Most programs require participants to attend a minimum of 2 days per week.

Dementia day programs can be provided as part of an ADH program that is reimbursed through Medicaid. In addition to providing regular ADHS, dementia day programs offer specially trained staff, enhanced personal care assistance, secure indoor and outdoor spaces and exits, and "failure-free" activities that promote self-esteem. When a program serves both individuals with dementia and those without, a separate space must be available for the dementia program.

Dementia day services are also provided through the Home Care program in a structured, secure environment for individuals with cognitive disabilities to: (1) maximize the individual's functional capacity; (2) reduce agitation, disruptive behavior, and the need for psychoactive medication; and (3) enhance cognitive functioning.

Supportive day programs provide support services in a group setting to help participants recover and rehabilitate from an acute illness or injury, or to help them manage a chronic illness. The services include social and recreational activities, some assistance with activities of daily living (ADLs), health-related services, social services, therapeutic activities, nutrition, and transportation. Supportive day care is for adults who can manage their own personal care and medications. No medical care is provided. Most programs are available Monday through Friday, 6 or more hours per day.

Parameters for Who Can Be Served

Adult Day Health. The definition of ADH program above indicates the parameters for who can be served in these programs. A program may enroll and care for only those participants in need of services and for whom it can provide care and services appropriate to their physical, cognitive, psychosocial, and behavioral needs. A program may not enroll a participant without a written order for services from a primary care provider, who has determined that the program of care is appropriate to meet the participant's needs. A program may also not enroll participants without their written consent or the consent of a legally authorized representative. Furthermore, a participant may only be admitted if he or she has had a physical examination within 12 months prior to enrollment, which has documented the following:

  • diagnoses and associated conditions;
  • known allergies;
  • pertinent findings of a physical exam;
  • significant medical history;
  • assessment of physical capability, including ADLs;
  • assessment of cognitive status; and
  • TB screening.

Admission to and reimbursement for dementia-specific programming is based on MassHealth's complex level of care definitions.

Discharge from an ADH program may be initiated by either the provider or the participant. Providers may discharge individuals whose health has improved sufficiently so they no longer need services; or if the safety and/or health of other participants in the program are endangered; or if the intensity of their medical and/or behavioral needs can no longer be met by the ADH program, in which case the provider must arrange for discharge to a more appropriate setting and may not discharge the participant until appropriate services are available.

Supportive Day Program. Providers may serve individuals who are in need of supervision, supportive services, socialization, and minimal assistance with ADLs. Participants may have multiple physical problems, but must be medically stable and not need nursing observation or intervention. Participants may have some cognitive impairment but behavior problems must be able to be handled with redirection and reassurance. Participants must be able to communicate personal needs. Supportive day care personnel reserve the right to discontinue services at any time to participants whosemedical, psychological or emotional health changes to the point where they can no longer benefit from the program.

Inspection and Monitoring

Adult Day Health. DPH or its agents may visit and inspect a program or licensure applicant at any time without prior notice in order to determine the program's or applicant's compliance with state law and the licensing regulations.

Supportive Day Programs and Dementia Day Programs. The Home Care Program regulations did not provide information regarding inspection or monitoring.

Required and Optional Services

All ADPs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

Required and Optional Services   Supportive Day Programs   Adult Day Health
  Required     Optional     Required     Optional  
ADL Assistance X1   X  
Health Education and Counseling     X  
Health Monitoring/Health-Related Services X   X  
Medication Administration     X  
Nursing Services     X  
Physical Therapy, Occupational Therapy, or Speech Therapy       X  
Skilled Nursing Services     X  
Social Services X   X  
Transportation X   X2  
  1. The provision of ADL assistance in Supportive Day Care is limited to verbal or visual prompts.
  2. Transportation is a required service only for MassHealth providers.

Medication Provisions

Supportive Day Programs. Participants are responsible for administering their own medications. Staff will observe all medication self-administration. Participants keep medications on a personal shelf and they must be in the original pharmacy container or a well-marked container with the participant's name, physician's name, medication name, pharmacy name, and dosage.

Adult Day Health. Nursing services for all levels of care provided in ADH programs must include administration of medications and treatments prescribed by the participant's physician during the time the participant is present.

Staffing Requirements

Supportive Day Programs

Type of Staff. The center must provide an adequate number of staff whose qualifications are commensurate with defined job responsibilities to provide essential program functions. Positions include administrator/program director and activities coordinator. The administrator has full authority and responsibility to plan, staff, direct, implement, and evaluate the program. The administrator or his/her designee must be on-site to provide day-to-day management during the center's hours of operation. The program director must organize, implement, and coordinate the daily operation of the program in accordance with participants' needs and any mandatory requirements. The program director may also fulfill the responsibilities of the administrator.

Staffing Ratios. There must be at least two responsible persons, one a paid staff member, at the center at all times when two or more participants are present. The staff-to-participant ratio must be at least 1:8.

Adult Day Health

Type of Staff. All programs must employ a qualified program director and ensure that licensed nursing staff are on site all hours of program operation to ensure that preventive measures, treatments, medications, nutritional care, rehabilitation services, therapeutic activities, and related services are carried out, recorded, and reviewed in accordance with participants' assessments and plans of care. A senior staff person may be designated to assume temporary responsibility for a program director in the event that the program director requires an absence longer than a full week. If the program director also serves the program as a registered nurse (RN), the temporary designee may only act in the capacity of program director, unless he or she is a licensed RN.

Adequate staff must be on duty at all times so that participants' health, safety, and care needs are met. At least one RN must be on site at least 6 hours per day for programs with a licensed capacity of 35 or fewer participants; and at least 8 hours per day for programs with a capacity of 36 or more participants. Programs must increase licensed nursing staff by 4 hours for each additional 1-12 participants attending the program.

If the program's average daily census is 24 or more participants, the program must provide a social worker for at least 20 hours per week. The program must provide a therapeutic activity director on site for at least 4 hours per day. Rehabilitation services must be provided by licensed physical therapists, occupational therapists, and speech, hearing, and language therapists.

The program must ensure that a sufficient number of qualified direct care staff and qualified program aide staff are available at all times to provide necessary supervision and assistance for each participant in accordance with participants' needs and plans of care, written policies and procedures, and licensing regulations. The program director will determine volunteers' duties and responsibilities. If a volunteer is to provide direct care, the volunteer must have the same qualifications as direct care staff.

Staffing Ratios. The program must provide at least one direct care staff person per six participants attending the program; one qualified program aide per 12 participants; and at least one licensed nurse per 24 participants. A program aide who performs maintenance, food preparation, or extensive housekeeping tasks during program hours of operation may not be considered a program aide for purposes of meeting minimum staffing requirements. A volunteer may not be counted as a licensed nurse, program aide, social worker, or activity director for the purpose of satisfying the minimum staffing requirements.

In addition to the licensing rules described above, MassHealth contractors must meet the following requirements. Programs must maintain proportionate direct care staff-to-participant ratios to meet participants' needs based on the number of participants requiring each level of care service. For the health promotion and prevention level of care, the ADH provider must maintain a minimum staff-to-participant ratio of 1:8; for basic level of care services, a minimum staffing ratio of 1:6; and for complex level of care services 1:4. For programs specializing in serving participants with dementia, the program must maintain a staff-to-participant ratio of at least 1:4.

Training Requirements

Supportive Day Programs. Staff are trained to identify the signs and indicators of potential abuse. Orientation, in-service training, and evaluations must be provided for all employees and volunteers, including training on the use of standard protocols for handling communicable diseases and infection control.

Adult Day Health. The program must provide an organized orientation program for all new employees that explains job responsibilities, duties, conditions of employment, and relevant participant care policies; and must provide a minimum of 12 hours of relevant in-service training per year for personnel who interact with participants. The in-service training must be relevant to the participant population and to the program's services. In addition, the program must ensure that all personnel are:

  • Knowledgeable about participants' medical and behavioral conditions and their cultural diversity, including, but not limited to, race, ethnicity, sexual orientation and gender identity, such that personnel are able to provide care that is appropriate to participants' needs.

  • Adequately trained to understand, respond to, and address the needs of participants with Alzheimer's disease and other dementia, training for which must include knowledge about Alzheimer's disease and other dementias; behavior management skills necessary to respond appropriately to participant behaviors and non-verbal communications; and group process skills in working with special need populations.

All program personnel in direct contact with participants must be trained in emergency procedures, and licensed nurses and program aides must be certified in cardiovascular pulmonary resuscitation and basic first-aid by an approved instructor.

On and after May 1, 2015, a program may not employ any individual for more than 4 months as a program aide unless the individual has demonstrated competence through satisfactory participation in a relevant health care training or competency evaluation; or an RN employed by or under contract with the program has determined that the individual is competent to provide direct care to participants based on the individual's demonstration of competency in basic nursing and nursing-related skills and techniques.

The program must provide at least 40 hours of a combination of classroom and experiential training prior to determining whether the individual is competent to be a program aide by demonstrating competency in the following required skill areas:

  • Communication and interpersonal skills.

  • Observation, reporting, and documentation of participant status and the care or service furnished.

  • Basic infection control procedures.

  • Basic delegated nursing and nursing-related skills.

  • Maintenance of a clean, safe, and healthy environment.

  • Recognizing, responding to, and reporting emergencies, and knowledge of emergency procedures.

  • Recognizing participants' physical, emotional, and developmental needs and working in a manner that respects participants, their privacy, and their property.

  • Preventing and reporting participant abuse, neglect, mistreatment, and property misappropriation.

  • Caring for program participants, including those with Alzheimer's disease and other dementias.

The program must provide each individual who has not been determined competent with at least 8 hours of orientation training regarding the required skills before that individual may provide any direct care to participants.

Location of Licensing, Certification, or Other Requirements

105 CMR: 158: The Licensure of Adult Day Health Programs. Commonwealth of Massachusetts, Department of Public Health. [January 30, 2015]http://www.mass.gov/courts/case-legal-res/law-lib/laws-by-source/cmr/100-199cmr/105cmr.html

MassHealth Transmittal Letter ADH 25. Adult Day Health Manual Revisions. Commonwealth of Massachusetts, Executive Office of Health and Human Services, Office of Medicaid. [March 1, 2010]http://www.mass.gov/eohhs/docs/masshealth/transletters-2010/adh-25.pdf

MassHealth Transmittal Letter ADH 15. Adult Day Health: Appendix D: Dementia Day Service. Commonwealth of Massachusetts, Executive Office of Health and Human Services, Office of Medicaid. [November 1, 2002]http://www.mass.gov/eohhs/docs/masshealth/providermanual/appx-d-adh.pdf

101 CMR: 310.00: Adult Day Health Services. Commonwealth of Massachusetts, Executive Office of Health and Human Services. [October 1, 2012]http://www.mass.gov/eohhs/docs/eohhs/eohhs-regs/101-cmr-310-adult-day-health.pdf

130 CMR: 404.00: Adult Day Health Services. Commonwealth of Massachusetts, Division of Medical Assistance.http://www.lawlib.state.ma.us/source/mass/cmr/cmrtext/130CMR404.pdf

130 CMR: 450:00: Administrative and Billing Regulations. Commonwealth of Massachusetts, Division of Medical Assistance.http://www.lawlib.state.ma.us/source/mass/cmr/cmrtext/130CMR450.pdf

651 CMR 3.00 Home Care Program Regulations. Commonwealth of Massachusetts, Executive Office of Elder Affairs. [June 19, 2004]http://umassmed.typepad.com/files/651.003.062804.pdf

A Supportive Day Program Start Up Manual for your Council on Aging. Massachusetts Councils on Aging in Cooperation with Executive Office of Elder Affairs.[October 10, 2008]http://www.mcoaonline.com/content/pdf/Supportive-Day-Manual.pdf

Information Sources

Danielle McKnightProgram ManagerAdult Day Health and Day Hab. ServicesOffice of Long-Term Services and SupportsMassHealth

Michele KeefeExecutive DirectorMassachusetts Adult Day Services Association

MICHIGAN

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-michigan

Overview

Michigan does not license or certify adult day services (ADS) and dementia adult day care (ADC), but providers of services funded by the Michigan Office of Services to the Aging (OSA) must comply with OSA's operating standards. ADS and dementia ADC may be provided only under an approved area plan through a formal contractual agreement between an Area Agency on Aging (AAA) and the provider.

ADS and dementia ADC are covered under a Medicaid 1915(c) waiver program and are called adult day health services (ADHS). The Medicaid waiver program's contractual requirements for ADHS adopt many elements from the OSA standards (e.g., admission criteria). Providers must meet the waiver program requirements for both types of care as well as the OSA's operating standards (the state has additional standards for dementia ADC), which are described in this profile.

Definitions

Adult day services is care provided for any part of a day, but less than 24 hours, to functionally and/or cognitively impaired elderly persons. It is provided through a structured program of social and rehabilitative and/or maintenance services in a supportive group setting other than the participant's home.

Dementia adult day care is care provided for any part of a day, but less than 24 hours, to older persons with dementia. It is provided through a structured program of social and rehabilitative and/or maintenance services in a supportive or group setting other than the participant's home.

Adult day health services means services furnished 4 or more hours per day on a regularly scheduled basis, for 1 or more days per week, or as specified in the service plan, in a non-institutional, community-based setting, encompassing both health and social services needed to ensure a participant's optimal functioning. Physical, occupational, and speech therapies may be furnished as component parts of this service. Transportation between the participant's place of residence and the adult day health center is provided as a component part of this service.

Parameters for Who Can Be Served

Adult day services providers may serve participants who:

  • Require regular supervision in order to live in their own homes or the home of a relative.

  • Require assistance with activities of daily living (ADLs).

  • Are capable of leaving their residence, with assistance, to receive services.

  • Need intervention in the form of enrichment and opportunities for social activities in order to prevent and/or postpone deterioration that would likely lead to institutionalization.

  • Require a substitute caregiver while their regular caregiver is in need of relief or otherwise unavailable.

Dementia adult day care providers may serve individuals who:

  • Have a diagnosis of Alzheimer's disease or another type of dementia.

  • Have significant impairments in cognition, communication, and ADLs.

  • Are responsive to redirection and other supportive verbal interventions when angry, anxious, lost, or upset.

  • May require one or more of the following: (1) modifications in environmental cues, communication approach, and task breakdown to enhance comprehension and participation in identified activities; (2) supervision to maintain personal safety; (3) hands-on assistance to perform toileting, grooming, hygiene, and bathing.

  • Do not have an acute medical illness.

  • Are free of communicable respiratory diseases and hepatitis.

The participant's family must understand and be willing to comply with program policies related to participation in service planning, communication of status changes, and planned absences.

Providers may not serve individuals who have an acute medical illness, a communicable respiratory disease, or hepatitis.

Inspection and Monitoring

Programs that receive federal and state funding through OSA are monitored at least once a year by an AAA to ensure compliance with its minimum operating standards. Medicaid waiver program services providers are monitored according to Medicaid requirements.

Required and Optional Services

All ADS and dementia ADC programs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

The Medicaid waiver program also requires dementia ADC programs to provide:

  • Outreach services to non-enrolled families through home visits, follow-up phone calls, and dissemination of printed materials that clearly describe the program's services.

  • Opportunities for caregivers to discuss concerns, feelings, physical care and stress management techniques via case consultation, care conferences, or supportive counseling.

  • Caregiver information and education about dementia or assistance for caregivers in obtaining it through referral to local self-help organizations or dementia resource libraries.

  • Referrals to other support services as needed, such as family support groups of the Alzheimer's Association, Parkinson's and Huntington's Disease Foundations; in-home, congregate and overnight respite; home-based nursing and personal care services; benefit entitlement programs; and brain autopsy services.

Medicaid providers must also ensure the availability of crisis response services for persons with dementia and their families. If this service is not provided directly by the host agency, the agency must have a formal arrangement with the local community mental health board or center to provide the service.

Required and Optional Services Adult Day Services   Dementia Adult Day Care  
  Required1     Optional2     Required     Optional  
ADL Assistance X   X  
Health Education and Counseling   X   X
Health Monitoring   X   X
Medication Administration        
Nursing Services   X   X
Physical Therapy, Occupational Therapy, or Speech Therapy     X   X
Skilled Nursing Services   X   X
Social Services       X
Transportation X   X  
  1. Care coordination is also a required service.
  2. Other optional services are medical support, dental, podiatric, and ophthalmologic.

Medication Provisions

Each program must establish written policies and procedures (reviewed and approved by a consulting pharmacist, physician, or registered nurse [RN]) that govern staff assistance to help participants take their own medications while participating in the program. The policies and procedures must minimally address: (1) written consent from the participant or participant's representative to receive assistance in taking medications; (2) the training and authority of staff to assist participants with taking their own prescription or non-prescription medications and under what conditions such assistance may take place; and (3) procedures for medication setup.

Staffing Requirements

Adult Day Services

Type of Staff. Each ADC program must employ a full-time program director. Health support services may be provided only under the supervision of a registered nurse.

Staffing Ratios. The program must continually provide support staff at a ratio of no less than one staff person for each ten participants.

Dementia Adult Day Care

Type of Staff. Each dementia program must have a coordinator with both formal education and prior work experience commensurate with the responsibilities of program development and operation; supervision and training of staff; interagency relations; and coordination and maintenance of all administrative, program and participant records.

All program personnel must be knowledgeable about Alzheimer's disease and other dementias and demonstrate the ability to communicate effectively with participants who have dementia. The program must arrange to use program consultants such as medical and mental health professionals, environmental specialists, and other therapists as necessary.

Dementia ADC programs must work toward developing20 the following as necessary: (1) an RN (or licensed practical nurse under RN supervision) to provide physical health and support services a minimum of 4 hours per month; (2) a social worker or certified counselor for a minimum of 4 hours per month to provide counseling and assist participants to obtain other services as needed; (3) arrangements to obtain cognitive and psychiatric specialists to evaluate difficult behaviors and to develop alternative interventions for caregivers to try; and (4) arrangements to obtain physical, speech, and occupational therapies.

Staffing Ratios. Dementia ADC programs must have a minimum staff/volunteer/student-to-participant ratio of 1:3. At least one staff must be on-site at all times when participants are in attendance.

Training Requirements

Both ADC staff and dementia ADC staff must receive orientation training that includes, in addition to the topics specified in the general requirements for all services programs, assessment/observation skills and basic first-aid.

Adult Day Services. Program staff must receive in-service training at least twice each year, which is specifically designed to increase their knowledge and understanding of the program, aging process issues, and to improve their skills in providing services. Topics addressed under the aging process may include, though are not limited to: cultural diversity, dementia, cognitive impairment, mental illness, abuse and exploitation.

Dementia Adult Day Care. All programs must have a formal staff development program. Dementia ADC program staff must be trained in crisis procedures. Inexperienced personnel must complete dementia care training prior to being scheduled to work with participants. All staff must complete an initial training program that includes content in the following areas: normal aging versus Alzheimer's disease and other types of dementia; the impact of Alzheimer's disease and other dementias on the person with dementia and family caregivers; and communication enhancement techniques.

After completing the initial training, all personnel must attend, at a minimum, two in-service training programs per year. All programs must have specific training for volunteers and students in the areas listed above and in assessment, management of difficult behaviors, and physical care techniques related to providing ADL assistance.

Location of Licensing, Certification, or Other Requirements

Operating Standards for Service Programs, Chapter III-C 1and 2: Adult Day Services and Dementia Adult Day Care. Michigan Office of Services to the Aging. [January 18, 2008]http://www.michigan.gov/documents/miseniors/OperatingStandardsServicePrograms_222072_7.pdf

Minimum Operating Standards for MI Choice Waiver Program Services, Section III: Specific Operating Standards, Adult Day Health. Michigan Department of Community Health. [October 1, 2011]http://hhshealthoptions.org/providertools/WaiverStandards.pdf

Information Sources

Sally Steiner, LMSWMichigan Office of Services to the Aging

Linda GibsonMichigan Adult Day Services Association

MINNESOTA

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-minnesota

Overview

Minnesota requires licensure for all adult day services (ADS), regardless of funding source. The services may be provided in a center or in a family home licensed to provide such services. A family ADS license may only be issued when the services are provided in the license holder's primary residence, and the license holder is the primary provider of care serving a maximum of eight adults at one time, including residents, if any.

The state pays for ADS provided to individuals aged 65 or older through the Medicaid 1915(c) Elderly Waiver program, and for individuals aged 0-64 through several other 1915(c) waivers. ADS are also available to dually-eligible Medicaid/ Medicare enrollees through the Minnesota Senior Care Project, under a Medicaid 1915(b) Home and Community-Based Services waiver.21

In addition, ADS are provided to individuals 65 or older through the Alternative Care program, which is a non-Medicaid program22 intended to reduce Medicaid-funded nursing home placements. Services can be provided free of charge or according to a sliding fee scale, up to 30 percent of the full cost of services.

Both the Elderly Waiver and the Alternative Care programs are overseen by the Department of Human Services, Aging and Adult Services Division. ADS providers must enroll with Minnesota Health Care Programs and meet specific standards in order to receive payment for services. This profile describes these standards as well as the state's licensing requirements.

Definitions

Adult day services are programs that provide functionally impaired adults with an individualized and coordinated set of services--including health services, social services, and nutritional services--that are directed at maintaining or improving participants' capabilities for self-care. Services must be furnished on a regularly scheduled basis 2 or more hours per day, but not more than 12 hours in a continuous 24-hour period, for 1 or more days per week.

Adult day services center means a facility that provides ADS on a regular basis for periods of less than 24 hours a day in a setting other than a participant's home or the residence of the facility operator. An identifiable unit in a licensed nursing home, hospital, or boarding care home that regularly provides day care at any given time for six or more functionally impaired adults who are not residents or patients of the nursing home, hospital, or boarding care home, must be licensed as an ADS center.

Parameters for Who Can Be Served

ADS are provided to functionally impaired adults, which is defined as having: (1) a condition that is characterized by substantial difficulty in carrying out one or more of the essential major activities of daily living (ADLs), performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, working; or (2) a thought or mood disorder that significantly impairs judgment, behavior, capacity to recognize reality, ability to cope with the ordinary demands of life, and that requires support to maintain independence in the community.

A center must have available for review, and must distribute to participants and their caregivers upon admission, a description of conditions that the center is not prepared to accept (e.g., a communicable disease requiring isolation, a history of violence to self or others, unmanageable incontinence, or uncontrollable wandering).

Inspection and Monitoring

Facilities must receive a compliance monitoring visit 24 months after the effective date of the initial license. Unless otherwise specified in statute, the commissioner may conduct routine inspections every 2 years. Where appropriate and feasible, the commissioner may identify and implement alternative methods of regulation and enforcement, including the use of an abbreviated inspection that employs key standards that have been shown to predict full compliance with the rules. Where administratively feasible and appropriate, the commissioner may work with the commissioners of health, public safety, administration, and education in conducting joint agency inspections of programs.

Required and Optional Services

All ADS programs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

Required and Optional Services Adult Day Services
  Required     Optional1  
ADL Assistance X  
Health Education and Counseling X  
Health Monitoring/Health-Related Services X  
Medication Administration X  
Nursing Services    
Physical Therapy, Occupational Therapy, or Speech Therapy      
Skilled Nursing Services    
Social Services X  
Transportation   X2
  1. A waiver participant may also receive a bath provided by an ADS provider. The reason for not providing a bath in the participant's home must be documented in the community support plan. This service is limited to two 15-minute units of service per day.
  2. If a center provides transportation, the maximum allowable transportation time for any participant being transported by a center vehicle between the participant's home and the center is 90 minutes, one way. The cost of transportation is not included in the reimbursement rate under the Elderly Waiver or Alternative Care programs and must be authorized as a separate service by the case manager.

Medication Provisions

Medication assistance means assisting participants to take medication and monitoring the effects of medication but does not include administering injections.

An employee, other than a physician, registered pharmacist, registered nurse (RN), or licensed practical nurse, who is responsible for medication assistance must provide a certificate verifying successful completion of a trained medication aid program for unlicensed personnel approved by the Minnesota Department of Health or must be trained by an RN to provide medication assistance in accordance with the relevant state rules.

Staffing Requirements

Type of Staff. The center director is responsible for managing the daily affairs of the center. In the temporary absence of the center director, a staff member must be designated to supervise the center. A person trained in basic first-aid and certified in cardiovascular pulmonary resuscitation and the treatment of obstructed airways must be present at all times.

ADS centers must offer health services developed in consultation with a registered nurse, who must review the health services at least monthly. The provision of health services must be preceded by the development of policies and monitoring procedures for participant self-administration of medications, for training and supervising unlicensed personnel who provide medication assistance, and for supervising staff distribution of medication.

Staffing Ratios. When an ADS center serves both participants who are capable of taking appropriate action for self-preservation under emergency conditions and participants who are not capable, the center must maintain a staff-to-participant ratio of one staff member present for every five participants present who are not capable of self-preservation and one staff member present for every eight participants present who are capable of self-preservation.

Only those employees whose primary center duties, as defined in their job descriptions, are to work directly with participants by providing care, supervision, and assistance in achieving care plan objectives must be counted as staff members in calculating the staff-to-participant ratio. A volunteer may be counted as a staff member in calculating the ratio if the volunteer meets the same standards and requirements as paid staff.

Training Requirements

ADS centers must provide all center employees with 20 hours of orientation within the employee's first 40 hours of employment. At least 4 hours of supervised orientation must be provided before employees work directly with center participants. The orientation must include training related to the kinds of functional impairments of current center participants and safety requirements and procedures. A center must provide a minimum of 8 hours in-service training annually in areas related to the care of center participants, including the provision of medication assistance.

ADS centers that serve persons with Alzheimer's disease or related disorders must ensure that the facility's direct care staff and their supervisors are trained in dementia care. Areas of required training include: (1) an explanation of Alzheimer's disease and other dementias; (2) ADL assistance; (3) problem solving with challenging behaviors; and (4) communication skills. The center must provide to participants, in written or electronic form, a description of the training program, the categories of employees trained, the frequency of training, and the basic topics covered.

Location of Licensing, Certification, or Other Requirements

Minnesota Administrative Rules, Chapter 9555: Social Services for Adults (Parts 9555.9600 to 9555.9730: Adult Day Care Center or Adult Day Services Center Licensure). Minnesota Department of Human Services. [October 8, 2007 and August 12, 2013]https://www.revisor.mn.gov/rules/?id=9555

Minnesota Statutes, Chapter 245A: Human Services Licensing Act. [2013]https://www.revisor.mn.gov/statutes/?id=245A&view=chapter&year=2013&keyword_type=all&keyword=Adult+day#stat.245A.02

Minnesota Statutes, Chapter 256B.0919: Adult Foster Care and Family Adult Day Care. [2013]https://www.revisor.mn.gov/statutes/?id=256B.0919&year=2013&keyword_type=exact&keyword=adult+day

Minnesota Statutes, Chapter 245A.143: Family Adult Day Services.https://www.revisor.mn.gov/statutes/?id=245A.143&year=2013&keyword_type=all&keyword=Adult+day

Minnesota Health Care Programs Provider Manual, Elderly Waiver and the Alternative Care Program. Minnesota Department of Human Services. [March 4, 2014]http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=id_056766#

Minnesota Department of Human Services website: Minnesota Health Care Programs Enrolled Providers--Home and Community-Based Waiver and Alternative Care Programs Services. [June 25, 2014]http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=dhs16_143093

http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=id_056766

Information Sources

Lisa RotegardManagerHCBS Policy Integration for SeniorsAging and Adult Services DivisionDepartment of Human Services

MISSISSIPPI

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-mississippi

Overview

Mississippi does not license adult day care (ADC) providers. The Mississippi Department of Human Services, Division of Aging and Adult Services, oversees and monitors ADC centers that wish to enter into an agreement to provide services funded by the Older Americans Act program through Area Agencies on Aging (AAAs). The Department requires these centers to meet quality assurance standards.

Medicaid covers ADC services under a 1915(c) Elderly and Disabled (E&D) waiver program. Providers must comply with the state's Division of Medicaid regulations published in the Home and Community-Based Services Provider Reference guide, which are described in this profile.

Definitions

Adult day care is a day program for aged and disabled individuals with serious health problems or impairments that providesrecreational activities, personal care supervision, nutrition, limited health care, and the opportunity to engage in individual activities and interact socially with other people in groups. Its purpose is to: (1) provide care, supervision, and services to individuals who are capable of only limited self-care; (2) meet health maintenance, prevention/intervention, and rehabilitation needs; and (3) promote a maximum level of independent functioning.

Parameters for Who Can Be Served

No specific admission or discharge requirements were identified. The definition of ADC (above) indicates the parameters for who can be served.

Inspection and Monitoring

The Mississippi Department of Human Services, Office of Monitoring inspects ADC programs up to three times a year and at least every 6 months. The AAAs monitor and evaluate local service providers for their efficiency and effectiveness in delivering services.

Medicaid waiver program staff conductan on-site visit after an application is approved and before a provider number is issued. Site visits are conducted at least every 2 years to ensure continued compliance with standards.

Required and Optional Services

All ADC programs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

Required and Optional Services Adult Day Care
  Required     Optional  
ADL Assistance X  
Health Education and Counseling X  
Health Monitoring/Health-Related Services X  
Medication Administration X1  
Nursing Services X2  
Physical Therapy, Occupational Therapy, or Speech Therapy      
Skilled Nursing Services X2  
Social Services X  
Transportation X  
  1. Medicaid administration is a required service for providers under the Quality Assurance Standards, but an optional service under the Medicaid E&D waiver program.
  2. Nursing and skilled nursing services are required services for providers under the Quality Assurance Standards, but are not required under the Medicaid E&D waiver program.

Medication Provisions

A registered nurse (RN) must prepare and administer medications if needed by participants.

Staffing Requirements

Type of Staff. ADC providers must have the following staff: a qualified administrator, responsible for the development, coordination, supervision, fiscal management, and evaluation of services provided through the ADC program; a program director (either center manager, site manager, or center coordinator), responsible for the organization, implementation, and coordination of the daily operation of the program in accordance with participants' needs and any mandatory requirements; a qualified social service staff person--either a licensed social worker or other health service professional such as certified rehabilitation counselors, licensed gerontologists, licensed professional counselors, or licensed/certified mental health workers; a registered nurse who must be on staff if the facility provides nursing services; an activities coordinator; and a program assistant.

Volunteers are permitted to supplement staff in established activities or to provide additional services for which the volunteer is qualified. The facility must not use volunteers in place of required staff and can use volunteers only on a periodic and temporary basis.

Staffing Ratios. At least two responsible persons--one a paid staff member (the other staff member can be a volunteer)--must be at the center at all times when two or more participants are in attendance. The staff-to-participant ratio must be between 1:6 and 1:10, except in programs serving a high percentage of severely impaired participants, in which case the ratio should be 1:4, or 1:5 in programs serving more than 20 participants. Volunteers can be included in this ratio only if they conform to the same standards as paid staff.

Training Requirements

All staff must complete first-aid, cardiovascular pulmonary resuscitation (CPR), and Heimlich Technique training. A minimum of 8 hours per year in-service training must be provided, preferably quarterly, and must be appropriate to job function and participant care needs. Program assistants must receive training in working with older adults and conducting activities for the population served.

All center staff providing direct care and participating in the day-to-day operation of the center must complete the Division's Adult Day Care Certification training within 12 months of their hire date. All staff and volunteers who have contact with and responsibility for special populations should receive specific training in serving that population.

All paid and volunteer staff must receive general orientation including, but not limited to: (1) the purpose and goals of adult day services; (2) roles and responsibilities of other staff members; (3) needs of the target population; (4) depression; (5) medication management; (6) the center's policies and regulations; (7) communication skills; (8) basic terminology; (9) advance directive policies; (10) elder abuse reporting; (11) safely and appropriately assisting participants with activities of daily living (ADLs); and (12) risk management.

Ongoing training includes at least four in-service training sessions per year. At the time of employment and annually, each employee must receive training about (1) participants' needs; (2) infection control; (3) the fire, safety, and disaster plan; (4) choking prevention and intervention techniques; (5) body mechanics, transfer techniques, and ADL assistance; (6) mandatory reporting laws for abuse/neglect; (7) basics of nutritional care, food safety, and safe feeding techniques; (8) CPR and first-aid; (9) behavioral acceptance, accommodation, and intervention; and (10) additional topics as available.

Location of Licensing, Certification, or Other Requirements

Mississippi Medicaid Provider Reference Guide, Part 208: Home and Community-Based Services. Mississippi Division of Medicaid. [March 2013]http://www.medicaid.ms.gov/wp-content/uploads/2014/01/Provider-Reference-Guide-208.pdf

Quality Assurance Standards, Adult Day Care. Mississippi Department of Human Services, Division of Aging and Adult Services.As of October 2014, The Quality Assurance standards were being revised. Because there is currently no URL link to the standards, Ms. Shirley Rainey of the Mississippi Department of Human Services provided them via e-mail.

Mississippi Division of Medicaid website: Information and Resources for the Elderly and Disabled Waiver.http://www.medicaid.ms.gov/programs/elderly-and-disabled-waiver/

Information Sources

Erin BarhamDivision of MedicaidBureau of Long Term Care

Shirley RaineyProgram CoordinatorMississippi Department of Human ServicesDivision of Aging and Adult Services

Karson LutherOffice of the GovernorDivision of Medicaid

MISSOURI

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-missouri

Overview

Missouri's Department of Health and Senior Services, Division of Senior Services and Regulation, licenses all adult day care programs in the state.23 An adult day care program that includes an Alzheimer's special care unit or program must submit to the Division a completed Alzheimer's Special Care Services Disclosure form, as part of the licensure application or renewal, stating how the care is different from the rest of the program.

Medicaid covers adult day health care (ADHC) through the 1915(c) Aged and Disabled Waiver program. An ADHC provider must be licensed as an adult day care program and must have entered into, and maintain, a valid participation agreement approved by the Missouri Medicaid Audit and Compliance Units.

Definitions

Adult day care is a group program designed to provide care and supervision to meet the needs of five or more functionally impaired adults for periods of less than 24 hours but more than 2 hours per day in a place other than the adult's own home.

Adult day health care is an adult day care program certified to provide Medicaid-reimbursed services to Medicaid-eligible participants, in accordance with standards set forth in the state's regulations.

Alzheimer's special care unit or program means any adult day care program that provides a designated separated unit or program for participants with a diagnosis of probable Alzheimer's disease or other dementia, to prevent or limit access by a participant outside the designated or separated area; or that advertises, markets or promotes the adult day care program as providing Alzheimer's or dementia care service.

Parameters for Who Can Be Served

Providers may serve functionally impaired adults age 18 or older who, by reason of age or infirmity, require care and supervision. No provider may knowingly admit participants whose needs the program cannot meet.

Because ADHC participants covered by the Aged and Disabled Waiver program must require a nursing facility level of care, they are likely to have functional limitations caused by physical and/or mental impairments, and some nursing/medical needs.

Inspection and Monitoring

The Director of the Department of Social Services or his/her authorized representative has the right to enter the premises of an adult day care applicant or licensee at any time during the center's hours of operation, to determine compliance with licensing provisions. Entry must also be granted for investigative purposes involving complaints regarding a program's operation. The Division of Aging makes at least two inspections per year, at least one of which is unannounced to the operator or provider. The Division may make other inspections, announced or unannounced, as it deems necessary.

Required and Optional Services

All adult day care and adult day health programs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

Required and Optional Services Adult Day Care   Adult Day Health Care  
  Required     Optional     Required     Optional  
ADL Assistance X   X  
Health Education and Counseling   X X  
Health Monitoring X   X  
Medication Administration   X X  
Nursing Services   X X  
Physical Therapy, Occupational Therapy, or Speech Therapy     X X  
Skilled Nursing Services   X X  
Social Services     X  
Transportation   X X  

Medication Provisions

Participants who are responsible for taking their own medication at home must be permitted and encouraged to continue to be responsible for taking their own medication during the hours spent in the adult day care center. If a participant is unable to self-administer medication, then the adult day care provider may assume responsibility. The licensed nurse is the only individual authorized to control and manage the medication and drug program. The licensed nurse must be responsible for the administration of medications and treatments.

Staffing Requirements

Type of Staff. The adult day care program must have a director who is responsible for the program's day-to-day operation. Either the program director or the program director's designee must be present and in charge during all hours that participants are on the premises. Paid direct care staff and any volunteer staff must be qualified by education, training, and experience to perform the duties in the written job description.

Staffing Ratios. The adult day care provider must have a sufficient number of direct care staff on duty at all times to meet the needs of each participant and ensure that participants are never left unattended. At a minimum, there must be at least two direct care staff persons when 2-16 participants are present and one additional direct care staff person for any eight, or part thereof, additional participants.

The director cannot be counted to meet the required staff ratio if there are nine or more participants present unless he or she is providing direct care to participants. Trained volunteers at least 18 years of age may be counted in the direct care staff-to-participant ratio only if a volunteer program description--including the volunteer training to be provided and the system for ensuring the presence of volunteer help as scheduled--has been submitted to and approved by the Division of Aging.

Secretaries, cooks, accountants and other non-direct care staff members must not be considered in calculating the staff-to-participant ratio. If an adult day care program is located in a long-term care or medical care facility, direct care staff cannot be counted simultaneously to meet the required staffing ratios for both the facility and the associated adult day care program.

Training Requirements

All staff, including non-direct care, direct care, and volunteers, must be given a general orientation to the program, its policies, and its fire, safety, and emergency procedures, prior to performing job responsibilities. The orientation must be sufficient in depth to enable staff to perform their assigned job responsibilities and to meet participants' individual needs.

In-service training must be provided at least quarterly to staff, as appropriate to their job function and participants' care needs. At a minimum, in-service training must address participants' care needs, both general and individualized; participants' rights; program policies; and specialized care needs, such as those related to dementia.

For employees providing care to persons with Alzheimer's disease or other dementias, the training must include the following topics: an overview of Alzheimer's disease and dementia, communicating with persons who have dementia, behavior management, promoting independence in activities of daily living, and understanding and dealing with family issues.

Location of Licensing, Certification, or Other Requirements

Missouri Code of State Regulations, Chapter 90: Adult Day Care Program Licensure. Rules of Department of Health and Senior Services. [February 28, 2005]http://www.sos.mo.gov/adrules/csr/current/19csr/19c30-90.pdf

Missouri Medicaid Aged and Disabled Waiver Provider Manual. Missouri Department of Social Services. [October 23, 2013]http://manuals.momed.com/manuals/hyperlinkPage.render?idLinkParmName=age

Missouri Revised Statutes, Chapter 660, Sections 400-420: Exceptions to Licensure Requirements for Adult Day Care Centers. Department of Social Services. [August 28, 2013]http://www.moga.mo.gov/statutes/C600-699/6600000405.HTM

Information Sources

Becky ThompsonHealth Program RepSection for Long-Term Care

Erin BarrowMedicaid SpecialistMissouri Medicaid Audit and ComplianceProvider Contracts

MONTANA

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-montana

Overview

Montana statutes require adult day care (ADC) licensure through the Department of Public Health and Human Services, Quality Assurance Division Licensure Bureau. All providers of ADC are licensed whether they serve only private pay participants or are reimbursed through Medicaid. No other publicly-funded programs pay for ADC.

The Department provides ADC, called adult day health (ADH), under the Medicaid 1915(b)/(c) Montana Big Sky Waiver program for Elderly and Physically Disabled Persons and also under the 1915(c) waiver for Adults with Severe Disabling Mental Illness. The ADH standards are based on the same licensure requirements as ADC in accordance with the administrative rules of Montana.

Adult day health services (ADHS) may only be furnished by a provider enrolled with the Department of Public Health and Human Services as a Medicaid provider or, in rare instances, by a provider with whom the Department is contracting for home and community-based case management services.

Definitions

Adult day care center means a facility, freestanding or connected to another health care facility, thatprovides adults, on a regularly scheduled basis, with the care necessary to meet the needs of daily living.

If an ADC center is operated on the premises of another licensed health care facility: the other facility may provide to ADC participants any of the services for which the other facility is licensed, subject to the limitation that overnight service to a participant may be provided for no more than 7 successive nights. An ADC center that is not operated on the premises of another licensed health care facility may not provide overnight service.

Adult day health provides a broad range of health, nutritional, recreational, and social services needed to ensure the optimal functioning of the participant. ADH does not include residential overnight services.

Parameters for Who Can Be Served

Providers may serve frail, impaired elderly,or other disabled adults.

Inspection and Monitoring

After receipt of an application for a new license, the Department conducts an initial inspection within 45 days. After receipt of an application for renewal of a license, the Department inspects the facility without prior notice to the operator or staff.

Routine licensure surveys are conducted every 1-3 years and are unannounced. The duration of a license is dependent on the number and type of deficiencies found during inspection. If any deficiencies relate to the health, safety, and welfare of a participant, a provisional license or a 1-year license is issued.

In addition to its annual licensure inspections, the Department may inspect any facility for compliance without prior notice to the owner or staff of the facility.

Some ADC centers are located in nursing homes. In this case, the nursing home monitors the center in cooperation with the Department.

Required and Optional Services

All ADC programs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs.

The table below lists additional required and optional services. Except for assistance with activities of daily living and transportation services, the state's administrative rules do not specify required or optional services for either ADC or ADHS. Services are provided as authorized in a participant's individual care plan.

Required and Optional Services Adult Day Care
  Required     Optional  
ADL Assistance X  
Health Education and Counseling    
Health Monitoring/Health-Related Services    
Medication Administration    
Nursing Services    
Physical Therapy, Occupational Therapy, or Speech Therapy      
Skilled Nursing Services    
Social Services    
Transportation X1  
  1. Transportation between the participant's place of residence and the ADC center is provided only as a component of ADHS and the cost is included in the rate paid to Medicaid providers.

Medication Provisions

If a participant is required to take medication while at an ADC center, the participant must be capable of taking his or her own medications, with the following assistance from staff: (1) reminding the participant to take the medication at the proper time; (2) removing medication containers from storage; (3) assisting with removal of a cap; (4) guiding the hand of the participant; and (5) observing that the participant takes the medication.

Staffing Requirements

Type of Staff. Each ADC center must employ a manager who is at all times responsible for the center and must oversee the center's day-to-day operation, including, but not limited to: (1) the provision of services to participants; (2) record-keeping; and (3) employing, training, and/or supervising employees. The owner of an ADC center who meets the necessary qualifications listed in the relevant rule may serve as the manager. At least one employee must be present in the center at all times when a participant is present.

Staffing Ratios. The center must at all times employ sufficient staff to provide the services required by the number and characteristics of its participants.

Training Requirements

Orientation must include: (1) an overview of the ADC center's policies and procedures manual and a presentation regarding how the policies and procedures are to be used and implemented; (2) a review of the employee's job description; (3) a review of services provided by the facility; (4) simulated fire prevention, evacuation, and disaster drills; (5) basic techniques of identifying and correcting potential safety hazards in the facility; and (6) emergency procedures, such as basic first-aid.

Location of Licensing, Certification, or Other Requirements

Montana Code Annotated, Title 50, Health and Safety, Chapter 5: Hospitals and Related Facilities, Part 1: General Provisions. [2005]http://www.hpm.umn.edu/NHRegsPlus/NHRegs_by_State/Montana/Montana%20Chapter%205.pdf?page=getobject&objectname=mcl-368-1978-17&highlight

Montana Code Annotated, Title 50, Health and Safety, Chapter 5: Hospitals and Related Facilities, Part 2: Licensing. [2005]http://www.hpm.umn.edu/nhregsplus/NHRegs_by_State/Montana/montana_chapter_5_hrf_part_2.pdf?page=getobject&objectname=mcl-368-1978-17&highlight

Administrative Rules of Montana, Chapter 37.106.26: Health Care Facilities, Adult Day Care. Department of Public Health and Human Services. [December 23, 1994]http://www.mtrules.org/gateway/Subchapterhome.asp?scn=37.106.26

Administrative Rules of Montana, Chapter 37.40.1407: Home and Community-Based Services for Elderly and Physically Disabled Persons, General Requirements. Department of Public Health and Human Services. [August 26, 2011]http://www.mtrules.org/gateway/ruleno.asp?RN=37.40.1407

Administrative Rules of Montana, Chapter 37.40.1445: Home and Community-Based Services for Elderly and Physically Disabled Persons, Adult Day Health. Department of Public Health and Human Services. [July 28, 2000]http://www.mtrules.org/gateway/RuleNo.asp?RN=37.40.1445

Administrative Rules of Montana, Chapter 37.90.430: Home and Community-Based Services Waiver for Adults with Severe Disabling Mental Illness, Adult Day Health Requirements. Department of Public Health and Human Services. [October 27, 2006]http://www.mtrules.org/gateway/RuleNo.asp?RN=37.90.430

Information Sources

Shelly HoovestalDirector of Special ServicesSt. John's Lutheran Ministries

Robin HomanProgram Manager, Home and Community-Based ServicesSenior and Long Term Care DivisionMontana Department of Public Health and Human Services

NEBRASKA

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-nebraska

Overview

The Nebraska Department of Health and Human Services (DHHS) requires licensure for any person or legal entity that provides adult day services (ADS) to four or more individuals.24 ADS are called adult day health care (ADHC) when covered by Medicaid. Both ADS and ADHC are medical models of care. Adult day care (ADC) is a social model of care. Whether furnishing a social or medical model of care, all providers must be licensed.

ADS may be delivered outside the home in either of the following settings: (1) a freestanding facility--an ADS license is required when four or more persons are receiving ADS in a location that is not licensed as another type of health care facility; or (2) a licensed facility--a separate ADS license is required when a licensed facility provides ADS to four or more persons who do not reside at the licensed facility. The ADS program in a licensed facility must have separate, identifiable space available for ADS activities during the hours that ADS are provided.

If a licensed health care facility provides ADS exclusively to individuals residing in that health care facility, it does not require an ADS license. In lieu of licensure, DHHS may accept accreditation or certification by a recognized independent accreditation body or public agency with standards that are at least as stringent as Nebraska's, as evidence that the health care facility complies with the relevant rules, regulations, and standards.

No public funding is available for ADS; participants or their families pay privately. ADHC is covered under the Medicaid 1915(c) waiver for Aged Persons or Adults and Children with Disabilities. In addition to licensure, ADHC providers must meet Medicaid contracting requirements. ADHC providers serving fewer than four persons do not require a license, but must have a provider agreement with the DHHS if they serve Medicaid waiver participants.

The state's social model of care--adult day care--can be reimbursed through Title XX funds. In addition to meeting licensure requirements, ADC providers have to meet requirements specified in the Social Services for Aged and Disabled Adults chapters of the state's administrative rules. These requirements are not described in this profile but links to the relevant rules are provided at the end.

Definitions

Adult day services means the provision of care and an array of social, medical, or other support services for a period of less than 24 consecutive hours, in a community-based program, to four or more participants who need services because of age or functional impairment.

Care is defined as the exercise of concern or responsibility for the comfort, welfare, and habilitation of participants, including the provision of a minimum amount of supervision and assistance with personal care, activities of daily living (ADLs), health maintenance activities, and other supportive services. ADLs are transfers, ambulation, exercise, toileting, self-administered medication, and similar activities.

Medical services are those that address the health concerns and/or needs of participants, including complex interventions within the scope of practice of the health care practitioner.

Social services are those activities that assist participants in carrying out their therapeutic activities as outlined in their participant agreement.

Support services are those that support personal care, provision of medications, ADLs, and health maintenance activities.

Adult day health care is a service that allows for structured social, habilitation25 and health activities. It may: (1) alleviate the deteriorating effects of isolation; (2) aid in transition from one living arrangement to another; (3) provide a supervised environment while the regular caregiver is working or otherwise unavailable; and/or (4) provide a setting for the receipt of multiple health services in a coordinated manner. ADHC is provided outside of the participant's place of residence for a period of 4 or more hours daily, but less than 24 hours. The need for this service must be reflected in one or more assessment areas of the participant's plan of services and supports.

Adult day care includes structured and monitored social, manual, physical, and intellectual services/activities provided for a minimum of 3 hours per day. These services are provided in a supervised, ambulatory setting (wheelchairs are permitted)--either a day services home or a center--outside an individual's own home. ADC also includes in-home supervision to allow caregiver participation in employment and training.

ADC is for adults who do not require 24-hour institutional care and yet, because of a physical or mental impairment (or because of social isolation), require services in a group setting to: (1) achieve or maintain self-sufficiency; (2) prevent or remedy neglect, abuse, or exploitation; and (3) prevent or reduce inappropriate institutional care.

Parameters for Who Can Be Served

Adult Day Services. No parameters are specified. ADS providers must have written admission criteria, which include the participant population served (age groups and other relevant characteristics), each level of care and the components of care and services provided, and must ensure that the decision to admit a participant is based upon the provider's capability to meet the participant's identified needs. The ADS program must also have written criteria for participant discharge and must ensure that the discharge decision is based upon its discharge criteria.

Adult Day Health Care. In addition to the provisions above, Medicaid waiver program participants must be assessed by a services coordinator and have care needs that can be met through waiver program services at a cost that does not exceed the average Medicaid monthly expenditure for care in a nursing facility.

Adult day care is authorized only for individuals 19 years or older who are current SSI or State Supplement recipients or low-income aged or disabled persons.

Inspection and Monitoring

To determine compliance with operational, care, services, and physical plant standards, DHHS inspects ADS and ADHC sites prior to and following licensure. DHHS determines compliance through on-site inspections, review of schematic and construction plans, and reports of qualified inspectors. DHHS may conduct an on-site inspection any time it deems necessary. Each year, DHHS may conduct an inspection of up to 25 percent of providers based on a random sample. In addition, DHHS will conduct focused inspections in response to complaints and incidents, or when 5 years have passed without an inspection.

Required and Optional Services

All ADS and ADHC programs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

Required and Optional Services Adult Day Services   Adult Day Health Care  
  Required     Optional     Required     Optional  
ADL Assistance X   X  
Health Education and Counseling     X  
Health Monitoring/Health-Related Services X   X  
Medication Administration X   X  
Nursing Services   X X  
Physical Therapy, Occupational Therapy, or Speech Therapy          
Skilled Nursing Services   X X  
Social Services X   X  
Transportation        

Medication Provisions

The ADS program must establish and implement policies and procedures to ensure that participants receive medications only as legally prescribed by a medical practitioner; and must ensure that medication aides and other unlicensed persons who provide medications are trained and have successfully passed a competency assessment as specified in the relevant rules. Documentation of successful course completion may be met by a signed statement from the licensed health care professional who provided or directed the competency assessment.

Medication administration means providing medications for another person according to the five rights (the right drug to the right recipient in the right dosage by the right route at the right time). Medication provision means giving or applying a dose of medication to an individual and includes helping an individual in giving or applying the medication to himself or herself. When the ADS program is not responsible for medication administration or provision, the program must maintain responsibility for the overall supervision, safety, and welfare of the participants.

Participants may be allowed to self-administer medications, with or without visual supervision, when the ADS program determines that the participant is competent and capable of doing so and has the capacity to make an informed decision about taking medications in a safe manner.

Staffing Requirements

Adult Day Services

Type of Staff. The administrator is responsible for planning, organizing, and directing the day-to-day operation of the ADS program. The administrator must be on the premises a sufficient number of hours to ensure adequate attention to the program's management and designate a responsible and accountable substitute to act in his or her absence. At least one staff person must be on-site at all times when participants are present.

Staffing Ratios. No requirements for staffing ratios are specified but the ADS program must ensure that staffing resources and training are sufficient to meet the level of supervision and assistance that participants need with ADLs, personal care, and health maintenance activities as defined in their services agreement.

Adult Day Health Care

Type of Staff. The provider must have a licensed nurse on staff, or contract with a licensed nurse, who will provide the health assessment/nursing services component of the ADHC program and supervise ADLs/personal care and ADL training. Counseling may be provided only by a certified social worker, a certified master social worker, or a certified professional counselor. Direct care staff members must have training or 1 or more years' experience in working with adults in a health care/social services setting, and have knowledge of cardiovascular pulmonary resuscitation and first-aid. Each ADHC center must be staffed at all times by at least one full-time trained staff person.

Staffing Ratios. The ADHC center shall maintain a ratio of direct care staff member to participants sufficient to ensure that participants' needs are met.

Training Requirements

Adult Day Services. The ADS program must provide each direct care staff person with orientation to the program before they have direct responsibility for care and services to participants. The training must include, but is not limited to: (1) job duties and responsibilities; (2) infection control practices; (3) information on any physical and mental special care needs of the ADS program participants; and (4) disaster preparedness plans.

The ADS program must provide and maintain evidence of ongoing/continuous in-services or continuing education for staff. Training must include, but is not limited to: (1) infection control practices; (2) the facility's emergency procedures and information regarding advance directives; (3) information on abuse, neglect, and misappropriation of money or property of a participant, and reporting procedures; (4) disaster preparedness plans; (5) participant rights; and (6) other topics determined by the program.

Adult Day Health Care. Training requirements are the same as for ADS above. No additional training requirements are specified for ADHC programs.

Location of Licensing, Certification, or Other Requirements

Nebraska Administrative Code. Title 175, Health Care Facilities and Services Licensure, Chapter 5: Adult Day Services. Nebraska Department of Health and Human Services. [June 16, 2008]http://www.sos.ne.gov/rules-and-regs/regsearch/Rules/Health_and_Human_Services_System/Title-175/Chapter-05.pdf

Nebraska Administrative Code, Title 172, Professional and Occupational Licensure, Chapter 95: Administration of Medications by Medication Aides and Medication Staff. Nebraska Department of Health and Human Services. [May 6, 2008]http://www.sos.ne.gov/rules-and-regs/regsearch/Rules/Health_and_Human_Services_System/Title-172/Chapter-095.pdf

Nebraska Administrative Code, Title 172, Professional and Occupational Licensure, Chapter 96: Medication Aide Registry. Nebraska Department of Health and Human Services. [May 6, 2008]http://www.sos.ne.gov/rules-and-regs/regsearch/Rules/Health_and_Human_Services_System/Title-172/Chapter-096.pdf

Nebraska Administrative Code, Title 473, Social Services for Aged and Disabled Adults, Chapter 3: Services Providers. Nebraska Department of Social Services Program Manual. [February 26, 2013]http://www.sos.ne.gov/rules-and-regs/regsearch/Rules/Health_and_Human_Services_System/Title-473/Chapter-3.pdf

Nebraska Administrative Code, Title 473, Social Services for Aged and Disabled Adults, Chapter: 5.002, Adult Day Services. Nebraska Department of Health and Human Services. [February 26, 2013]http://www.sos.ne.gov/rules-and-regs/regsearch/Rules/Health_and_Human_Services_System/Title-473/Chapter-5.pdf

Nebraska Administrative Code, Title 480, Home and Community-Based Waiver Services for Aged Persons or Adults or Children with Disabilities, Chapter 5-005: Waiver Services, Adult Day Health Care. Nebraska Department of Health and Human Services. [June 8, 1998]http://www.sos.ne.gov/rules-and-regs/regsearch/Rules/Health_and_Human_Services_System/Title-480/Chapter-05.pdf

Nebraska Department of Health and Human Services, official website: Adult Day Services, Licensing requirements. [last updated December 6, 2013]http://dhhs.ne.gov/publichealth/Pages/crl_adultday_adultday.aspx#description

Information Sources

Jeanette DensonAdministratorCuster Care Adult Day Services     andPresidentNebraska Adult Day Services Association

NEVADA

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-nevada

Overview

All facilities offering adult day care (ADC)--a social model--or adult day health care (ADHC) must be licensed by the Bureau of Health Care Quality and Compliance in the Nevada Department of Health and Human Services. Before a license is issued, applicants must receive training to recognize and prevent the abuse of older persons. If an applicant has completed such training within the year preceding the date of the license application and the application includes evidence of the training, the applicant shall be deemed to have complied with the requirement.

Nevada provides ADC under a Medicaid 1915(c) Frail Elderly Waiver program and under the Community Options for the Elderly (COPE) program--a non-Medicaid program. The state also provides ADHC under a 1915(i) Medicaid State Plan Home and Community-Based Services program.

All Medicaid providers must be licensed, and 1915(i) State Plan providers must also be certified by the Nevada Department of Health Care Financing and Policy (DHCFP). Waiver program providers have additional requirements outlined in the waiver manual.

The Department of Human Resources Division for Aging Services also funds ADC through grants to licensed providers who, in addition to licensure, must also comply with additional service specifications. This profile contains licensing requirements, grant program requirements, and Medicaid 1915(i) State Plan certification standards.

Definitions

Licensing

Facilities for the care of adults during the day means an establishment operated and maintained to provide care during the day on a temporary or permanent basis for aged or infirm persons. The term does not include a halfway house for recovering alcohol and drug abusers.

Grant Program

Adult day care/social model is the provision of personal care for adults in a supervised, protective, congregate setting during some portion of a 24-hour day. Services typically include social and recreational activities, counseling, nutrition, memory retention activities, music therapy, pet therapy, and arts and crafts.

Medicaid 1915(i) State Plan

Adult Day Health Care. The goals of ADHC services are to: (1) safeguard participants' safety and well-being and maintain and/or enhance their quality of life; and (2) improve and maintain participants' level of functioning or lessen any decline in functioning due to disease and/or the aging process.

ADHC facilities provide medical services on a regularly scheduled basis as specified in a participant's care plan. Services must be provided in a non-institutional community-based setting, encompassing both health and social services needed to ensure participants' optimal functioning. The inclusion of "health" in a day care setting should indicate that elements of health care are provided and that it is not just a socialization model for seniors.

Parameters for Who Can Be Served

Licensing. None identified.

Grant Program. Providers may not serve participants who are bedridden, unmanageable, have a contagious disease, or who lack the stamina needed to attend the program for 5 hours per day. Persons who are HIV positive or have AIDS are not considered contagious.

Medicaid 1915(i) State Plan. Providers may serve individuals age 18 or older who meet the criteria for placement in a nursing facility and are in need of the medical and social services provided by ADHC.

Medicaid 1915(c) Waiver Program. An individual must meet the eligibility criteria for a nursing home level of care.

COPE Program. The program is intended to assist seniors who are in need of the level of care typically provided in a nursing home, which generally means they are unable to bathe, use a toilet, or feed themselves without assistance.

Inspection and Monitoring

Licensing. Licensed facilities may be entered and inspected at any time to ensure compliance with--or to prevent a violation of--licensing requirements. Licenses are issued for 1 year and must be renewed annually. An annual unscheduled survey is conducted after initial licensure.

Medicaid 1915(i) State Plan. As part of the contracting process, DHCFP staff conduct an on-site review of the ADHC facility to determine whether certification requirements are met. Subsequent to the initial review, DHCFP may schedule an on-site review at any given time (at least annually), without cause, to ensure that the facility maintains compliance with Medicaid requirements.

DHCFP staff also conduct an annual review to ensure participants' health and welfare. Additionally, a review of providers is conducted annually to verify that they continue to meet licensure requirements and to ensure that claims are paid in accordance with the State Plan and all federal and state regulations.

Grant Program. No provisions identified.

Required and Optional Services

All ADC and ADHC programs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

Required and Optional Services Adult Day Care 1915(i) State Plan  Adult Day Health Care  
  Required     Optional     Required1     Optional  
ADL Assistance X   X  
Health Education and Counseling     X  
Health Monitoring X   X  
Medication Administration   X X  
Nursing Services     X  
Physical Therapy, Occupational Therapy, or Speech Therapy     X X  
Skilled Nursing Services        
Social Services   X X  
Transportation       X
  1. Restorative therapy is also a required service.

Medication Provisions

Licensing. Providers must establish procedures for participant self-medication and medication administration by an employee.

Grant Program. Participants in social ADC programs must be able to administer their own medications. If the facility accepts a participant who is unable to self-administer medications, a licensed practical nurse (LPN) may provide this service under the supervision of a contracted registered nurse (RN).

Medicaid 1915(i) State Plan. Medication assistance is provided for participants receiving adult day health services. An RN, or an LPN under the supervision of an RN, will administer participants' medications while they are in the facility's care.

Staffing Requirements

Licensing

Type of Staff. Each facility must have the number and kind of employees required by the facility's physical characteristics, the number of participants, and the services to be provided. The facility director must designate an acting director to act when the director is absent from the facility. At least one employee trained to administer first-aid and cardiovascular pulmonary resuscitation must be on the premises at all times.

Staffing Ratios. No ratios identified. Participants must be supervised by an employee of the facility at all times during the operational hours of the facility.

Grant Program

Type of Staff. None identified.

Staffing Ratios. No ratios identified. Participants must be supervised by a facility employee at all times during the facility's operational hours.

Medicaid 1915(i) State Plan

An ADHC facility must employ persons with the necessary education, skills, and training to provide the required services. Medical services must be provided by Nevada licensed/certified personnel.

Type of Staff. The facility must employ a program director to develop plans and policies for the facility's operation; the recruitment, employment and training of qualified staff; and for the supervision and appropriate disciplinary action of staff.

The facility must employ a registered nurse to oversee and provide medical services ordered by a physician. An RN, or licensed practical nurse under the supervision of an RN, must be on duty during the hours in which a Medicaid-eligible participant is in the facility.

The facility must have direct care staff who observe participants' functioning and provide assistance to participants with activities of daily living.

The facility must also provide for activity staff--or other staff as necessary--to provide the required services and ensure that each participant's needs are met.

Staffing Ratios. None identified.

Training Requirements

Licensing. All employees and volunteers must participate in a program of general orientation to inform them of the facility's programs, policies, and services, and must receive training at the facility on a regular basis for not less than 12 hours per year.

Before a license is issued or renewed, the licensee must receive training in the prevention and recognition of abuse of older persons. An administrator or other person in charge of operations, and all employees who will provide care to participants, must also receive the same training before care is provided to participants, and annually thereafter.

Grant Program. Staff and volunteers must be provided training related to working with adults with disabilities.

Medicaid 1915(i) State Plan. Staff must have the necessary training to provide the Medicaid required services.

Location of Licensing, Certification, or Other Requirements

Medicaid Services Manual, Adult day Health Care. Department of Health Care Financing and Policy. [July 1, 2014]http://dhcfp.nv.gov/MSM/Archives/CH1800/Ch%201800%20Final%205-10-11.pdf

Service Specifications Adult Day Care. State of Nevada Aging and Disability Services Division. [July 2009]http://www.nvaging.net/grants/serv_specs/AdultDaycare7-09.pdf

Nevada Administrative Code Chapter 449. Medical and Other Related Entities. General Provisions. This site includes licensing requirements for many types of medical facilities, including Facilities for Care of Adults During the Day, which provide adult care and adult day health care.https://www.leg.state.nv.us/NRS/NRS-449.html

Information Sources

Michele SmothersBureau of Health Care Quality and ComplianceDepartment of Health and Human ServicesNevada Division of Public and Behavioral Health

NEW HAMPSHIRE

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-new-hampshire

Overview

The Bureau of Health Facilities Administration in New Hampshire's Department of Health and Human Services (DHHS) requires adult day programs (ADPs) serving three or more individuals to be licensed. Licensing requirements apply to all ADPs regardless of funding sources, whether public or private pay. ADPs provide a medical model of care. The state also has a social model of care called adult day non-medical program services. Providers of both models have to meet licensing requirements.

In addition to complying with all licensing rules, an ADP that is physically located in a senior center, nursing home or assisted living residence/supported residential health care facility, must designate at least one room as the licensed ADP to be used exclusively by the participants and staff of that program, and must have a designated medication storage area.

The Medicaid State Plan program and the 1915(c) Choices for Independence Waiver program26 pays for ADP services, which Medicaid calls adult medical day services.27 The Medicaid program is administered by the DHHS Division of Community-Based Care Services, Bureau of Elderly and Adult Services. Adult medical day services are reimbursed only when provided by a licensed ADP that is also enrolled as a New Hampshire Medicaid provider.

Both ADP services and adult day non-medical program services can be reimbursed with funding under the Title XX Social Service Block Grant, and Title III B Supportive Services, under the Older Americans Act. Providers wishing to furnish such services must be licensed and under contract with the Bureau of Elderly and Adult Services. For participants receiving Title III B services, voluntary cost-sharing is encouraged.

The licensing regulations described in this summary apply to all ADPs, both medical and social. Adult day non-medical programs funded by the Title XX Social Service Block Grant and Title III B Supportive Services have some different requirements, which are not described here but can be found at the websites listed at the end of this summary.

Definitions

Adult day program services means a program that provides one or more of the following services, for less than 12 hours a day, to participants age 18 years or older: (1) supervision; (2) assistance with activities of daily living; (3) nursing care; (4) rehabilitation; (5) recreational, social, cognitive and physical stimulation; and (6) nutrition. If services are reimbursed through Title IIIB funds, the participant must be age 60 years or older.

Adult medical day services is the term used by Medicaid for services provided at a facility licensed as an ADP. Services include the same array of social and health care services provided by all ADPs to eligible participants in accordance with an individual care plan for 4 or more hours per day on a regularly scheduled basis, for one or more days per week.

Adult day non-medical program services is the term used for the social model of ADP services reimbursed through Title XX and Title IIIB funds. Services are provided for a portion of the 24-hour day, in a community-based setting, and include a nutritious meal and support of the individual's needs for socialization and activities within a structured environment. If the services are reimbursed through Title IIIB funds, the participant must be age 60 years or older and also receive referrals to other resources and programs as needed.

Parameters for Who Can Be Served

Participants in ADPs are elderly or have a chronic illness or disability. Providers must not admit a participant whose needs exceed the services offered by the ADP. ADP services are not available to anyone who is primarily seeking services to support needs related to a diagnosis of mental illness or developmental disability. Providers may discharge any participant who poses a danger to self or others. The provider must develop a discharge plan with the input of the participant and the guardian or agent, if any.

Inspection and Monitoring

DHHS makes at least one annual unannounced inspection to determine that the licensed premises and all programs and services are in compliance with the provisions of the relevant licensing chapter and the administrative rules.

If an adult day care program has been inspected and is found to be deficiency-free for 2 consecutive years, it may be granted a 1-year waiver and thereafter may be inspected every other year, provided that the facility remains deficiency-free when it is inspected and is not the subject of a founded complaint investigation, and the facility remains under the same administrator who is responsible for its day-to-day operation.

Required and Optional Services

All ADPs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

Required and Optional Services Adult Day Program
  Required     Optional  
ADL Assistance X  
Health Education and Counseling X  
Health Monitoring/Health-Related Services X  
Medication Administration X  
Nursing Services X  
Physical Therapy, Occupational Therapy, or Speech Therapy   X1  
Skilled Nursing Services X  
Social Services X  
Transportation X2  
  1. Required for Medicaid adult medical day services if authorized in a participant's plan of care. These services are not included in the daily rate and are billed to the appropriate first payer (e.g., Medicare).
  2. Required for Medicaid adult medical day services. Transportation is reimbursed by Medicaid at a per-person, per-trip rate in addition to the adult medical day services flat rate.

Medication Provisions

All medications must be administered in accordance with the orders of a licensed practitioner or other professional with prescribing authority. Participants must receive their medications by one of the following methods: (1) self-administration; (2) self-directed administration, which means a participant, who has a physical limitation that prohibits him or her from self-administering, directs personnel to physically assist in the medication process; (3) self-administration with supervision, which means the participant takes his or her own medication after being prompted by personnel but without requiring physical assistance from others; or (4) administration by individuals authorized by law.

Personnel who are not otherwise licensed practitioners, nurses, or medication nursing assistants--and who assist a participant with self-administration with supervision, self-directed administration, or administration of medication through nurse delegation--must complete, at a minimum, a 4-hour medication supervision education program covering both prescription and non-prescription medication. The medication supervision education program must be taught by a licensed nurse, licensed practitioner or pharmacist, or other person who has undergone training by a licensed nurse, licensed practitioner, or pharmacist and must include:

  1. Infection control and proper hand washing techniques.

  2. The "five rights" of medication administration (the right participant, the right medication, the right dose, administered at the right time, and administered through the right route).

  3. Documentation requirements.

  4. General categories of medications such as anti-hypertensives or antibiotics.

  5. Desired effects and potential side effects of medications.

  6. Medication precautions and interactions.

The administrator may accept documentation of required training if it was previously obtained by the applicant for employment at another licensed ADP.

Staffing Requirements

Type of Staff. Each ADP must appoint a full-time administrator who may also hold the position of licensed nurse, if the person is a licensed nurse, or to hold the position of activities coordinator, if the ADP is limited by its license to 6 or fewer participants per day. Social services may be provided by the administrator, licensed nurse, or a social worker. The administrator must designate, in writing, an alternate staff person who will assume the responsibilities of the administrator in his or her absence; and must hire support staff necessary to assist the administrator in maintaining regulatory compliance.

The ADP must provide sufficient numbers of personnel who are present on the premises and are qualified to meet the needs of participants during all hours of operation. When an ADP is in operation, at least one personnel member must be present. This person must be currently certified in adult cardiovascular pulmonary resuscitation equivalent to basic life support, from either the American Red Cross or the American Heart Association.

Adult medical day programs reimbursed by Medicaid must have at least one full-time registered nurse or a licensed practical nurse, or both, available at the program's location whenever one or more participants are present.

Any provider who admits or who has a participant with a diagnosis of dementia or Alzheimer's disease must require all direct care personnel caring for the participant to be trained in the special care needs of participants with dementia or Alzheimer's disease. The provider must also have a physical environment that has a safety and security system that prevents a participant from leaving the premises without the knowledge of staff, if: (1) the participant has wandered from the ADP in the last 60 days; (2) has had a change in wandering behavior as determined by a nursing assessment; or (3) is a danger to self or others.

Staffing Ratios. Minimum staffing ratios, which may be met by both nursing and activities personnel, are as follows: When fewer than eight participants are in attendance, at least one paid personnel member must be present at all times; when there are 8-16 participants in attendance, there must be at least two personnel present at all times, one of which must be a paid personnel member; when there are more than 16 participants in attendance, there must be a minimum of one personnel member for each additional eight participants or part thereof. Notwithstanding these minimum requirements, staffing ratios must be sufficient to meet the needs of all participants at all times.

Training Requirements

All personnel must receive an orientation within the first 3 days of work including: (1) the ADP's policies on patient's rights and responsibilities and complaint procedures; (2) the duties and responsibilities of the position they were hired for; (3) the ADP's policies, procedures and guidelines; (4) the ADP's infection control program; (5) the ADP's fire and emergency plans; and (6) any mandatory reporting requirements.

All personnel must complete annual continuing education, including a review of the ADP's policies and procedures relative to participant rights and complaint procedure, its infection control program, and its education program on fire and emergency procedures.

Location of Licensing, Certification, or Other Requirements

New Hampshire Revised Statutes Annotated (RSA) 151 serves as the legal authority for all adult day programs and licensing and program rules are promulgated in the New Hampshire Code of Administrative Rules Chapter He-P 818. In addition, the Medical Assistance Chapter He-E 800 describes requirements for adult medical day services providers.

State of New Hampshire Revised Statutes Online, Title XI, Hospitals and Sanitaria, Chapter 151: Residential Care and Health Facility Licensing. [2013]http://law.justia.com/codes/new-hampshire/2006/nhtoc-xi/151-2.html

New Hampshire Code of Administrative Rules, Chapter He-P 800: Residential Care and Health Facility Rules (Part He-P 818: Adult Day Programs). Department of Health and Human Services. [March 18, 2008]http://www.gencourt.state.nh.us/rules/state_agencies/he-p800.html

New Hampshire Code of Administrative Rules, Chapter He-E 800: Medical Assistance (Part He-P 801.16 and He-E 803: Adult Medical Day Care Services). Department of Health and Human Services. [October 28, 2011]http://gencourt.state.nh.us/rules/state_agencies/he-e800.html

New Hampshire Code of Administrative Rules, Chapter He-E 500: Social Services. Department of Health and Human Services. [January 12, 2011] These rules apply to services funded by Title IIIB Supportive Services under the Older Americans Act and Title XX Social Service Block Grant.http://www.gencourt.state.nh.us/rules/state_agencies/he-e500.html

Information Sources

Paula Faist, MS, LSWPresidentNew Hampshire Adult Day Services Association     andDirectorSilverthorne Adult Medical Day Center

NEW JERSEY

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-new-jersey

Overview

The New Jersey Department of Health and Senior Services (DHSS) licenses all facilities that provide adult day health services (ADHS), regardless of payment source. The state's administrative code contains both the standards for facility licensure and the Medicaid rules for ADHS, which are described in this profile.

Social adult day care (ADC) centers do not have to be licensed but must meet all local building code requirements. The Department of Human Services Division of Aging Services recommends that providers wishing to furnish ADC review the National Adult Day Services Association's guidelines to learn what services should be included. The principle source of funding for social ADC in New Jersey is through Social Services Block Grants. The Division of Aging Services apportions funding to 21 Area Agencies on Aging, which in turn contract with ADC providers in their county. ADC is also provided under the state's Assistance for Community Caregiving--a non-Medicaid program to support elderly persons who require assistance with activities of daily living (ADLs) and are at risk for nursing home placement.

New Jersey covers ADHS, called medical day care services, under the Medicaid State Plan and under an 1115 waiver program called managed long-term services and supports (MLTSS). MLTSS also covers social ADC when required for at least 5 consecutive hours daily (exclusive of transportation time) up to 5 days per week.

DHSS administers a solely state-funded adult day services program for persons with Alzheimer's disease, dementia, or memory disorders (hereafter, called the Alzheimer's Program). The department enters into letters of agreement with social ADC agencies and licensed ADHS providers, who must comply with the rules for this program, which can be found in the citations at the end of this profile.

Definitions

Adult day health services facility means a facility or a distinct part of a facility licensed to provide preventive, diagnostic, therapeutic, and rehabilitative services under medical supervision to meet the needs of functionally impaired adult participants who are not related to the members of the governing authority by marriage, blood, or adoption. ADHS facilities may not provide services to participants for more than 12 hours a day.

Adult day services (Alzheimer's Program) means a community-based group program designed to meet the needs of functionally or cognitively impaired adults through an individual care plan structured to provide a variety of health, social, and related supportive services in a protective setting during any part of a day, but for less than 24 hours.

Medical day care is a program of medically supervised, health-related services provided in an ambulatory care setting to persons who are non-residents of the facility in which the medical day care program is located, and who, because of their physical and/or mental impairment, need health maintenance and restorative services to support their community living.

Social adult day care emphasizes social and recreational activities in a group setting, and provides some health monitoring. Participants attending social ADC usually do not need medical attention during the day but may need supervision for safety and assistance with ADLs.

Parameters for Who Can Be Served

All participants in ADHS facilities must be age 16 years or older. ADHS providers may serve individuals who need ongoing skilled nursing services and/or physical, occupational, or speech therapy, and assistance with one or more ADLs, but who do not need services 24 hours a day on an inpatient basis in a hospital or nursing facility, except under special circumstances. Persons can be served only if their needs can be satisfactorily met by the ADHS program.

Providers may not admit or retain participants who: (1) are suffering exclusively from substance abuse or misuse; and (2) manifest such a degree of behavioral disorder that they are a danger to themselves or others, or whose behavior may interfere with other participants' health, safety, or well-being.

Inspection and Monitoring

When a written application for licensure is approved and the facility is ready for occupancy, DHSS conducts an on-site survey at its discretion to determine compliance with the rules. Licenses are issued for 1 year or less as determined by the Department. The license, unless suspended or revoked, must be renewed annually on the anniversary date of the issuance of the original license. Facilities are inspected in connection with the annual renewal of the license, although inspections may be more than a year apart due to scheduling delays.

Survey visits may be made to a facility at any time by the Department's authorized representatives. Such visits may include, but not be limited to, a review of all facility documents and participants' records, as well as conferences with participants and staff.

The department or its designee may also conduct periodic surveys of facilities on behalf of the U.S. Department of Health and Human Services or other federal agency for purposes of evaluating compliance with all applicable federal regulations or Medicare and Medicaid certification regulations.

Required and Optional Services

All ADHS programs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

Required and Optional Services Adult Day Health Services
  Required1     Optional2  
ADL Assistance X  
Health Education and Counseling X  
Health Monitoring X  
Medication Administration X  
Nursing Services X  
Physical Therapy, Occupational Therapy, or Speech Therapy     X*
Skilled Nursing Services   X*
Social Services X  
Transportation X  
  1. Pharmaceutical and medical services are also required if they are part of the care plan and ordered by a physician.
  2. Services with an asterisk (*) are required by Medicaid.

Medication Provisions

Medication administration means a procedure in which a prescribed medication is given to a participant by an authorized person in accordance with all laws and rules governing such procedures. The complete procedure of administration includes removing an individual dose from a previously dispensed, properly labeled container (including a unit dose container), verifying it with the prescriber's orders, giving the individual dose to the participant, seeing that the participant takes it, and recording the required information, including the method of administration.

Medications must be accurately administered by properly authorized licensed nursing staff, who must ensure that the right drug is administered to the right person, in the right dose, through the right route of administration, at the right time.

Staffing Requirements

Type of Staff. At a minimum, the facility must have an administrator/director, a registered professional nurse, a social worker, and an activities director. The facility must designate a pharmaceutical consultant, who is not the pharmacy provider and does not have an affiliation with the pharmacy provider, and a physician to serve as the facility's medical consultant. If the food service supervisor is not a dietitian, the administrator must designate a consultant dietitian who will review the dietary services on a regularly scheduled basis, make recommendations, assess the nutritional needs of participants, and provide nutritional counseling.

A full-time administrator/director must be available on the premises of the facility during the hours when participant care services are being provided. An alternate must be designated in writing to act in the absence of the administrator.

The director of nursing services must be a registered professional nurse and must not perform the functions of any other position while functioning as the director of nursing services. The director--or a designated registered professional nurse--must be on duty and available in the facility at all times when the facility is operating and services are being provided.

Additional licensed professional personnel must be present in facilities where the daily attendance exceeds 60 participants. Additional licensed nursing personnel and unlicensed assistive personnel must be provided in accordance with the facility's policies and procedures for determining staffing levels on the basis of an assessment of participants' acuity.

Staffing Ratios. ADHS facilities must provide at least one full-time, or full-time equivalent direct care staff member for every nine participants. Additional staff must be provided as needed based on the daily census and participants' acuity. The facility must have adequate staff capability to provide services and supervision to participants at all times.

The Alzheimer's Program requires a minimum staff-to-participant ratio of 1:5 in programming for participants with dementia.

Training Requirements

The facility must develop and implement a staff orientation plan and a staff training and education plan, including plans for each service, and must designate person(s) responsible for ongoing training. All personnel must receive orientation at the time of employment and at least annual in-service education regarding, at a minimum, emergency plans and procedures, the facility's infection prevention and control services, and elder abuse. The facility must document ongoing in-service training of all staff.

Alzheimer's Program providers must provide an orientation to new staff within 30 days of employment, which, in addition to covering their job responsibilities, includes: (1) methods of dealing with the specific problems encountered in the care of people with Alzheimer's disease, such as communicating with participants, necessary safety measures, and common behavior concerns; and (2) an overview of the progression of dementia and the different types of dementia. Staff must also regularly attend specialized training through, for example, associations or universities, in order to have the most current information about people with Alzheimer's disease and other dementias.

Location of Licensing, Certification, or Other Requirements

New Jersey Administrative Code, Chapters 8:43E and 8:43F: General Licensure Procedures and Standards for Licensure of Adult and Pediatric Day Health Services Facilities. New Jersey Department of Health and Senior Services. [2011, 2012]http://www.nj.gov/health/healthfacilities/documents/ltc/njac8-43f_2006_8-43e.pdf

New Jersey Administrative Code, Chapter 86: Adult Day Health Services. New Jersey Department of Health and Senior Services. [March 15, 2010]http://njlmn2.rutgers.edu/sites/default/files/private/NJAC-8-86-AdultDayHealthServices.pdf

New Jersey Administrative Code, Title 8, Chapter 92: Adult Day Services Program for Persons with Alzheimer's Disease or Related Disorders. New Jersey Department of Health and Senior Services. [July 7, 2014]This document has no URL. A google search for N.J.A.C 8:92 State of New Jersey will bring up a site from which the document can be downloaded as a Word document.

New Jersey Department of Human Services, Division of Aging Services website: Social Adult Day Care Services.http://www.nj.gov/humanservices/doas/home/sadcfact.html

Adult Day Social Program in New Jersey: Frequently Asked Questions.http://www.nj.gov/humanservices/doas/documents/asdc_faq.pdf

Information Sources

Theresa EdelsteinRegulatory ConsultantLeading Age New Jersey

Nancy DayNew Jersey Department of Human Services

Margaret Vilardo McLeanOffice of Community OptionsNew Jersey Department of Human Services

NEW MEXICO

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-new-mexico

Overview

The state has two models of adult day services (ADS)--adult day care (social model) and adult day health care (medical model). The New Mexico Department of Health (DOH) licenses two types of adult day care (ADC) facilities: ADC centers and ADC homes.

Adult day health care (ADHC) is provided under the Community Benefit section of the New Mexico Centennial Care Program, an 1115 Research and Demonstration waiver program that replaced the state's Medicaid program on January 1, 2014. Medicaid services are provided by four managed care organizations (MCOs). In addition to DOH licensure as an ADC facility, Community Benefit ADHC providers must meet the minimum, applicable qualifications set forth by the Human Services Department/Medical Assistance Division, and must be certified as a Medicaid provider prior to contracting with a Centennial Care MCO .

Because of the recent implementation of the state's new Medicaid program, information about Medicaid's minimum applicable qualifications for ADHC providers was not yet available online or from staff at the Human Services Department/Medical Assistance Division. The requirements described in this profile are based on the licensing regulations and standards.

Definitions

Adult day care center means a licensed facility where care, services, and supervision are provided to three or more adults who, because of diminished mental or physical capacity, find it difficult to care for themselves in their own residence during the day. An ADC center may be located in any building that meets the applicable state and local building and safety codes.

Adult day care home means a private licensed residence where care, services, and supervision are provided to at least three but not more than five adults who, because of diminished mental or physical capacity, find it difficult to care for themselves in their own residence during the day.

Adult day health care services provide structured therapeutic, social, and rehabilitative services designed to meet the specific needs and interests of Medicaid Community Benefit participants as determined by an individual care plan. The services are generally provided for 2 or more hours per day on a regularly scheduled basis, for 1 or more days per week, by a licensed ADC, community-based facility that offers health and social services to assist participants to achieve optimal functioning.

Parameters for Who Can Be Served

Participants may have diminished mental or physical capacity that makes it difficult to care for themselves in their own residence during the day, but they must be able to ambulate on their own or use a wheelchair with minimal assistance. No provisions for discharge are specified other than that each facility must have written rules pertaining to participants' admission and discharge. Facilities that are able to appropriately mainstream special needs adults may do so at their own discretion. An adult with a severe diagnosed mental or physical handicap may be admitted to a facility upon the written recommendation of a licensed physician or therapist.

Inspection and Monitoring

An annual license is issued for a 1-year period to a facility that has met all regulatory requirements, which is determined in part by an initial survey of the proposed licensee. A survey is conducted at least once annually by licensing authority personnel. Additional surveys or visits may be made to assist the facility with technical advice, to check on progress in correction of identified violations, or to investigate complaints.

Required and Optional Services

All ADS programs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services for ADHC.

Licensing requirements for ADC providers do not specify required or optional services. They state only that ADC activities must be designed to meet participants' specific needs and interests as determined by individual care plans.

Required and Optional Services Adult Day Health Care
  Required     Optional  
ADL Assistance   X
Health Education and Counseling    
Health Monitoring/Health-Related Services    
Medication Administration   X1
Nursing Services   X2
Physical Therapy, Occupational Therapy, or Speech Therapy     X2
Skilled Nursing Services   X2
Social Services   X
Transportation   X3
  1. The rules only provide for supervision of self-administered medication.
  2. Private duty nursing services and skilled maintenance therapies (physical, occupational and speech) may be provided in conjunction with ADC health services by the ADHC provider or by another provider. Private duty nursing and therapy services must be provided by licensed nurses and therapists in a private setting at the facility.
  3. Transportation to and from the adult day health (ADH) center must be coordinated by the ADH program.

Medication Provisions

The rules only provide for supervision of self-administered medication. Any licensed facility with staff who supervise self-administration of medication by participants or safeguard medications must have an appropriate custodial drug permit as determined by the state board of pharmacy. Only medications that can be self-administered by the participant can be kept by a facility, unless they will be administered by a licensed physician, dentist, or nurse.

Staffing Requirements

Type of Staff. The ADC center must have a full-time program director with the authority and responsibility for the management of activities and the direction of staff to ensure that activities and services are provided appropriately and in accordance with established policies. At all times there must be one staff member on duty who has a current first-aid certificate and has completed an approved cardiovascular pulmonary resuscitation (CPR) course. When volunteers are used in an ADC program, the volunteer must be provided with a written description of his or her duties and responsibilities prior to placement.

Staffing ratios for ADC centers and ADC homes are the same: one full-time equivalent staff position with responsibility for direct participant care is required for each five participants. Participants must never be left unattended. Staff members must be physically present with the participants at all times.

The responsibility of staff members included in the staff-to-participant ratio must be direct care of the participants. The licensing authority may require higher staff-to-participant ratios and staff qualifications to properly care for adults with special needs, if deemed necessary. (The term "special needs" is not defined.)

Training Requirements

Before each staff member begins work, all ADC providers must furnish orientation that includes the following at a minimum: (1) scope of services, activities, and programs offered by the facility; (2) emergency first-aid procedures, recognition of illness, and indicators of abuse; (3) fire prevention measures and emergency evacuation plans; (4) review of licensing regulations; (5) special problems of the elderly and disabled; (6) participant rights; and (7) sanitation procedures. All facilities are strongly encouraged to send all of their personnel to an approved CPR course. (The term "strongly encouraged" is not defined.)

Volunteers must take part in a formal or informal orientation and training session to inform them of the program's goals; the program's operation and daily schedule; specific needs of the adults being served; and any necessary, specialized approaches the volunteer will be expected to use.

Additional training requirements include the following:

Adult Day Care Centers. All staff members, including the director, must participate in at least 40 documented hours of training during each year of employment. Twenty of the 40 hours must be in areas covering the physical, emotional, intellectual, and social needs of adults. Other training may include, but is not limited to, nutrition, sanitation procedures, first-aid, and CPR techniques.

Adult Day Care Homes. All staff members must participate in at least 24 documented hours of training during each year of licensure. The required training must be in the subjects specified for ADC centers.

Training may be provided by a staff member whose qualifications are approved by the licensing authority, or obtained from, but not limited to, the following resources: (1) Public Health Division, DOH; (2) Social Services Division, Department of Human Services; (3) ADC associations and information and referral services; (4) university-related programs; or (5) vocational/technical schools.

Location of Licensing, Certification, or Other Requirements

New Mexico Administrative Code. Title 7, Chapter 13: Adult Day Care, Part 2-Requirements for Adult Day Care Facilities. Licensing and Certification Bureau, Public Health Division, New Mexico Department of Health. [October 31, 2001]http://www.nmcpr.state.nm.us/nmac/parts/title07/07.013.0002.pdf

New Mexico Administrative Code. Title 8, Chapter 308: Managed Care Program, Part 12-Community Benefit. New Mexico Human Services Department [January 1, 20/14]http://www.nmcpr.state.nm.us/nmac/parts/title08/08.308.0012.htm

Medical Assistance Division Managed Care Policy Manual. New Mexico Human Services Department. [January 1, 2014]http://www.hsd.state.nm.us/providers/managed-care-policy-manual.aspx

Information Sources

Jonni Lu PoolSpecial Projects Manager and Public Records CustodianOffice of the SecretaryNew Mexico Human Services Department

NEW YORK

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-new-york

Overview

New York has two types of adult day services (ADS) programs: social adult day services (SADS), which is neither licensed nor certified, and adult day health care (ADHC), which must be approved by the New York State Department of Health (DOH) through New York's Certificate of Need Process. ADHC providers must comply with state rules and regulations governing this service.

Medicaid requires that providers meet applicable state requirements. SADS providers serving Medicaid waiver participants and Medicaid managed long-term care (MLTC) participants must meet New York State Office for the Aging requirements. Current regulations prohibit facilities from operating ADHC programs and SADS programs in the same physical space during the same time period.

Medicaid covers ADHC under the State Plan and SADS under the 1915(c) Long-Term Home Health Care Waiver program. Both types of ADS programs are covered under the state's Medicaid MLTC program. MLTC plans have a contract with the state, which outlines expectations for the managed care plan and the providers with whom the MLTC contracts. Per their contract, MLTC plans are expected to credential the providers they use to furnish covered services.

Most social models operate with multiple diverse funding sources, including: (1) funds from the New York State Office for the Aging and local Area Agencies on Aging (AAAs); (2) contracts with agencies such as the Department of Veterans Affairs and the New York State Office of Mental Health; (3) private pay fees; and (4) grants. Depending on the demographics of a particular geographic area, some programs serve predominantly private pay participants and others primarily Medicaid participants enrolled in Medicaid MLTC programs.

SADS may be provided as a standalone service or in an adult care facility. When provided in the latter, they are called day programs. The term adult care facility includes adult homes, residences for adults, and enriched housing programs. Day programs provided in an adult care facility can only serve individuals who do not reside in the facility.

All ADHC programs are operated by nursing homes under their operating certificate, although they are not necessarily located at the nursing home.28 For a nursing home to operate an ADHC program, approval must be obtained through the Certificate of Need process, which includes an analysis of the entity's financial viability, adherence to strict environmental standards, and a character and competence review. DOH regulates and oversees ADHC programs, and requires all adult day health providers to adhere to the same standards for all the individuals they serve irrespective of funding sources.

New York's ADHC model is highly regulated and has high operational expenses because of state requirements for professional staff and the need to comply with health care facility environmental standards. The state imposed a moratorium on ADHC expansion for more than a dozen years beginning in 1998. Currently, the need for ADHC has been met in many of New York's 62 counties. If a provider wishes to open an ADHC program, it would only be allowed in a county with unmet need, and the provider would be required by DOH to demonstrate the need for their services in the community.

Definitions

Social adult day service programs provide services to groups of functionally impaired individuals in a protective congregate setting during any part of the day, but for less than a 24-hour period. Functional limitations may be caused by either physical or cognitive impairments. The four core services are: socialization/therapeutic recreation, supervision and monitoring, personal care/assistance with activities of daily living (ADLs), and nutrition. Additional services may include, but are not limited to, maintenance and enhancement of daily living skills, transportation, caregiver assistance, and case coordination and assistance. Services are provided in accordance with an individualized care plan.

Adult day health care is a community-based long-term care program that provides comprehensive health care services in a congregate day setting. Programs provide medically supervised services, as well as personal care and socialization to individuals with physical and mental impairments or chronic illnesses. All individuals must be functionally impaired and referred by a physician. Participants' needs are assessed and met through an individualized care plan that is developed and implemented by an interdisciplinary team of medical professionals, including the participant's personal community physician.

Day programs provided in adult homes, residences for adults, and enriched housing programs--for non-residents of these facilities--are structured programs that furnish personal care, supervision, and such other services that the operator is authorized to provide to residents of such facilities, but which are provided for less than 24 hours during any period of the day or night.

Parameters for Who Can Be Served

Social adult day services programs can only serve functionally impaired individuals whose needs can be met and managed by the program and who can benefit from the program. Participants who cannot be safely or adequately served must be discharged.

Adult Day Health Care. A participant in this setting is defined as a person: (1) who is not a resident of a nursing home; is functionally impaired and not homebound; and requires supervision, monitoring, preventive, diagnostic, therapeutic, rehabilitative or palliative care or services, but does not require continuous 24-hour-a-day inpatient care and services; (2) whose assessed social and health care needs can be met satisfactorily in whole or in part by the delivery of appropriate services in the community setting; and (3) who has been admitted to an ADHC program based on an authorized practitioner's order and the ADHC program's interdisciplinary comprehensive assessment.

ADHC operators may admit and retain only those persons for whom adequate care and needed services can be provided and who, according to their interdisciplinary needs assessments, can benefit from the services and require a minimum of at least one visit per week to the program. No individual suffering from a communicable disease that constitutes a danger to other participants or staff may be admitted or retained.

Day programs can serve non-residents with social, physical, and/or mental dependencies to enable them remain in the community. Operators are required to give admission priority to persons who: (1) require supervision in order to live in the community; (2) need assistance with ADLs to remain in the community; (3) are socially isolated or disoriented and need opportunities for social interaction to prevent deterioration that would lead to placement in congregate facilities; (4) are in transition from a higher level of care; (5) are in danger of being neglected or abused by a caregiver or have needs that the caregiver is unable to meet; or (6) are receiving services as part of a protective services for adults program.

The operator of an adult home, residence for adults, or enriched housing program may not serve anyone in a day program if that person would be inappropriate for admission to the facility (e.g., individuals who have a serious physical or mental dysfunction that constitutes an immediate and present danger to themselves or others).

Inspection and Monitoring

Social Adult Day Services. The New York State Office for the Aging and the local AAAs are responsible for the oversight of SADS programs that they fund, and they monitor them on a regular basis. If funded under a managed care contract, the managed care entity monitors providers to ensure that they are in compliance with state requirements.

Adult day health care programs are surveyed by the staff of DOH. This may or may not happen at the same time that the sponsoring nursing home is surveyed.

Day Program. To ensure compliance with department regulations and the maintenance of standards to ensure that appropriate care is provided to participants, DOH administers a system of supervision, inspection, and enforcement.

Required and Optional Services

All SADS and ADHC programs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

To provide specialized ADHC services for individuals with AIDS/HIV, a nursing home must be approved to do so by DOH. ADHC programs may offer the following additional services for persons with AIDS: (1) substance abuse services, if appropriate; (2) mental health services; (3) HIV prevention and counseling services; (4) pastoral counseling; (5) tuberculosis screening and ongoing follow-up; and (6) specialized medical services including gynecology, as needed. ADHC services are provided under the Medicaid State Plan.

The only mandatory service for day programs is ADL assistance; transportation and medication assistance are optional services.

Required and Optional Services   Social Adult Day Services1     Adult Day Health Care  
  Required     Optional     Required2     Optional  
ADL Assistance X   X  
Health Education and Counseling   X X  
Health Monitoring/Health-Related Services     X  
Medication Administration     X  
Nursing Services     X  
Physical Therapy, Occupational Therapy, or Speech Therapy       X  
Skilled Nursing Services     X  
Social Services     X  
Transportation   X X  
  1. Caregiver support services are optional.
  2. Case management is also a required service in all ADHC programs.

Medication Provisions

Social Adult Day Services. SADS providers do not administer medications. Programs must have policies and procedures for assisting participants with self-administration, which includes prompting the participant with regard to time, identifying the medication, bringing the medication and any necessary supplies or equipment to the participant, opening the container, and disposing of used supplies and materials.

Adult Day Health Care. The operator must develop and implement written policies and procedures governing medications brought to the program site by participants. All medications administered to participants must be ordered in writing by a legally authorized practitioner unless unusual circumstances justify a verbal order, in which case the verbal order shall be given to a licensed nurse or to a licensed pharmacist, immediately recorded in writing, authenticated by the nurse or registered pharmacist, and countersigned by the prescriber within 48 hours.

In the event a verbal order is not signed by the prescriber or a legally designated alternate practitioner within 48 hours, the order must be terminated and the facility must ensure that the participant's medication needs are promptly evaluated by the medical director or another legally authorized prescribing practitioner. Each participant's drug regimen must be reviewed by a licensed pharmacist every 6 months. Any potential negative drug interactions/issues must be reported to the program director and community physician.

Day Program. Participants must be permitted to retain and self-administer their own medications provided their physicians have certified, in writing, that they are capable of doing so. For participants who require, by order of their physicians, assistance with self-administration of medication, the operator may: (1) remind the participant when it is time to take the medication; (2) read the label to the participant; (3) help the participant to open the container; and (4) observe the participant to see that the correct dosage is being taken according to the prescription. If participants are assisted in self-administration, the operator must keep a record of the assistance provided. Neither the operator nor staff of a non-resident services program can administer medication to a program participant.

Every 6 months, beginning on the date of admission to the program, participants must obtain and provide to the operator a written, dated, and signed statement from their physician indicating whether there are changes in their needs for assistance with self-administration of medication.

Staffing Requirements

Social Adult Day Services

Type of Staff. Each program must have a paid qualified director with appropriate educational qualifications and work experience to ensure that activities and services are provided appropriately and in accordance with participants' needs.

Staffing Ratios. During hours of operation when participants are present, the program must have at least two staff on site, one of whom must be a paid staff person and the other can be a volunteer. No staffing ratio is specified but programs are required to have an adequate number of qualified staff, which may include volunteers, to perform all of the required functions and to ensure participants' health, safety, and welfare.

Adult Day Health Care

Type of Staff. The operator must designate a director responsible for day-to-day management and administration of the ADHC program, including, but not limited to, assigning adequate and appropriately licensed personnel to be on duty at all times when the program is in operation to ensure safe care of the participants. Each program must have a full-time registered nurse (RN), a social worker, a certified nursing assistant (CNA), a physical therapist, an occupational therapist, a dietitian, a pharmacist consultant, and a medical director. The ADHC program is also required to employ or contract with speech therapists.

Nursing services are provided to participants under the direction of an RN who is on site in the ADHC program during all hours of program operation. Based on the participants' care needs, for a program located at the sponsoring nursing home, a licensed practical nurse may provide the on-site services when an RN is available in the nursing home or on the campus to provide immediate direction or consultation.

The ADHC program must employ a full-time or part-time qualified social worker to ensure that psychosocial needs are assessed, evaluated, and recorded, and that services are provided to meet the identified needs as part of the coordinated care plan.

Additional staffing requirements for services provided to participants with AIDS include: (1) specialty oversight of the AIDS program by a practitioner who has experience in the care and clinical management of persons with AIDS; and (2) nursing services for the AIDS program under the supervision of an RN with experience in the care and management of persons with AIDS.

Staffing Ratios. No mandatory staffing ratios are specified. A program's approved Certificate of Need establishes how many of each type of staff will be needed based on each program's DOH-approved capacity.

Day Program

Type of Staff. The operator must designate a program director who will coordinate the services provided to both day program recipients and residents of the adult care facility. If fewer than 15 daily participants are enrolled in a day program, the following facility staff, approved by the department, may act as program director: the facility administrator, the case manager, or the activities director.

Staffing Ratios. The operator must ensure that adequate personnel are on duty at all times when the non-resident day program is in operation to ensure care of the program's participants. Adequate is defined as a ratio of one staff member in addition to those required for residents of the home to each seven full-time participants receiving day and evening care, and one additional staff member for each 15 daily participants receiving night care. This ratio may include the program director, if the program director is not serving in any other capacity on the adult home staff, or if the individual's time as director is in addition to the hours required for adult home or residence duties.

Each operator must designate sufficient staff to provide supervision during all hours of operation. Staff must be immediately accessible at all times while on duty, and provision must be made for backup staff. At least one individual currently qualified by a recognized organization to administer basic first-aid must be on duty and on site at all times.

Training Requirements

Social Adult Day Services

All staff--including volunteers--must receive: (1) an orientation to the program provider, the community, and the program itself; (2) training on working with the elderly, participants' rights, safety, and accident prevention; (3) at least 6 hours of in-service training annually to develop, review, or expand skills or knowledge; and (4) training at least annually in the use of fire extinguishers, written procedures concerning evacuation and emergency situations, and emergency telephone numbers.

Prior to delivering any social adult day care (ADC) services, all service staff, including volunteer service staff, must complete basic training in--or have equivalent knowledge and skills related to--personal care skills, body mechanics, and behavior management. Within 3 months of being assigned to provide social ADC services, all service staff, including volunteer service staff, must complete 20 additional hours of training in--or have equivalent knowledge and skills related to--socialization skills and activities; supervision and monitoring; personal care skills, taught by an RN; family and family relationships; mental illness and mental health; and cardiovascular pulmonary resuscitation.

The program must also provide all service staff with periodic on-the-job training, as considered necessary by the program director or an individual who supervises service staff according to criteria for evaluating job performance and the ability to function competently and safely.

Adult Day Health Care

The operator must designate a person responsible for arranging in-service orientation, training, and staff development. Staff in ADHC programs must meet licensing and educational requirements established by the New York State Department of Education. ADHC programs must also follow staff development standards established for nursing homes in New York State. The standards include requirements for recertifying CNAs, whose initial training requirements are the same as for CNAs in nursing homes: 100 hours in long-term care skills.

Day Program

The operator must conduct an initial program of orientation and in-service training for employees and volunteers, which includes: (1) orientation to the characteristics and needs of the population; (2) discussion of the participants' rights and the facility's rules and regulations for residents; (3) discussion of all staff members' duties and responsibilities; (4) discussion of the general duties and responsibilities of the individual(s) being trained; (5) discussion relative to the specific duties and tasks to be performed; and (6) training in emergency procedures.

The operator must conduct ongoing in-service training and must provide opportunities for employees and volunteers to participate in work-related training provided by the operator or others.

Location of Licensing, Certification, or Other Requirements

Official Compilation of Codes, Rules, and Regulations of the State of New York, Title 10, Part 425: Adult Day Health Care. [March 17, 2004]http://w3.health.state.ny.us/dbspace/NYCRR10.nsf/56cf2e25d626f9f785256538006c3ed7/d5974737f3482af8852568c500605c7f?OpenDocument

Official Compilation of Codes, Rules, and Regulations of the State of New York, Title 9, Part 6654.20: Social Adult Day Care Programs. [January 31, 2013]http://www.nysadultday.com/uploads/2/7/3/1/2731986/title_9_part_6654_20.pdf

Official Compilation of Codes, Rules, and Regulations of the State of New York, Title 18, Part 492: Adult Care Facilities, Standards for Day Programs for Non-Residents.http://w3.health.state.ny.us/dbspace/NYCRR18.nsf/56cf2e25d626f9f785256538006c3ed7/06be90fb78d322fe8525672200769087?OpenDocument&Highlight=0,Adult,Day,Programs

Standards for Adult Homes. New York State Department of Health.http://www.ny-assisted-living.org/nysdoh/pdf/DOHPart487.pdf

Long Term Home Health Care Program Medicaid Waiver Program Manual. New York State Department of Health, Office of Health Insurance Programs, Division of Long Term Care. [May 18, 2012]http://www.health.ny.gov/health_care/medicaid/reference/lthhcp/lthhcpmanual.pdf

Information Sources

Elizabeth Geary, MEd, LMSWPresidentNew York State Adult Day Services Association

Christine M. FitzpatrickExecutive DirectorAdult Day Health Care Council

NORTH CAROLINA

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-north-carolina

Overview

The Division of Aging and Adult Services in the North Carolina Department of Health and Human Services oversees adult day care (ADC) and adult day health services (ADHS). All providers must meet state certification standards. Programs may be certified to provide both ADC and ADHS. The certification standards include additional requirements for both ADC programs and ADHS programs that market themselves as providing special care services.

An ADC or ADHS program that advertises, markets, or otherwise promotes itself as providing special care services for persons with Alzheimer's disease or other dementias; a mental health disability; or other special needs, diseases, or conditions must provide written disclosures to the Department and to persons seeking special care services from an ADC or ADHS program. The disclosure must address the process and criteria for enrollment in and discharge from special care services.

Only programs that meet these requirements may advertise or represent themselves as providing special care services. However, an ADC or ADHS program that does not advertise, market, or otherwise promote itself as providing special care services is not prohibited from providing ADC or ADHS to persons with Alzheimer's disease or other dementias; a mental health disability; or other special needs, diseases, or conditions.

Medicaid covers ADHS under a 1915(c) waiver--Community Alternatives Program for Disabled Adults--and contracts only with certified providers.

Definitions

Adult day care means the provision of group care and supervision on a less than 24-hour basis to adults with physical and/or mental disabilities in a place other than their usual residence. Services include a variety of program activities designed to meet the individual needs and interests of participants, a nutritious meal and snacks as appropriate to the program, and referral to and assistance with using appropriate community resources.

Services must be provided in a home or a center certified to meet state standards for such programs. Programs operated in a single family dwelling limited to 16 adults are called adult day care homes. Those operating in a structure other than a single family dwelling are called adult day care centers.

Adult day health services means the provision of an organized program of services during the day in a community group setting for the purpose of supporting an adult's personal independence and promoting his or her social, physical, and emotional well-being. Services must include health care services as defined in state standards and a variety of program activities designed to meet participants' individual needs and interests, and referral to and assistance with using appropriate community resources. The health care component of ADHS distinguishes it from ADC .

Adult day health (ADH) centers operate in a structure other than a family dwelling, but adult day health homes for up to 16 adults can operate in a single family dwelling.

Adult day health combination programs can operate both ADC and ADH in one program.

Special care services are those furnished by a certified ADC or ADHS program that promotes itself as providing programming, activities, or care specifically designed for persons with Alzheimer's disease or other dementias; mental health disabilities; or other special needs, diseases, or conditions as determined by the Medical Care Commission.

Parameters for Who Can Be Served

Adults who need ADC and ADHS are aged and disabled persons who have impairments that prevent them from living independently without supportive services and put them at risk of becoming institutionalized. Some have conditions that have led or will lead to substantial deterioration of their physical, emotional, mental, and social well-being.

Providers must have specific enrollment policies to guard against enrolling people whose needs cannot be met by the planned activities. The policies should also provide for dismissal of participants whose needs can no longer be met or who can no longer be cared for safely. Providers may serve both semi-ambulatory and non-ambulatory individuals.

ADHS programs have additional requirements. Providers may serve individuals who are age 18 years or older who need ADHS in order to support their independence and who require: (1) monitoring of a medical condition; (2) provision of assistance with or supervision of activities of daily living (ADLs); and (3) administration of medication, special feedings, or provision of other treatment or services related to health care needs. Participants enrolled in ADH must require daily nursing supervision.

A participant transferring from standard ADC services to special care services must meet the criteria for the special care services. The participant's medical examination report must specify a diagnosis, disability, or condition consistent with the program's special care services.

Inspection and Monitoring

Following review of the initial certification application, the North Carolina Division of Aging and Adult Services makes a precertification visit. To ensure compliance with certification standards, the Division recertifies ADC and ADHS programs annually in addition to monthly monitoring of compliance by county Departments of Social Services. ADHS programs receive additional monitoring at least quarterly by county Departments of Health. Certification is for a 12-month period from issuance unless it is revoked for cause, voluntarily or involuntarily terminated, or changed to provisional certification status.

Required and Optional Services

All ADC and ADHS programs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the adult day services program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

Required and Optional Services Adult Day Care Adult Day Health Services
  Required     Optional     Required     Optional  
ADL Assistance   X1 X  
Health Education and Counseling   X X  
Health Monitoring/Health-Related Services     X  
Medication Administration X   X  
Nursing Services     X  
Physical Therapy, Occupational Therapy, or Speech Therapy     X2 X  
Skilled Nursing Services     X  
Social Services        
Transportation   X   X
  1. ADL assistance is optional. Providers determine if they will furnish this service based on the population they are targeting. The provision of assistance with ADLs may be a criterion for some funding sources, such as the Home and Community Care Block Grant. The majority of ADC providers in North Carolina do offer assistance with ADLs on some level.
  2. These services may be provided by program staff, if qualified, or arranged for through the program if available through community resources.

Medication Provisions

All ADC programs must have written policies on participant medication use, changes to medication administration orders, and medical disposal. Only ADHS or ADC and ADH combination programs can enroll or serve participants who require intravenous, intramuscular, or subcutaneous medications while attending the program.

Staffing Requirements

Type of Staff. ADC and ADH centers must have a full-time program director. In ADC homes where the only staff person is the operator, the operator must meet the same requirements as the director. Substitute or relief staff must meet the same requirements as the operator.

ADH centers must have a health care coordinator to organize the delivery of health care services and participate in direct care. The health care coordinator must be either a registered nurse (RN) or a licensed practical nurse (LPN), currently licensed to practice in North Carolina. If the health care coordinator is an LPN, an RN must provide supervision consistent with the Nursing Practice Act, and on-site supervision by the RN must occur no less frequently than every 2 weeks.

In ADH centers with ten or fewer participants, the director may also serve as the health care coordinator.

Staffing Ratios. The staffing pattern is dependent upon the enrollment criteria and the participants' needs. The ratio of staff to participants must be adequate to meet the goals and objectives of the program. Whenever regularly scheduled staff are absent, substitutes must be used to maintain the staff-to-participant ratio and, for ADH programs, to ensure proper supervision of the delivery of the health care services. The minimum ratios are:

Adult day care homes. One full-time equivalent staff person with responsibility for direct participant care for each six participants--up to 16 participants--the maximum number that can be served in this setting.

Adult day care centers. One full-time equivalent staff person with responsibility for direct participant care for each eight participants.

Adult day health centers and adult day health homes. One full-time equivalent staff person with responsibility for direct participant care for each five participants.

Adult day health combination. One full-time equivalent staff person with responsibility for direct participant care for each six participants.

Special care services. The ADC program must disclose in writing procedures that address staff-to-participant ratios in the special care services to meet participants' needs.

In ADH centers, the health care coordinator must be on-site a minimum of 4 hours per day and any additional hours necessary to meet requirements for the provision of health and personal care services.

In ADC homes where the only staff person is the operator, a minimum of one staff person must be present during all hours of operation and the operator must ensure that substitute or relief staff are available to enable the ADC home to remain open on days when the operator is not available to supervise the program.

Training Requirements

Providers must have a written plan for orientation and staff development of new employees and volunteers and ongoing development and training of all staff.

Special Care Services. An ADC program providing special care services must ensure that special care services staff receive at least the following orientation and training, which must be documented in the center's files.

  • The program director must have in place a written plan for training staff that identifies content, sources, evaluations and training schedules. The plan must be reviewed and updated annually.

  • The program director must ensure that within a month of employment, each staff person assigned to special care services shall demonstrate knowledge of participants' needs, interests, and levels of abilities. This information must be documented in the center's files.

  • Within 6 months of employment, each staff person assigned to special care services must complete three trainings. The training must include, but not be limited to, population specific techniques for communication, behaviors, and ADLs.

  • Each staff person working directly with participants in special care services must complete a minimum of two population specific educational experiences annually.

Location of Licensing, Certification, or Other Requirements

The following site contains information about adult care and links to additional information, including the certification standards for both adult day care and adult day health services: North Carolina Adult Day Care and Day Health Services Standards for Certification. North Carolina Department of Health and Human Services, Division of Aging and Adult Services. [July 2007]

North Carolina Division of Aging and Adult Services website: Adult Day Care.http://www.ncdhhs.gov/aging/adcsvc.htm

Information Sources

Michael BolesPresidentNorth Carolina Adult Day Services Association

Theresa JohnsonManaging DirectorNational Adult Day Services Association

Wrenia Bratts-BrownCAP/DA ManagerNorth Carolina Department of Health and Human ServicesDivision of Medical Assistance

NORTH DAKOTA

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-north-dakota

Overview

North Dakota does not license adult day care (ADC). However, an ADC provider who serves publicly-funded participants must be enrolled with the North Dakota Department of Human Services as a qualified service provider (QSP)--either as a self-employed individual or as an agency--that meets all of the QSP standards/requirements. To maintain enrollment as QSPs, individuals and agencies must demonstrate that they meet the standards every 2 years. The QSP standards are described in this profile.

Licensed hospitals, nursing facilities, and basic care facilities can provide ADC services to individuals who do not remain in the facility overnight. To do so, they must obtain approval from the Department of Health, which licenses these facilities. Such facilities are required to develop policies and procedures covering all aspects of the ADC services they provide and must enroll as QSPs and meet QSP standards.

Individual applicants for QSP provider status for ADC must complete a form confirming that they are competent in the Standards and Allowable Tasks Activities for ADC providers. These standards comprise specific knowledge and skills, such as assistance with activities of daily living (ADLs) and with self-administration of medications, and incontinence care. Agency QSPs must confirm that their staff have the necessary knowledge and skills to provide ADC services.

Competency may be demonstrated through various processes, including self-verification (through a written, verbal, or physical demonstration) or verification by a licensed professional. Written verification of competency is not required if the individual holds one of the following licenses or certifications in good standing: physician, chiropractor, registered nurse, licensed practical nurse, registered physical therapist, registered occupational therapist, or certified nurse assistant.

ADC is provided under a Medicaid 1915(c) waiver program and two non-Medicaid programs funded solely with state funds, all administered by the Department of Human Services.

Definitions

Adult day care is a program of non-residential activities provided at least 3 hours per day on a regularly scheduled basis 1 or more days per week and includes both health and social services needed to ensure participant's optimal functioning.

Adult day care services provided by basic care facilities and nursing facilities means the provision of services by these facilities to meet the needs of participants who do not remain in the facility overnight.

Parameters for Who Can Be Served

Individuals may be served who require assistance with ADLs or instrumental ADLs, who are able to function in an ambulatory care setting, who are able to participate in group activities, and/or whose primary caregiver, residing with the individual, will benefit from the temporary relief from caregiving. Program participants must be assessed as needing a nursing facility level of care but whose functional impairment is not the result of a mental illness or a condition of mental retardation, or a closely related condition.

Inspection and Monitoring

ADC provided in a home or in an unlicensed freestanding facility must meet standards established by the Department of Human Services. The County Social Service Board is responsible for inspecting and ensuring that these facilities meet the required standards. An on-site inspection is conducted prior to enrollment as a QSP. Basic care facilities and nursing facilities that offer ADC services are inspected and monitored for compliance with licensure standards for these facilities.

Required and Optional Services

All ADC programs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

Required and Optional Services Adult Day Care
  Required     Optional  
ADL Assistance X  
Health Education and Counseling    
Health Monitoring X  
Medication Administration   X
Nursing Services   X
Physical Therapy, Occupational Therapy, or Speech Therapy     X1
Skilled Nursing Services   X
Social Services X  
Transportation   X
  1. Therapies can only be furnished if the provider is licensed by the Department of Health as a basic care or skilled nursing facility.

Medication Provisions

QSPs can furnish assistance with self-administration of medications. Providers with licensed nurses on staff can provide medication administration in accordance with state nurse practice laws. Unlicensed staff can provide assistance with medication when trained and supervised by a licensed staff member.

Staffing Requirements

Adult Day Care

Type of Staff. No requirements.

Staffing Ratios. One employee is required for every eight participants.

Training Requirements

No requirements.

Location of Licensing, Certification, or Other Requirements

State Administrative Rules, Chapter 33-03-24.1: Basic Care Facilities. State Department of Health. [January 1, 1995]http://www.legis.nd.gov/information/acdata/pdf/33-03-24.1.pdf?20140325223132

State Administrative Rules, Chapter 33-07-03.2: Nursing Facilities. State Department of Health. [July 1, 1996]http://www.legis.nd.gov/information/acdata/pdf/33-07-03.2.pdf?20140815111047

Compliance Checklist Adult Day Care Standards. North Dakota Department of Human Services, Medical Services/HCBS. [June 2006]http://www.nd.gov/eforms/Doc/sfn01703.pdf

Qualified Service Provider Handbook (Individual Provider), Enrollment Processes and Standards. North Dakota Department of Human Services, Medical Services/HCBS. [May 2014]http://www.nd.gov/dhs/info/pubs/docs/medicaid/qsp-handbook-individual-provider.pdf

Agency Provider, Qualified Service Provider Handbook, Enrollment Processes and Standards. North Dakota Department of Human Services, Medical Services/HCBS. [June 2013]http://www.nd.gov/dhs/info/pubs/docs/medicaid/qsp-handbook-agency-provider.pdf

State Administrative Rules, Chapter 75-03-23: Provision of Home and Community-Based Services under the Service Payments for Elderly and Disabled Program and the Medicaid Waiver for the Aged and Disabled Program. Department of Human Services. [October 1, 2014]http://www.legis.nd.gov/information/acdata/pdf/75-03-23.pdf?20140326083734

Qualified Service Provider Fact Sheet.http://www.nd.gov/dhs/info/pubs/docs/medicaid/fact-sheet-qsp.pdf

Documentation of Competency. North Dakota Department of Human Services, Medical Services/HCBS. [August 2014]http://www.nd.gov/eforms/Doc/sfn00750.pdf

Information Sources

Judy TschiderProgram AdministratorAging Services DivisionNorth Dakota Department of Human Services

Nancy Nikolas MaierHCBS Program AdministratorMedical Services DivisionNorth Dakota Department of Human Services

OHIO

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-ohio

Overview

Ohio does not license adult day services (ADS) providers. Certification of ADS centers is required only for Medicaid providers. ADS are provided under several 1915(c) waiver programs, including the Pre-Admission Screening System Providing Options and Resources Today (PASSPORT) waiver program, which is administered by the Ohio Department on Aging (DOA). Programs certified by DOA are certified as either enhanced or intensive service providers depending on the type and level of services they furnish. This profile describes the DOA certification requirements for the PASSPORT waiver program.

Definitions

Adult day services are regularly scheduled services delivered in a non-institutional, community-based setting. ADS include recreational and educational activities to support participants' health and independence goals; at least one meal, but no more than two meals per day that meet participant's dietary requirements; and, sometimes, health status monitoring, skilled therapy services, and transportation to and from the ADS center.

Enhanced adult day services include structured activity programming, health assessments, supervision of all activities of daily living (ADLs), supervision of medication administration, hands-on assistance with ADLs and personal hygiene (except bathing) and hands-on assistance with medication administration, comprehensive therapeutic activities, and intermittent monitoring of health status.

Intensive adult day services include all the components of enhanced ADS plus hands-on assistance with two or more ADLs; hands-on assistance with bathing; regular monitoring of health status, with interventions as need to address changes in condition; skilled nursing services (e.g., dressing changes and other treatments) and rehabilitative nursing procedures; rehabilitative and restorative services, including physical therapy, speech therapy, and occupational therapy; and social work services.

Parameters for Who Can Be Served

The services provided in enhanced and intensive ADS (listed above) indicate the types of individuals who can be served in ADS programs.

Inspection and Monitoring

The PASSPORT Administrative Agency conducts an on-site visit within 45 calendar days after the receipt of a completed certification application to determine compliance with the PASSPORT conditions of participation. An on-site provider structural compliance review is conducted at least annually.

Providers are required to provide general access to their facility to representatives of the Centers for Medicare and Medicaid Services, the Ohio Department of Human Services, the Ohio Department of Aging, and the PASSPORT Administrative Agency.

Required and Optional Services

All ADS programs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

Required and Optional Services   Enhanced Adult Day Service     Intensive Adult Day Service  
  Required     Optional     Required     Optional  
ADL Assistance X   X  
Health Education and Counseling     X  
Health Monitoring   X X  
Medication Administration X   X  
Nursing Services X   X  
Physical Therapy, Occupational Therapy, or Speech Therapy     X X  
Skilled Nursing Services   X X  
Social Services     X  
Transportation X   X  

Medication Provisions

Medication administration must be performed by a licensed nurse for participants who require assistance. A trained staff person must supervise participants who self-administer medications.

Staffing Requirements

Type of Staff. A registered nurse (RN) or licensed practical nurse (LPN) under the supervision of an RN must be on site at the ADS center to provide those nursing services that require the skills of an RN or an LPN under the supervision of an RN. An activity director must supervise participants' activities.

Staffing Ratios. At least two staff members must be present in the ADS center when more than one participant is in attendance, at least one of whom is a paid direct service staff member. The staff-to-participant ratio must be at least 1:6.

Training Requirements

Before each new personal care staff member can assist participants, the provider must train the staff member on all of the following: (1) employees' expectations; (2) the provider's ethical standards; (3) overview of the provider's personnel policies; (4) description of the provider's organization and lines of communication; (5) incident reporting procedures; and (6) universal precautions for infection control. The provider must also furnish task-based training.

ADS staff must participate in at least 8 hours of in-service training or continuing education each calendar year.

Location of Licensing, Certification, or Other Requirements

Ohio Administrative Code, Chapter 173-39: Certification of Community-Based Long-Term Care Service Providers--Ohio Adult Day Service. [November 1, 2013]http://codes.ohio.gov/oac/173-39-02.1

Information Sources

Shirley McGloneCommunity Living DivisionOhio Department of Aging

OKLAHOMA

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-oklahoma

Overview

All adult day services (ADS) centers, including those that serve only private pay participants, must be licensed by the Oklahoma Department of Health.29 In addition, administrators of health care facilities, including ADS centers, are required to be licensed by the Oklahoma State Board of Examiners for Long-Term Care Administrators.

ADS are reimbursed through the non-Medicaid Aging Services program of the Oklahoma Department of Human Services (DHS). In addition to licensure, providers are required to have a contract with the DHS Aging Services Division in accordance with the Department's minimum standards for ADS, which are provided with the contract.

The state also reimburses ADS--called adult day health care (ADHC)--through the Medicaid 1915(c) ADvantage waiver program. This program serves frail elderly individuals age 65 or older and adults age 21 or older with physical disabilities, who do not have mental retardation or a cognitive impairment. The state has additional waiver programs that provide ADHC for other populations.

In addition to licensure, ADHC providers reimbursed through the ADvantage Program must have a Medicaid contract with the Oklahoma Health Care Authority and a current ADvantage Program certification.

The provisions in this profile are from the state's licensing requirements, the DHS Aging Services Division's minimum standards for ADS, and the ADvantage Program provider standards for ADHC.

Definitions

Adult day services are designed to meet the needs of elderly and disabled persons through an individual care plan. Services are provided in a community-based structured and comprehensive daytime program that serves functionally impaired adults who cannot take care of themselves and who continue to live in their own homes, usually with the aid of family caregivers. Basic services include supervision, assistance with activities of daily living, planned activities, social services, nutritious meals, and emergency and first-aid services.

Adult day services center means a distinct entity, either freestanding or a separate program of a larger organization with a separately verifiable staff, space, budget, and participant record system. The term ADS center does not include retirement centers and senior citizen centers.

Adult day health care as provided under the ADvantage waiver program means services furnished on a regularly scheduled basis, for 1 or more days per week, in a community setting, encompassing both health and social services needed to ensure the optimal functioning of the individual. Services are authorized in 15-minute units, with no more than 24 units (6 hours) authorized per day.

Parameters for Who Can Be Served

ADS centers serve functionally impaired adults, defined as an individual age 18 years or older who requires care and/or supervision. Each center must have written enrollment policies that contain admission criteria to define the participants who can be served by the center and that prohibit enrollment of persons whose needs exceed the capability of the center's program, as well as persons excluded by statute. The provider may discharge participants whose continued attendance would infringe on the safety or well-being of other participants or staff.

Inspection and Monitoring

Licenses must be renewed annually. The Department of Health inspects each ADS center to determine compliance with the licensing rules and ADS standards. Inspections are conducted at least annually and whenever deemed necessary by the Department. The DHS Aging Services Division also conducts annual site visits to determine compliance with provider contract requirements.

Required and Optional Services

All ADS programs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

Service enhancements to ADHC include personal care (assistance with bathing and associated hair and nail care authorized to maintain health and safety) and skilled therapies (physical, occupational, speech and respiratory), which are furnished as component parts of ADHC when indicated in an individual's service plan, but are billed as additional units of service.

Required and Optional Services Adult Day Services
  Required     Optional  
ADL Assistance X  
Health Education and Counseling X  
Health Monitoring/Health-Related Services X  
Medication Administration X  
Nursing Services X  
Physical Therapy, Occupational Therapy, or Speech Therapy     X
Skilled Nursing Services   X
Social Services X  
Transportation X1  
  1. Non-Medicaid ADS centers are required to provide, formally arrange, or contract for transportation; however, it is not a provided service under the ADvantage waiver Program.

Medication Provisions

Policies and procedures for self-administration and staff administration of medication must be developed and implemented. Participants are encouraged to retain and administer their own medications while attending the ADS program. Centers that administer medication must have a registered nurse (RN), licensed practical nurse (LPN), certified medication aide (CMA), or a medication administration technician (MAT) who has successfully completed a course of training in medication administration approved by the Department of Health. Monthly consultation by an RN or LPN is required for centers where medications are administered by a CMA or MAT.

Staffing Requirements

Type of Staff. Each ADS center must have the following staff: a licensed director with the authority and responsibility for managing and implementing the day care program, an activity director, a social services coordinator or case manager, and a dietary supervisor. Centers that are a part of a larger organization that provides food service to the center or centers that contract with an outside service for food service may employ a part-time dietary supervisor. Each ADS center must have an adequate number of staff who are appropriately qualified and trained to provide the center's essential services and must employ additional staff, such as nurses, therapists, consultants, and drivers, as needed.

Nurses employed by the center must be either a RN or a licensed vocational nurse/LPN, currently licensed by Oklahoma, with experience working with aged and chronically impaired adults. Physical therapists, occupational therapists, recreational therapists, and speech therapists who provide services to the center and/or its participants must have valid state credentials. Staff may work independently under the directions of a licensed therapist.

The ADvantage Program standards require that therapy services ordered by a physician be provided by licensed physical, occupational, respiratory, and/or speech therapists, or by an appropriate certified therapy aide working under the direction of the licensed therapist.

Staffing Ratios. At least two responsible persons must be at the center when participants are present, one of whom must be a staff member, and a sufficient number of direct care staff must be on duty at all times to meet the needs of each participant. A minimum of one full-time equivalent direct care staff person is required for every eight participants who are present and one additional direct care staff person for eight additional participants or part thereof. Programs serving a high percentage of participants who are severely impaired must have a staff-to-participant ratio of 1:4. Volunteer staff who are counted in the staffing ratio must be qualified by training and/or experience to perform duties and responsibilities required by the written job description.

Training Requirements

All staff, prior to performing job responsibilities, including non-direct care staff, direct care staff, and volunteers, must be given a general orientation to the program and its policies and to fire, safety, and emergency procedures. In-service training for each staff person must be provided quarterly.

ADHC providers must ensure that all direct care employees have completed an ADvantage Program-approved training program that incorporates the agency's Service Delivery Principles and a Bill of Consumer Assurances.

Location of Licensing, Certification, or Other Requirements

Oklahoma State Department of Health website links for Adult Day Care Center Licensure.http://www.ok.gov/health/Protective_Health/Health_Resources_Development_Service/Health_Facility_Systems_/Adult_Day_Care_Center_Licensure/

Oklahoma Administrative Code, Title 310, Chapter 605: Adult Day Care Centers. Oklahoma State Department of Health. [July 7, 2004]http://www.ok.gov/health2/documents/HRDS%20-Chapter%20605%20Adultdaycarerules.pdf

Oklahoma Statutes, Adult Day Care Act, Title 63, Section1-870 et seq. [November 1, 2007]http://www.ok.gov/health2/documents/HRDS%20Chapter%20605Adultdaycareact%201107.pdf

ADvantage Program Service Standards. [July 2007]http://advantage.ok.gov/Documents/ADvantage%20Program%20Service%20Standards_July%202007.pdf

Provider letter regarding certification of adult day care administrators from the Oklahoma State Board of Examiners for Long Term Care Administrators. [June 2012]http://www.ok.gov/health2/documents/06%202012%20OSBELTCA%20Grandfathering%20letter.pdf

Oklahoma Administrative Rules, Title 490, 10-1-3.5: Requirements for initial licensure for adult day care administrators. [July 1, 2012]http://www.oar.state.ok.us/viewhtml/490_10-1-3.5.htm

Information Sources

Mary BrinkleyExecutive DirectorLeadingAge Oklahoma

Eleanor KurtzPrograms AdministratorContracts and Coalitions UnitOklahoma Aging Services DivisionOklahoma Department of Human Services

Gayle FreemanAdult Day Services CoordinatorOklahoma Aging Services DivisionOklahoma Department of Human Services

Megan HaddockDirector of Medicaid ServicesOklahoma Aging Services DivisionOklahoma Department of Human Services

OREGON

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-oregon

Overview

Oregon does not license adult day services (ADS). The state has operational standards, which ADS programs comply with on a voluntary basis. These standards are summarized in this profile. However, all ADS providers are required to register their programs on a registry administered by the Oregon Department of Human Services (DHS), Aging and People with Disabilities Division (APD). When registering, providers are required to indicate on a checklist the extent to which they are voluntarily complying with the standards. Licensed long-term care facilities that provide ADS programs--for example, nursing homes or residential care facilities--are not required to register.

Medicaid covers ADS through the 1915(k) State Plan option, which was authorized under the Affordable Care Act. ADS providers who want to serve Medicaid participants must comply with the standards and APD must certify that they meet them. The certification process requires: (1) completion of the ADS self-assessment demonstrating the program meets the standards for ADS; (2) documentation of the providers' qualifications and specific experience in delivering ADS (at least 6 months in Oregon); and (3) an on-site inspection. Certification may continue for up to 2 years as long as long as the ADS program complies with the certification standards.

Definitions

Adult day services means a community-based group program designed to meet the needs of adults with functional impairments through individual service plans. These structured, comprehensive, non-residential programs provide health, social and related support services in a protective setting during part of a day, but for less than 24 hours.

Parameters for Who Can Be Served

ADS programs may serve adults with impairments. Each program's operational plan must include a definition of the target population with the number, age range, and needs of participants who will be served.

Prior to admission, providers must complete an intake screening to determine the appropriateness of the ADS program for the participant and to determine that the participant's needs are within the scope of the ADS program. For each participant, providers must develop a service plan based on the services needed and the program's ability to provide those services. The standards do not provide guidance regarding individuals who may not be served, but providers are required to have criteria for admission and discharge.

Inspection and Monitoring

Only ADS programs contracting with DHS are inspected and monitored. The initial certification requires an on-site inspection by APD to determine if the standards are met. The certification continues for up to 2 years from the effective date as long as the ADS program complies with the standards for certification. Recertification requires an ADS self-assessment demonstrating that the program continues to meet the certification standards for ADS and an on-site inspection by APD.

Ninety days prior to certification ending, ADS programs renewing certification and their DHS Medicaid contract must demonstrate through a self-assessment that the program continues to meet the certification standards, and must participate in an on-site inspection by APD.

APD may perform an unannounced on-site certification review at any time during the certification period to ensure that quality and safety standards continue to be met, and may immediately suspend certification for threat to the participant's health, safety, welfare, or failure to comply with the standards.

Required and Optional Services

All ADS programs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

Required and Optional Services Adult Day Services
  Required     Optional  
ADL Assistance X  
Health Education and Counseling X  
Health Monitoring X  
Medication Administration   X
Nursing Services   X
Physical Therapy, Occupational Therapy, or Speech Therapy      
Skilled Nursing Services    
Social Services X  
Transportation X  

Medication Provisions

Each ADS program must have a written policy for medication management and must designate which staff are trained and authorized to administer medications. The medication management policy, which must include a medication training program, must be approved by a registered nurse or pharmacist. Licensed nurses are required to oversee medication administration but administering medications can be a delegated task performed by trained staff.

Staffing Requirements

Type of Staff. The state has no standards regarding the type of staff that must be employed. The standards state only that each staff person and volunteer must have the education and experience needed for the position held. Specifically, staff must have sufficient knowledge to provide essential services to program participants.

Staffing Ratios. The staff-to-participant ratio must be a minimum of one staff person to six participants. As the number and/or impairment level of participants increase, the staff-to-participant ratio must be adjusted accordingly. ADS programs with over 50 percent of participants requiring full assistance with three or more activities of daily living (ADLs) must have a staff-to-participant ratio of 1:4. To ensure adequate care and participants' safety, ADS providers must have provisions to ensure that qualified substitute staff are available when needed.

Volunteers can be included in the staff ratio only when they conform to the same standards and requirements as paid staff, meet the job qualifications, have designated responsibilities, a signed written job description, and documentation of their schedule in the facility.

There must be at least one staff person or combination of staff on duty at all times who are knowledgeable about: (1) the program's fire, safety, and disaster plan; (2) infection control; (3) cardiovascular pulmonary resuscitation and first-aid; (4) body mechanics/transfer techniques; (5) mandatory reporting laws of abuse/neglect; (6) personal care; (7) managing behavioral symptoms; and (8) the participants' needs.

Each ADS program that is located within the same facility as another program, (e.g., a hospital, nursing facility, senior center, church, or community-based care facility) must be separate and distinct with designated staff and staff hours committed to the ADS program.

Training Requirements

General orientation and continued in-service training must be provided for both paid staff and volunteers, including, but not limited to, the following topics: (1) program mission/philosophy; (2) mandatory reporting laws of abuse/neglect and indicators of abuse; (3) behavioral intervention/behavior acceptance/accommodations; (4) standard precautions; (5) participant rights; (6) fire, safety, and disaster plan and emergency procedures; and (7) body mechanics/transfer techniques/ADL assistance.

Location of Licensing, Certification, or Other Requirements

Oregon Administrative Rules, Chapter 411: Registration and Certification Standards for Adult Day Services Programs. Oregon Department of Human Services, Aging and People with Disabilities. [November 7, 2007]http://www.dhs.state.or.us/policy/spd/rules/411_066.pdf

Information Sources

Marcie JonesOregon Association of Adult Day Services

Darwin FrankenhoffOregon Department of Health ServicesAging and People with Disabilities

PENNSYLVANIA

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-pennsylvania

Overview

The Pennsylvania Department of Aging licenses older adult daily living centers under the Commonwealth Older Adult Daily Living Centers Licensing Act, whose provisions are cited in this profile. Medicaid covers adult daily living services under the1915(c) Home and Community-Based waiver for individuals age 60 and over.

Definitions

Older adult daily living services are services provided or arranged to assist in meeting participants' needs, including personal care, social, nutritional, health and educational needs. These services are provided, as appropriate for each participant, through a planned program of social, educational, recreational, therapeutic, and rehabilitative activities. They do not include services provided for persons whose needs are such that they can only be met in a long-term care facility on an inpatient basis, receiving professionally supervised nursing care and related medical and other health services.

Older Adult Daily Living Center. Premises operated for profit or not for profit in which older adult daily living services are simultaneously provided for part of a 24-hour day for four or more participants who are not relatives of the operator.

Parameters for Who Can Be Served

Providers may serve individuals with functional impairments caused by conditions such as a post-stroke dementia, Parkinson's disease, or dementia-related disease such as Alzheimer's or other organic brain syndrome--or who require assistance to meet personal needs and perform basic daily activities--and who are in need of a structured program of activities or services, as determined by an intake screening process. Participants must be capable of being transported to and from the service site. Providers may limit admissions to individuals who can be served in a manner consistent with the center's goals.

Individuals may not be admitted or retained if they are bedfast; have a communicable disease; have emotional or behavioral disorders; are habitually addicted to alcohol or drugs and, as a consequence of the addiction, are disruptive in a group setting; or do not need the activities and services provided in the older adult daily living center and need referral to other, more appropriate programs, such as a senior center or nutrition site.

Providers may involuntarily discharge participants for one or more of the following reasons: (1) a participant experiences a sudden change in level of functioning that the center determines to be a threat to the participant or others; (2) a participant is no longer capable of being transported to the center; (3) a participant does not have a functional impairment and is not in need of the structured program of activities or services offered by the center; or (4) a participant no longer meets the admission criteria.

Inspection and Monitoring

Centers are subject to announced and unannounced on-site inspections to determine:

  • the suitability of the applicants;
  • the suitability of the premises;
  • whether or not the premises qualify as a center;
  • the continuing conformity of licensees to regulatory requirements; and
  • whether or not the center is violating laws and regulations under which it is licensed.

     

An authorized agent of the department conducts an on-site inspection of a center 6 months after approval for an initial license (to give providers time to enroll participants), and then at least once every 12 months for providers with a full license. The center is advised in advance of the date of the annual inspection, which is an announced inspection and occurs during normal business hours.

Unannounced inspections not based on a complaint will occur during normal business hours. Unannounced inspections based on a complaint may, as determined by the department in accordance with the nature of the complaint, occur at any time.

Required and Optional Services

All adult day services programs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

Required and Optional Services   Older Adult Daily Living Services  
  Required     Optional  
ADL Assistance X  
Health Education and Counseling X  
Health Monitoring X  
Medication Administration X  
Nursing Services X  
Physical Therapy, Occupational Therapy, or Speech Therapy     X
Skilled Nursing Services X  
Social Services X  
Transportation   X

Medication Provisions

A center must provide participants with assistance, as needed, with medications prescribed for self-administration. This assistance includes helping the participant remember the schedule for taking the medication, storing the medication in a secure place, and making the medication available at the prescribed times. If a participant refuses to take a prescribed medication, the refusal must be promptly reported to the responsible party or practitioner, or both, and documented in the participant's record.

To be considered capable of self-administration of medications, a participant must be able to identify the medication, acknowledge the amount of medication to be taken and the schedule for taking it, remember to take the medication on schedule with infrequent reminders from staff persons, and obtain medication from its container without assistance or with minimal assistance.

Medications and injections of substances that are not self-administered by participants must be administered by one of the following qualified professionals: a licensed physician, licensed dentist, certified physician's assistant, certified registered nurse (RN) practitioner, RN, or licensed practical nurse (LPN); a graduate of an approved nursing program functioning under the direct supervision of a professional nurse who is present in the center; or a student nurse of an approved nursing program functioning under the direct supervision of a member of the nursing school faculty who is present in the center.

Oral, topical, and eye and ear drop prescription medications may be administered by center staff persons who have completed the Department of Public Welfare's Medications Administration course and otherwise meet requirements for medication administration training set forth in the requirements for adult training facilities.30

Staffing Requirements

Type of Staff. A program director/administrator must be responsible for the center's administration and general management.

The center must obtain the services of either a registered nurse or a currently licensed practical nurse. The nurse may be a full-time or part-time staff member or a consultant, or may serve through some other arrangement that meets participants' needs.

Center staff must include an activities coordinator and a program assistant/aide. Program assistants/aides provide personal care and assistance to participants, work with other staff members as required to implement services and activities to meet participants' needs, and assist with transportation or escorting clients to, from, and within the center, if appropriate.

A staff person may simultaneously perform the duties and responsibilities of more than one of the positions if he or she meets the licensure and minimum education or equivalent experience requirements for each of the positions held.

A sufficient number of staff persons must be trained, certified, and recertified in cardiovascular pulmonary resuscitation and in first-aid so that at least one staff person who is accordingly trained, certified, and recertified is present in the center at all times.

Volunteer duties are mutually determined by volunteers and staff persons. Duties, to be performed under the supervision of a staff member, must either supplement the staff in established activities or provide additional services for which the volunteer has special talents.

Staffing Ratios. Program staff are center employees who directly assist participants with activities of daily living or provide older adult daily living services, or both. The term does not include a person whose totality or majority of time involves the provision of housekeeping, maintenance, accounting/bookkeeping or clerical services. The term also does not include a nurse or social worker retained by the center as an independent contractor to give advice, guidance or other assistance in accordance with the standards of the nursing or social work profession. The program staff-to-participant ratio must be a minimum of 1:7 at all times.

Staff members must be physically located close enough to participants to monitor their condition at all times and be able to respond immediately to an emergency.

Training Requirements

Providers--using center staff members, outside resources, or both--must provide program staff with the following:

  • A general orientation in the following areas, within 3 months of employment: (1) the purpose and goals of older adult daily living services; (2) the roles and responsibilities of staff members; (3) positive approach methods to manage challenging behaviors; (4) health and safety precautions, including infection control; (5) information on fire and safety measures/codes; (6) the program's philosophy, and, if applicable, the parent organization; (7) confidentiality; (8) interdisciplinary team approach; (9) participants' rights; (10) the population served; (11) the center's policies and regulations; (12) communication skills; and (13) the center's emergency procedures.

  • Training in the following areas, within 3 months of employment and annually thereafter: (1) the needs of the participants in the center's target population; (2) body mechanics/transfer techniques; (3) reporting laws regarding abuse, neglect, and exploitation; and (4) positive approach methods to manage challenging behaviors.

  • At least two training sessions, totaling at least 8 hours of training a year, to enhance quality of care and job performance, in addition to the general orientation and annual training.

When protective devices--such as helmets, mitts, and muffs are used to prevent self-injury--at least one staff person who has completed training in the use of protective devices, including the use of alternative positive approaches--must be available. Staff persons applying protective devices must be trained in the use of the specific techniques or procedures

To assist centers in complying with provisions relating to program staff orientation and training, and to ensure that they provide general orientation, annual and enhancement training designed to ensure basic skills and knowledge, to introduce new skills and knowledge, and to enhance professional competencies, the regulations state that centers should consider using numerous training topics for each type of staff--program assistants/aide, activities coordinator, nurse, and program director/administrator.

The recommended topics are intentionally stated in broad terms so that they may include many specific subtopics, chosen by a particular center to meet its own needs. Topics recommended for a specific job function are not necessarily unique to that function, and may also be appropriately chosen for program staff persons performing other job functions. Suitable training topics are not limited to those recommended under each older adult day living center's staff function. Centers may appropriately choose other topics.

Location of Licensing, Certification, or Other Requirements

Pennsylvania Code, Chapter 11, Subchapter A: Older Adult Daily Living Centers, Licensure and Operating Requirements.http://www.pacode.com/secure/data/006/chapter11/chap11toc.html

Information Sources

Dianne ThealBureau of Quality AssuranceDivision of LicensingPennsylvania Department of Aging

RHODE ISLAND

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-rhode-island

Overview

The Rhode Island Department of Elderly Affairs requires all adult day care (ADC) programs to be licensed, regardless of payment source. ADC is covered by the Medicaid State Plan but not by any waiver programs. Medicaid requires all of its contracted providers to be licensed.

Any ADC program that offers to provide or provides special care services to participants with Alzheimer's dementia or other dementia is required to disclose the type of services provided to the Department and to any person seeking placement in the special care component of its program.

Definitions

Adult day care program means a comprehensive, non-residential program designed to address the physical, psychological, and social needs of adults through individual care plans that incorporate, as needed, a variety of health, social, and related support services in a protective setting.

Alzheimer's dementia or other dementia special care services means a program that offers services to one or more participants with a diagnosis of Alzheimer's dementia or other dementia.

Parameters for Who Can Be Served

ADC programs are required to define the target population(s) they intend to serve. Each program may serve only participants whose needs do not exceed the program's resources. Each participant must have a physical/mental condition indicating a need for nursing care, supervision, therapeutic services, support services, and/or socialization.

Providers are required to develop discharge/transition plans for participants with changes in service needs or functional status who require another level of care. Participants may be discharged from the program if they: (1) require specialized institutional care because of illness; or (2) develop behavioral problems that may endanger and/or disrupt other participants or staff members, and that are not modifiable by steps taken under the program's re-evaluation protocol.

Inspection and Monitoring

The Department of Elderly Affairs conducts or delegates inspections and investigations at such times and frequencies as it deems necessary. A duly authorized representative of the Department has the right to enter an ADC facility at any time without prior notice to inspect the premises and services prior to and after licensure.

Licenses are issued for 1 year, unless suspended or revoked sooner. Prior to renewing a license, the Department inspects the facility. Such inspection may be made any time prior to the date of the license's expiration. A newly licensed ADC facility must undergo an additional on-site inspection when ten participants have been enrolled and are in attendance on a regular basis.

An ADC facility that has been licensed for two consecutive 1-year periods, unless sooner suspended or revoked, may renew its license for additional, successive 2-year periods after inspection and approval by the Department. Such inspection may be made any time prior to the date of expiration of the current license.

Required and Optional Services

All ADC programs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

Required and Optional Services Adult Day Care
  Required     Optional  
ADL Assistance X  
Health Education and Counseling X  
Health Monitoring X  
Medication Administration X  
Nursing Services X  
Physical Therapy, Occupational Therapy, or Speech Therapy   X  
Skilled Nursing Services X  
Social Services X  
Transportation X  

Medication Provisions

The program must store and administer medications to participants as required in accordance with all applicable state and federal laws and regulations. The program has the right to not accept and/or to discharge a participant who refuses assistance with medications if the program reasonably feels that the participant cannot safely possess and control his/her medications. Licensed nurses and medication aides may administer medications. A nurse must monitor medication administration for all participants.

Staffing Requirements

Type of Staff. The program must designate one full-time staff member as the program director. The director has full authority and responsibility to plan, staff, direct, implement, and evaluate the program. The program director must designate a staff member to act in his/her absence. The director or designee must be on site to provide the program's day-to-day management during hours of operation.

The program must employ a nurse who will be on site daily for a minimum of 6 scheduled hours. Each program must employ at least one certified nursing assistant licensed by the State of Rhode Island.

The program must identify a staff person responsible for the functions of the activities director who will be on site daily for a minimum of 4 scheduled hours. If the program's daily enrollment is 24 or more participants, the program must have access to case management services on site or available for a minimum of 20 hours each week. During all operating hours, the program must have at least one staff member on site trained in first-aid, cardiovascular pulmonary resuscitation (CPR), and the Heimlich maneuver.

The ADC program that has an Alzheimer's dementia or other dementia special care services program must have no less than one registered nurse (RN) on staff and available for consultation at all times to manage and supervise all participant dementia-related health and behavioral issues. The RN must have appropriate training and/or experience with dementia.

Staffing Ratios. Each program must employ sufficient staff to maintain a ratio of one full-time staff member involved in direct service provision for each nine participants; however, a ratio of 1:6 is recommended. Secretaries, cooks, accountants, and other non-direct care staff members must not be considered in calculating the 1:9 ratio. The program must have an adequate number of qualified staff to meet participants' needs.

Training Requirements

Each program must have a written plan for staff training and development. Training must be completed within 30 days of hire and prior to working without direct supervision. Training must be provided no less than 10 hours annually and as needed and must include at least the following topics:

  • Orientation for all staff at the start of employment.

  • First-aid training, including CPR and the Heimlich maneuver, for appropriate staff.

  • Standard precautions and latex safety.

  • Developing, implementing, and evaluating individual care plans.

  • Specialized services (e.g., behavior management) offered by the program.

  • Identifying participants who abuse alcohol and/or other substances, suffer from depression, or are victims of elder abuse or self-neglect.

  • Information about services available to participants from outside programs or agencies.

  • Information about the medications prescribed for participants, benefits of the medications, common side effects and risks, and laws governing the administration of prescribed medications.

  • Participants' rights.

  • Confidentiality of participant information and records.

  • Diversity and cultural sensitivity.

In addition to training in the areas stipulated above, the director must ensure that all new employees who assist participants with personal care at the Alzheimer's dementia or other dementias special care services level of care receive at least 12 hours of orientation and training in the following topics: (1) understanding various dementias; (2) communicating effectively with persons with dementia; and (3) managing behaviors. Training must be within 30 days of hire and prior to beginning work alone in the ADC program.

Location of Licensing, Certification, or Other Requirements

Rules and Regulations for Licensing Adult Day Care Programs. State of Rhode Island and Providence Plantations, Department of Health. [November 2008]http://sos.ri.gov/documents/archives/regdocs/released/pdf/DOH/5333.pdf

Information Sources

Catherine LynnPrincipal Nursing Care EvaluatorFacilities RegulationsDepartment of Health

Andrew PowersChief of LicensingFacilities RegulationsDepartment of Health

SOUTH CAROLINA

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-south-carolina

Overview

All adult day care (ADC) facilities are required to be licensed by the South Carolina Department of Health and Environmental Control (DHEC), whether they serve publicly-funded or only private pay participants.

The South Carolina Department of Health and Human Services Community Long-Term Care program operates a Medicaid 1915(c) waiver program called Community Choices that authorizes adult day health care (ADHC) as a covered service. The Department of Disabilities and Special Needs also operates several 1915(c) waiver programs that offer ADHC services to different populations. In addition to being licensed as an ADC provider, ADHC providers must meet additional Medicaid requirements. Out-of-state ADHC providers must maintain a current ADC license from an equivalent licensing agency.

ADC services for participants who are not eligible for Medicaid are supported by small grants from the Family Caregiver Support Program, the Alzheimer's Association, and the South Carolina Respite Coalition. The source of this funding is a mix of federal and state grants. The Department of Veterans Affairs also provides funding for ADC.

Both licensing and Medicaid requirements are described in this profile.

Definitions

Adult day care services means activities and therapies offered in a day care facility for adults through an individualized care plan that sets forth measurable goals or behaviorally stated objectives, with such services being designed to activate, motivate, and retrain impaired or other categories of adults to enable them to sustain or regain functional independence.

Day care facility for adults is a facility for adults age 18 years or older that offers a program of individual and group activities and therapies in a group setting. The program is directed toward providing community-based day care services for adults in need of a supportive setting, thereby preventing unnecessary institutionalization. The program must operate a minimum of 4 hours and a maximum of 14 hours a day.

Adult Day Health Care. The objective of ADHC services is to restore, maintain, and promote the health status of Medicaid waiver participants through the provision of ambulatory health care and health-related supportive services in an ADC center. Providers may subcontract for licensed nursing services. The unit of service is a participant day of ADHC services consisting of a minimum of 5 hours at the center. When a participant needs to be at the center for more than 5 hours per day because no one is at home to care for the participant, the ADHC provider must allow the participant to remain at the center for up to 8 hours. The hours of operation may be any 8-hour period between 7:00am and 6:00pm.

Parameters for Who Can Be Served

Adults needing a supportive setting to prevent unnecessary institutionalization can be served in an ADC facility. However, individuals who are confined to a bed because of a physical or mental condition may not be served. The physician's report for each participant will enable an ADC facility to determine if it has the services needed to meet the individual's needs. Day care facilities for adults shall not serve participants whose needs exceed the resources outlined in the regulations.

Inspection and Monitoring

Each facility must be inspected before initial licensure and at least annually by authorized representatives of DHEC. All licensed and prospective licensed facilities are subject to inspection at any time. Medicaid providers are surveyed with unannounced site visits. The Division of Long-Term Care Waiver Management, Provider Compliance Department has developed a policy for clarification of the ADHC provider compliance process. A sanction scoring process has been developed to ensure that reviews are equitable and that providers know what to expect when they are reviewed. The policy gives detailed information on how provider compliance sanctions are implemented.

Required and Optional Services

All ADC and ADHC programs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

Required and Optional Services Adult Day Care   Adult Day Health Care  
  Required     Optional     Required     Optional  
ADL Assistance X   X  
Health Education and Counseling     X  
Health Monitoring/Health-Related Services     X  
Medication Administration   X X  
Nursing Services     X  
Physical Therapy, Occupational Therapy, or Speech Therapy          
Skilled Nursing Services        
Social Services        
Transportation     X1  
  1. Transportation is required for all ADHC participants who reside within 15 miles of the center.

Medication Provisions

Each participant's physician's report must include information regarding medications (name, type, dosage, and whether the individual is capable of self-administering). The licensing standards do not include any requirements regarding the conditions under which participants can self-administer medications or the conditions for administering medications to participants. Medicaid requires a registered nurse (RN) to supervise medication administration.

Staffing Requirements

Type of Staff. Each facility must have staff capable of providing program services and supervision for participants. A full-time administrator has the authority to manage and administer the facility. An individual must be appointed in writing to act in the absence of the administrator. At least one staff member who is certified with American Red Cross first-aid training and cardiovascular pulmonary resuscitation (CPR) (or American Heart Association CPR) and capable of recognizing symptoms of distress must be present when participants are in the facility. If the staff member is a licensed nurse, first-aid training is not required.

In addition, Medicaid requires ADHC providers to have on staff a registered nurse to monitor vital signs as needed; to observe the functional level of the participants and note any changes in the physical condition of each participant; to supervise the administration of medications; and to coordinate treatment plans with the physician, therapist, and other involved service delivery agencies. The RN must approve the documentation of the services provided. Should the RN position become vacant, the ADHC provider must notify the local Community Long-Term Care office no later than the next business day.

Staffing Ratios. The minimum staff-to-participant ratio is one direct care staff member to eight participants. Volunteers and interns may be used to augment the staff.

In addition to the minimum staffing required by licensing, the following staffing standards for nurses and case managers apply whenever Medicaid waiver program participants are present:

  • For 1-44 participants, one RN must be present as follows: 1-10, present for 2 hours minimum; 11-20, present for 3 hours minimum; 21-25, present for 4 hours minimum; 26-35, present for 5 hours minimum; and 36-44, present for 6 hours minimum.

  • For 45-88 participants, one RN and one additional RN or licensed practical nurse (LPN) must be present for a minimum of 5 hours.

  • For 89-133 participants, one RN and two additional RNs or LPNs; or one RN, one additional RN or LPN, and one case manager must be present for a minimum of 5 hours.

  • For 134 or more participants, one RN and three additional RNs or LPNs; or one RN, two additional RNs or LPNs, and one case manager must be present for a minimum of 5 hours.

Training Requirements

Each facility must have and execute a written orientation program to familiarize each new staff member with the facility and its policies and procedures. The program must include, at a minimum, fire safety measures and infection control. In-service training programs must be planned and provided for all employees to ensure and maintain their understanding of their duties and responsibilities.

Location of Licensing, Certification, or Other Requirements

Regulation Number 61-75, Standards for Licensing Day Care Facilities for Adults. South Carolina Department of Health and Environmental Control. [Updated December 5, 2003]http://www.scdhec.gov/Health/docs/61-75.pdf

Medicaid Home and Community-Based Waiver, Scope of Services for Adult Day Health Care Services. Source: Office of the Director, Community Long-Term Care Waiver Management, Department of Health and Human Services. [August 1, 2014]

Information Sources

Denise RiversProgram ManagerDivision for Community ResourcesSouth Carolina Lieutenant Governor's Office on Aging

Tony MatthewsProgram Coordinator IISouth Carolina MedicaidDepartment of Health and Human Services

Tammy QuarlesDirectorColumbia Adult Care, Inc.Columbia, South Carolina

SOUTH DAKOTA

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-south-dakota

Overview

South Dakota does not require licensure for adult day services (ADS). Providers serving participants funded through the Older Americans Act (OAA), the State's Caregiver Program, and the Medicaid 1915(c) Home and Community-Based Services waiver for South Dakotans program must have an approved contract or signed agreement with the South Dakota Department of Social Services, Division of Adult Services and Aging and meet its requirements, which are presented in this profile.

ADS can be co-located within a senior center, nursing facility, assisted living facility, hospital, church, child day care center, or can be a standalone program.

Definitions

Adult day services provide structured activities, care, and supervision outside of the home for part of a day. This enables the primary caregiver to work or pursue other daytime activities and provides a needed respite for the caregiver. The program also offers a nutritious meal at lunch time and snacks during the day. Limited nursing services, such as health screening, blood pressure checks, medication management, and a general assessment of the individual's condition, may be provided.

Adult day care provided under OAA, Title III State and Community Programs furnishes regularly scheduled, structured health and social services outside an individual's home for part of a 24-hour period.

Parameters for Who Can Be Served

Individuals must: (1) have a permanent physical disability that severely restricts mobility; (2) be blind, chronically ill, or have an acute medical condition that severely restricts mobility and requires temporary services; or (3) have the potential of entering a nursing or assisted living facility unless the services are provided.

The three various funding programs have specific eligibility criteria, which indicate the parameters for who can be served.

OAA-funded providers may serve persons 60 years of age or older who are not capable of full-time independent living because of physical, social, or mental impairment but who do not need 24-hour institutional care.

Waiver program providers may serve Medicaid-eligible adults who need a nursing facility level of care and receive one or more waiver services at least once per month.

The South Dakota Caregiver Program is primarily a respite program for caregivers. The program has complex requirements based on the age of the caregiver and the age of the person being cared for and his or her diagnosis or level of disability.

Inspection and Monitoring

A survey is conducted by State Department of Social Services prior to approval of the ADS contract.

Required and Optional Services

All ADS programs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

Required and Optional Services Adult Day Services
  Required     Optional  
ADL Assistance X  
Health Education and Counseling   X
Health Monitoring X  
Medication Administration   X
Nursing Services   X
Physical Therapy, Occupational Therapy, or Speech Therapy     X
Skilled Nursing Services   X
Social Services X  
Transportation   X

Medication Provisions

Licensed nurses or medication aides may assist with self-administration of medications.

Staffing Requirements

Type of Staff. Each program must have a director. The director and at least one other staff person must be certified in cardiovascular pulmonary resuscitation (CPR) and first-aid. A registered nurse or licensed practical nurse must be available to provide a monthly health screening for participants.

Staffing Ratios. None required.

OAA-Funded Providers

Type of Staff. A minimum of 10 hours of licensed nursing services shall be provided in the facility per month to provide general consultation and health screening services.

Staffing Ratios. The minimum ratio is one staff person to six participants and 1:5 if a high percentage of the participants are severely impaired.

Training Requirements

OAA-Funded Providers. Ongoing training includes at least four in-service training sessions per year to enhance quality of care and job performance. At the time of employment and annually each employee must receive training in the following: (1) needs of the ADS center's target population; (2) fire, safety, disaster, and emergency plans; (3) choking prevention and intervention techniques; (4) body mechanics/transfer techniques/assistance with activities of daily living; (5) basics of nutritional care, food safety, and safe feeding techniques; and (6) CPR and first-aid.

Location of Licensing, Certification, or Other Requirements

South Dakota Adult Services and Aging Programs Handbook. South Dakota Department of Social Services. [September 2010]http://dss.sd.gov/formspubs/docs/ELDERLY/ASAHandbook2010.pdf

Older Americans Act, Title III State and Community Programs. South Dakota Department of Social Services.http://dss.sd.gov/elderlyservices/services/funding/oldact/titleIII.asp

Adult Day Services. South Dakota Department of Social Services.http://dss.sd.gov/elderlyservices/services/adultdayservices.asp

State Regulations, Article 67:40:19: Home and Community-Based Services. Office of Adult Services and Aging.http://legis.sd.gov/Rules/DisplayRule.aspx?Rule=67:40:19

State Regulations, Article 67:40:20: Caregiver Support. Office of Adult Services and Aging.http://legis.sd.gov/rules/Displayrule.aspx?Rule=67:40:20

Information Sources

Molly KeeganDirector of Adult Day ProgramsSouth Dakota Adult Day Services Association

Yvette ThompsonSouth Dakota Department of Social ServicesDivision of Adult Services and Aging

TENNESSEE

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-tennessee

Overview

Tennessee requires that any adult day care (ADC) program caring for ten or more participants be licensed by the Tennessee Department of Human Services (DHS). If an ADC center is licensed by another agency of state government--for example, if it is operated by a nursing facility under that facility's license--after consultation with that agency, the Commissioner may determine that the provisions of the other licensing body adequately regulate the ADC center's program and that DHS licensing of the entity is unnecessary. In addition to licensing requirements, DHS promulgates rules that set the standards for ADC services; these rules apply to all licensed ADC programs.

The ADC program, regardless of its affiliation or location (e.g., in a nursing home or assisted living facility) must comply with the program content requirements as detailed in the rules. If an ADC center markets itself as a specific Alzheimer's disease program, then it is subject to further rules regarding the disclosure of treatment for Alzheimer's disease.

ADC services have multiple funding sources, including private pay, government grants (federal, state, county), United Way, the Department of Veterans Affairs, private foundations, individuals, and religious organizations. Title XX Social Services Block Grants and Title III Older Americans Act funding also cover ADC services, depending on the program's location in the state.

Tennessee does not cover ADC services under Medicaid 1915(c) waiver programs or under its State Plan. It is one of the few states that operates an 1115 Medicaid waiver program--TennCare CHOICES--which pays for ADC services.31 The program is administered by the TennCare managed care organizations (MCOs) under contract with the Bureau of TennCare. Each participating MCO creates its own contract with providers, who must be licensed as an ADC center and meet all other requirements for providing ADC services.

Definitions

Adult day care services are services provided to ten or more adults who are age 18 years32 or older, for more than 3 hours but less than 24 hours a day, by a provider of such services who is not related to such adults, pursuant to an individualized care plan designed to maintain or restore each adult's optimal capacity for self-care through medical or social services. ADC services provide: (1) supervised programs for adults with physical, neurological, or emotional problems requiring special intervention or care; (2) opportunities for socialization; (3) activities that help cognitively or physically-challenged adults maintain or improve their levels of functioning; and (4) respite for caregivers and family members as well as other services that delay institutionalization as long as possible.

Persons with Alzheimer's disease or other dementias or disabling diseases must be provided some type of therapy/intervention or special service which is specific to treating or assisting the affected person to better cope with his or her disability.

Parameters for Who Can Be Served

Individuals who require a structured program of organized activities that provides personal care, self-enhancement, and personal growth and development are appropriate for ADC services. Individuals who present a significant threat to themselves or others, or whose intellectual, emotional, or behavioral level prevents them from benefiting from a center's care plan, are not appropriate for ADC services, nor are individuals who need only leisure time activities, respite care, or sitter services.

Inspection and Monitoring

When an ADC program applies for a license, all necessary fire, safety, environmental, and food service establishment approvals must be received before DHS can conduct an initial inspection and any further inspections necessary to make a determination regarding the issuance of the license. DHS licensing evaluators perform both announced and unannounced visits to ADC programs throughout the year to ensure that they are complying with the rules.

All facilities must be inspected and approved annually by an environmentalist of the Tennessee Department of Health (DOH) or must receive annual approval as a licensed nursing home, a licensed hospital, a licensed assisted living facility, a licensed home for the aged, or licensed residential hospice by the DOH Division of Health Care Facilities. If proof of a DOH inspection is not provided, proof of an approved inspection by an environmentalist of the local health department must be received by DHS.

Required and Optional Services

All ADC programs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

Required and Optional Services Adult Day Care
  Required     Optional  
ADL Assistance X  
Health Education and Counseling   X
Health Monitoring/Health-Related Services   X
Medication Administration   X
Nursing Services   X
Physical Therapy, Occupational Therapy, or Speech Therapy      
Skilled Nursing Services   X
Social Services X  
Transportation   X

Medication Provisions

ADC centers must have a written policy that allows a participant to self-medicate or that allows staff to provide assistance to the participant for this purpose. Self-administration of medication permits staff to assist participants to read labels and open bottles, remind participants to take their medication, check the self-administered dose against the dosage shown on the prescription, observe the participant while taking medication, reassure participants that they are taking the correct dosage, and report any noticeable changes in a participant's condition to a physician and to the responsible party.

Under no circumstances may an employee or volunteer administer prescribed and non-prescribed, internal and external medication to a participant unless the employee is licensed to do so.

Staffing Requirements

Type of Staff. Center staff must be adequate in number and skill to ensure the safety and proper supervision of the participants and to carry out the center's objectives. At least one direct care staff member trained in cardiovascular pulmonary resuscitation, first-aid, fire safety, and the Heimlich maneuver must be present at all times.

Staffing Ratios. At least one direct care staff person must be available for every eight participants. Direct care staff are individuals whose regular job responsibilities place them in face-to-face contact with participants. Volunteers may be considered in determining direct care staff-to-participant ratios, provided that the volunteers' education and training meet the minimum requirements of the staff positions being filled. Volunteers who do not meet these minimum requirements may not be counted in the required ratio but may assist staff and other qualified volunteers. One responsible paid direct care staff member must, however, be present at all times if volunteers are used. Volunteers who do not possess the minimum qualifications must always be supervised by a direct care staff member.

For activities conducted inside the facility that involve all participants, such as viewing movies, watching special presentations, or observing performances, it may not be necessary to have a staff-to-participant ratio of 1:8, and a smaller number of staff may be used. There can, however, never be fewer than two direct care staff present when there are nine or more participants. For activities outside the facility such as field trips, staff numbers exceeding the 1:8 staff ratio may need to be used as necessary to provide adequate supervision for the participants because of their physical or mental status.

Training Requirements

Centers must provide staff with orientation and ongoing training/education to perform their duties. Staff development training must be provided to all employees on a regular basis at least 8 hours a year. This training may include consultations, workshops, or conferences as well as in-service education provided by the center. Training must include education to enable staff to recognize the signs and symptoms of abuse, neglect, or exploitation of an adult, as well as the duty to report abuse, neglect, or exploitation of an adult to the department.

Location of Licensing, Certification, or Other Requirements

Rules of the Tennessee Department of Human Services, Chapter 1240, 7-10.01 through 7-10.15: Adult Day Care Services Standards. Division of Community and Field Services. [February 27, 2000]http://www.state.tn.us/sos/rules/1240/1240-07/1240-07-10.pdf

Rules of the Tennessee Department of Finance and Administration, Bureau of TennCare, Chapter 1200-13-01-02 and -05: TennCare Long-Term Care Programs. [September 2011]http://tn.gov/sos/rules/1200/1200-13/1200-13-01.20110923.pdf

Tennessee Code Annotated. Title 68, Health, Safety and Environmental Protection, Chapter 11, Part 14: Alzheimer's Disease Treatment.http://law.justia.com/codes/tennessee/2010/title-68/chapter-11/part-14/

Tennessee Code Annotated. Title71, Welfare, Chapter 2, Part 4: Adult Day Care.http://law.justia.com/codes/tennessee/2010/title-71/chapter-2/part-4/

TennCare New and Existing Provider Registration.http://www.tn.gov/tenncare/pro-forms.shtml

Information Sources

J.J. DoughtieAssistant Executive DirectorAlzheimer's Day ServicesMemphis, Tennessee

Ruthann SheltonExecutive DirectorAlzheimer's Day ServicesMemphis, Tennessee

TEXAS

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-texas

Overview

The Texas Department of Aging and Disability Services (DADS) licenses adult day care (ADC) facilities. When covered by Medicaid, ADC is called day activities and health services (DAHS). ADC providers can serve private pay participants and they can also enter into a contract with DADS to furnish DAHS to Medicaid-eligible individuals.

Medicaid covers DAHS under Star+Plus--an 1115 managed care waiver program--and under a 1915(c) waiver program.33 Medicaid providers must be licensed.

Definitions

An adult day care program is a structured, comprehensive program designed to meet the needs of adults with functional impairments through an individual care plan by providing health, social, and related support services in a protective setting.

An adult day care facility provides services through an ADC program on a daily or regular basis, but not overnight, to four or more elderly persons or persons with disabilities who are not related by blood, marriage, or adoption to the owner of the facility.

Day activity and health services are provided under a contract with DADS to participants residing in the community as an alternative to living in a nursing facility or other institution. Services address physical, mental, medical, and social needs. ADC facilities must: (1) provide services at least 10 continuous hours each day, Monday through Friday, except for published holidays; (2) serve eligible participants, unless an ADC facility is at licensed capacity; and (3) participate in the Child and Adult Care Food Program.

Parameters for Who Can Be Served

Facilities may not admit or retain individuals whose needs it cannot meet.

To receive DAHS, individuals must be Medicaid-eligible, age 18 years or older, have a medical diagnosis and physician's order that care or supervision by a licensed nurse is required, have a functional disability related to a medical diagnosis, and need assistance with one or more personal care tasks.

Inspection and Monitoring

DADS determines if a facility meets the licensing rules, including both physical plant and facility operation requirements. Department inspection and survey personnel may enter the premises of a facility at reasonable times and make an inspection necessary to issue a license or renew a license. They perform inspections and surveys, follow-up visits, complaint investigations, investigations of abuse or neglect, and other contact visits as required for carrying out licensing responsibilities.

Generally, all inspections, surveys, complaint investigations, and other visits, whether routine or non-routine, made for the purpose of determining the appropriateness of participant care and day-to-day operations of a facility will be unannounced. Any exceptions must be justified.

The DAHS program may monitor providers to ensure that contract requirements are being met. The Health and Human Service Commission does not have specific inspection and monitoring requirements for DAHS provided under the Star+Plus program. However, the managed care organizations (MCOs) may have their own inspection and monitoring requirements, which can vary among MCOs.

Required and Optional Services

All ADC programs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

Required and Optional Services Adult Day Care
  Required1     Optional  
ADL Assistance X  
Health Education and Counseling X  
Health Monitoring/Health-Related Services X  
Medication Administration X  
Nursing Services X  
Physical Therapy, Occupational Therapy, or Speech Therapy      
Skilled Nursing Services    
Social Services X  
Transportation   X2
  1. ADC providers with DADS contracts who furnish DAHS through Medicaid programs are required to provide physical rehabilitative services, which include restorative nursing and group and individual exercises, including range of motion exercises.
  2. Transportation is a required service for DAHS providers.

Medication Provisions

Self-Administration. Participants who self-administer their own medications must be counseled at least once a month by licensed nursing staff to ascertain if they continue to be capable of self-administering their medications.

Assistance with Self-Administration. Assistance with self-administration of participants' medication regimen by licensed nursing staff may be provided to participants who are incapable of self-administering without assistance. Assistance with self-medication includes and is limited to: (1) reminders to take their medications at the prescribed time; (2) opening containers or packages and replacing lids; (3) pouring prescribed dosage according to medication profile record; (4) returning medications to the proper locked areas; (5) obtaining medications from a pharmacy; and (6) listing on an individual participant's medication profile record the medication name, strength, dosage, amount received, directions for use, route of administration, prescription number, pharmacy name, and the date each medication was issued by the pharmacy.

Administration. Participants who choose not to or cannot self-administer their medications must have their medications administered by a person who holds a current license under state law that authorizes the licensee to administer medications.

Staffing Requirements

Type of Staff. The director is responsible for the overall operation of the facility, including managing the ADC program and the facility and training and supervising facility staff. The activities director is responsible for planning and directing the daily program of activities, including physical fitness exercises or other recreational activities, and may fulfill the function of facility director if he/she meets the qualifications for this position.

The facility nurse must be a registered nurse (RN) or a licensed vocational nurse (LVN), with a current Texas license. If a nurse serving as director leaves the facility to perform other duties related to the provisions of the ADC program, an LVN or another RN must fulfill the duties of the facility nurse. One person may not serve as facility nurse, activities director, and facility director, regardless of qualifications. A professional staff person must be at the facility when participants are present.

In facilities where the nurse employed is a LVN, a registered nurse consultant must provide on-site consultation 4 hours per week. The RN consultant must provide the consultation during the time when participants are present in the facility and document the consultation provided. The RN consultant may provide the following types of assistance: (1) reviewing care plans and suggesting changes, if appropriate; (2) assessing participants' health conditions; (3) consulting with the LVN in solving problems involving participant care and service planning; (4) counseling participants on their health needs; (5) training, consulting, and assisting the LVN in maintaining proper medical records; and (6) providing in-service training for direct services staff.

Attendants provide personal care services (assistance with activities of daily living) and protective supervision (observation and monitoring), as well as assisting the activities director with recreational activities.

The facility must receive consultation at least 4 hours each month from a dietitian consultant, whether or not the facility has meals delivered from another facility with its own dietitian consultant. A consultant may provide consultation to several facilities as long as each facility receives at least 4 hours a month. The 4 hours cannot be "shared" by several facilities.

Staffing Ratios. Sufficient staff must be on duty at all times to meet participants' needs. The facility must ensure that the ratio of direct services staff to participants is at least 1:8 during the provision of all covered services except during facility-provided transportation.

At a minimum, one RN or LVN must be working on-site, 8 hours per day. The facility may schedule nursing hours according to participant needs. Sufficient licensed nursing staff must be on site to meet participants' nursing needs.

The facility director works a minimum of 40 hours per week performing duties relating to ADC services provision, and the activities director works 40 hours a week.

Training Requirements

The director must show evidence of 12 contact hours of annual continuing education in at least two of the following areas: (1) individual and provider rights and responsibilities; abuse, neglect, and confidentiality; (2) basic principles of supervision; (3) skills for working with individuals, families, and other professional service providers; (4) individual characteristics and needs; (5) community resources; (6) basic emergency first-aid, such as cardiovascular pulmonary resuscitation (CPR) or choking; or (7) federal laws, such as Americans with Disabilities Act, Civil Rights Act of 1991, the Rehabilitation Act of 1993, and the Family and Medical Leave Act of 1993.

Initial Training. The facility must provide all staff with training in fire, disaster, and evacuation procedures within 3 work days of employment. The facility must also provide direct services staff a minimum of 18 hours of training during the first 3 months of employment. Training must include: (1) any nationally or locally recognized adult CPR course/certification; (2) first-aid; and (3) orientation to health care delivery, including the following components:

  • Safe body function and mechanics;
  • Personal care techniques and procedures;
  • Overview of the population served at the facility; and
  • Identification and reporting of abuse, neglect, or exploitation.

Staff employed as substitutes on an infrequent and irregular basis are not required to have 18 hours of initial training. Substitute and consultant staff must receive a minimum of 3 hours of orientation. Substitutes for direct services staff used by a facility on a regular basis must meet all training requirements as specified above.

Ongoing Training. The facility must provide a minimum of 3 hours of ongoing training to direct services staff quarterly and must ensure that they maintain current certification in CPR.

Location of Licensing, Certification, or Other Requirements

Texas Administrative Code, Title 40, Chapter 98: Adult Day Care and Day Activity and Health Services Requirements. Department of Aging and Disability Services. [Various dates, the latest being May 1, 2013]http://info.sos.state.tx.us/pls/pub/readtac$ext.ViewTAC?tac_view=4&ti=40&pt=1&ch=98

STAR+PLUS Handbook. Texas Health and Human Services Commission. [March 4, 2014]http://www.dads.state.tx.us/handbooks/sph/index.htm

Day Activity and Health Services Provider Manual. Department of Aging and Disability Services. [February 28, 2005]http://www.dads.state.tx.us/handbooks/dahs/

Information Sources

Lorraine BradyProgram SpecialistAssisted Living Facilities, Adult Day CareTexas Department on Aging and Disability ServicesRegulatory Services

Armando DelgadoProgram SpecialistLong-Term Services and SupportsCenter for Policy and InnovationTexas Department on Aging and Disability Services

Troy CarterPresidentAdult Day Care Association of Texas

UTAH

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-utah

Overview

The Utah Department of Human Services licenses adult day care (ADC) providers, who must meet the requirements in the state's administrative rules that are described in this profile. A publicly-operated program must document its statutory basis for existence; a privately operated program must document ownership or incorporation.

Nursing facilities and certain assisted living facilities that offer ADC are not required to obtain a license but must submit policies and procedures for Department approval.

Utah offers ADC, called adult day health care (ADHC), through licensed providers under the following Medicaid 1915(c) waiver programs: Waiver for Individuals Aged 65 or Older, sometimes called the Aging waiver, and the New Choices waiver. The New Choices waiver program was developed to provide Medicaid program participants who have been residing long-term in a nursing facility or assisted living facility with the option of receiving long-term care services in home and community-based settings. In order to serve waiver program participants, ADHC providers must be licensed and enrolled with the state Medicaid agency.

The state also covers ADC under The Alternatives Program (TAP),34 a non-Medicaid assistance program specifically designed to prevent individuals from having to spend down their resources and become eligible for Medicaid. To be eligible, state residents must be at least 18 years of age and have a functional ability challenge which puts them at risk for nursing home placement.

TAP is funded by the Older Americans Act Title IIIB program and by a variety of state and local community resources, program fees, and voluntary and public contributions. The Utah Department of Human Services, Division of Aging and Adult Services oversees the program. In addition to licensure, TAP providers must meet additional requirements described in the state's administrative rules.

Definitions

Adult day care means continuous care and supervision for three or more adults aged 18 years and older--for at least 4 but less than 24 hours a day--that meets the needs of functionally impaired adults through a comprehensive program that provides a variety of health, social, recreational, and related support services in a protective setting.

Parameters for Who Can Be Served

ADC programs may serve functionally impaired adults 18 years of age or older. The programs must have written eligibility, admission, and discharge policies and procedures.

The New Choices waiver program serves older adult and working-age adults with a disability. Participants' primary condition must not be attributable to a mental illness and they must not need an "intensive skilled" nursing facility level of care or meet the level of care criteria for admission to an intermediate care facility for people with intellectual disabilities.

Waiver participants may be disenrolled if: (1) they no longer meet the institutional level of care requirements; (2) their health and safety needs cannot be met by the current program's services and supports; or (3) they have demonstrated non-compliance with the agreed-upon care plan and are unwilling to negotiate a plan of care that meets minimal safety standards.

Inspection and Monitoring

The Office of Licensing has the authority to review program records at any time.

Required and Optional Services

All ADC programs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

With the exception of medication administration and transportation, the state's regulations do not specify any of the services listed in this table as required or optional. Providers may decide what population they are going to serve and what services they will offer. Some providers may offer many of the services listed below while others offer only a few.

When serving Medicaid waiver program participants, providers are required to furnish any assistance needed to ensure participants' health and safety.

Required and Optional Services Adult Day Care
  Required     Optional  
ADL Assistance    
Health Education and Counseling    
Health Monitoring/Health-Related Services    
Medication Administration   X
Nursing Services    
Physical Therapy, Occupational Therapy, or Speech Therapy      
Skilled Nursing Services    
Social Services    
Transportation   X

Medication Provisions

All prescribed and over-the-counter medications must be provided by the participant, the responsible person, or by special arrangement with a licensed pharmacy. Providers must have written policies and procedures for participant self-administration of medications and for medication administration by persons with the legal authority to do so.

Staffing Requirements

Type of Staff. A qualified director must be designated by the governing body to be responsible for day-to-day program and facility management. The director must be either a: (1) licensed nurse; (2) licensed social worker; (3) licensed psychologist; (4) licensed or certified recreational or physical therapist; (5) licensed professional in a related field who has demonstrated competence in working with functionally impaired adults; or (6) person who has received verifiable training to work with functionally impaired adults and is in consultation on an ongoing basis with a licensed or certified professional with director credentials. The director or designee must be on site at all times during program operating hours.

The program must employ a sufficient number of trained, licensed, and qualified staff to meet participants' needs, implement the service plan, and comply with licensing rules. The program must have access to a physician licensed to practice medicine in the State of Utah, and must have a staff person trained by a certified instructor in first-aid and cardiovascular pulmonary resuscitation on duty with the participants at all times.

A program using volunteers, student interns, or other personnel must have a written policy to include direct supervision by a paid staff member.

Staffing Ratios. When eight or fewer participants are present, one staff person must provide direct supervision at all times with a second staff person meeting minimum staff requirements immediately available. When 9-16 participants are present, two staff must provide direct supervision at all times. The ratio of 1:8 will continue progressively. For programs with nine or more participants, administrative and maintenance staff must not be included in the staff-to-participant ratio.

In all programs where one-half or more of the participants are diagnosed by a physician's assessment with Alzheimer's disease or other dementia, the ratio must be 1:6.

Training Requirements

Staff members must be trained in all program policies and procedures. Staff must receive 8 hours of initial orientation training designed by the director to meet the program's needs, plus 10 hours of work-related training annually. Directors must also obtain 10 hours of relevant training annually. Volunteers must receive orientation and training in the program's philosophy, participants' needs, and methods for meeting those needs.

Providers must have written policies and procedures for behavior management that are given to all staff prior to working with participants. Staff must receive annual training regarding behavior management.

The Department of Human Services may require further specific training when contracting with providers to furnish services in publicly-funded programs.

Location of Licensing, Certification, or Other Requirements

Utah Administrative Code. Rule 501-13: Adult Day Care Licensing. Utah Department of Human Services, Division of Administrative Rules. [September 1, 2014]http://www.rules.utah.gov/publicat/code/r501/r501-13.htm

Utah Administrative Code. Rule R510-400: Home and Community-Based Alternatives Program. Utah Department of Human Services, Division of Administrative Rules. [September 1, 2014]http://www.rules.utah.gov/publicat/code/r510/r510-400.htm

Utah Administrative Code. Rule 432-150-6. Adult Day Care Services provided by nursing facilities.http://www.rules.utah.gov/publicat/code/r432/r432-150.htm#T6

Utah Administrative Code. Rule 432-270-29b. Adult Day Care Services provided by assisted living facilities.http://www.rules.utah.gov/publicat/code/r432/r432-270.htm#E30

Utah Department of Health website, Home and Community-Based Services Waiver Programs: Aging Waiver.http://health.utah.gov/ltc/AG/AGHome.htm

Utah Department of Health website, Home and Community-Based Services Waiver Programs: New Choices Waiver.http://health.utah.gov/ltc/NC/NCProviders.htm

Information Sources

Jeffery S. HarrisProgram ManagerDepartment of Health ServicesOffice of Licensing

VERMONT

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-vermont

Overview

Adult day services (ADS) programs must be certified by the Vermont Department of Disabilities, Aging and Independent Living (DAIL) and must meet the requirements specified in the Department's standards for ADS. Technically, an ADS provider does not need certification to open a center if services are not provided through DAIL-administered programs; however, the state is not aware of any such providers.

Many funding streams support ADS, including private payment, veteran's benefits, and state general revenue funds.35 Medicaid also pays for ADS through the Vermont Choices for Care 1115 Long-Term Care waiver program and through the Medicaid State Plan. In addition to the state's certification standards, Medicaid providers must also comply with additional Medicaid requirements. This profile includes both certification and Medicaid requirements.

Definitions

Adult day centers provide a safe, supportive environment where participants can receive a range of professional health, social, and therapeutic services. Any adult day center that shares a facility with another type of program or service (e.g., a nursing home, residential care home, or senior center) must have dedicated staff with hours committed to the adult day center only.

Adult day services are community-based non-residential services designed to assist adults with physical and/or cognitive impairments to remain as active in their communities as possible by maximizing their level of health and independence and ensuring their optimal functioning. ADS also provide respite, support, and education to family members, caregivers, and legal representatives.

The Choices for Care Medicaid waiver program defines adult day services as a range of health and social services provided at a certified adult day center; they are furnished for a specified number of hours per day on a regularly scheduled basis for 1 or more days per week, limited to a maximum of 12 hours per day. The program has three levels of assessed needs: highest needs, high needs, or moderate needs. Participants in the moderate needs group are limited to a maximum of 50 hours per week.

Parameters for Who Can Be Served

Adult day centers are required to make every reasonable effort to first serve those applicants most at risk of institutionalization, taking into account the needs of other participants. Participants cannot be involuntarily discharged unless their care needs exceed those an adult day center is certified to provide or the participant presents a threat to himself or herself, other participants, or staff.

The Medicaid Choices for Care waiver program eligibility rules state that an individual must have a functional physical limitation associated with aging or resulting from a physical condition (including stroke, dementia, traumatic brain injury, and similar conditions). Individuals whose need for services is due to intellectual disability, autism, or mental illness are not eligible for the Choices for Care waiver program.

Inspection and Monitoring

DAIL completes an initial certification visit and thereafter a scheduled and announced annual site certification review. The Department reserves the right to perform an unannounced site visit at any time to verify that the adult day center is in compliance with the standards.

Required and Optional Services

All ADS programs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

Required and Optional Services Adult Day Services
  Required     Optional  
ADL Assistance   X
Health Education and Counseling   X
Health Monitoring/Health-Related Services X  
Medication Administration X  
Nursing Services X  
Physical Therapy, Occupational Therapy, or Speech Therapy      
Skilled Nursing Services   X
Social Services X  
Transportation   X1
  1. When feasible, centers must provide, formally arrange, or contract for transportation to enable participants to attend the center. The cost of transportation services is not included in Medicaid-reimbursed ADS, but programs serving high and highest needs participants must assist in arranging and coordinating transportation. The costs of transporting Medicaid waiver participants to and from the ADS site may be eligible for reimbursement under the Medicaid State Plan as a transportation service.

Medication Provisions

An adult day center must have the capacity to administer medications to its participants. A medication management policy must describe a center's medication management practices with due regard for state requirements, including the Vermont Nurse Practice Act. An adult day center must provide medication management under the supervision of a registered nurse (RN) or a licensed practical nurse (LPN) under the direction of an RN. A participant may self-administer medication, which must be stored by the adult day center. If a participant requires medication administration, unlicensed staff may administer medications under certain conditions (e.g., there is a physician's written order on file and an RN, or an LPN under the direction of an RN, has delegated administration of specific medications to designated staff for designated participants).

Staffing Requirements

Type of Staff. An adult day center must have a qualified administrator who is responsible for meeting and maintaining continual compliance with the standards and all relevant federal, state, local, or municipal laws, regulations, policies, and/or procedures. In addition, the center must have a program coordinator who is responsible for the organization, implementation, and coordination of the adult day center's daily operation. The same individual may fulfill both positions, in which case the administrator minimum qualifications apply.

A qualified staff member must be designated to oversee the center's operations in the absence of the person responsible for administration/program coordination. The staff member(s) providing health coordination services (e.g., health assessments) must have a current Vermont RN license and a minimum of 1 year of applicable experience.

Staffing Ratios. During hours of operation, the center must have a sufficient number of responsible persons to safely meet participants' needs, including one full-time or part-time direct services staff member. The required direct services staff-to-participant ratio is a minimum of 1:7. As the number of participants with functional or cognitive impairments increases or the severity of the impairment increases, the direct services staff-to-participant ratio must be adjusted accordingly to meet participants' needs. Paid program consultants and contractors, persons working under agency contract, and volunteers may be included in the direct services staff-to-participant ratio only when they are performing the job tasks and responsibilities defined in a job description, and possess the qualifications necessary to fill that position.

Training Requirements

An adult day center must develop and implement an orientation policy for persons employed full-time or part-time, paid consultants or contractors, persons working under agency contract, and volunteers who provide unsupervised direct services to participants. A center must also develop and implement a training policy for all of its full-time and part-time employees.

For each direct services staff person, a center must provide a minimum of 12 hours of training per year that will build his or her capacity to provide quality ADS; for administrative staff, a center must provide training as necessary. For each dual-role staff, a center must provide a minimum of 12 hours of training per year and additional administrative training as necessary.

Location of Licensing, Certification, or Other Requirements

Standards for Adult Day Services in Vermont, Agency of Human Services, Vermont Department of Disabilities, Aging and Independent Living. [March 1, 2012]http://ddas.vermont.gov/ddas-programs/ddas-policies/policies-adult-day/policies-adult-day-documents/standards-for-adult-day-services-vt

Choices for Care, 1115 Long-Term Care Medicaid Waiver. Division of Disability and Aging Services, Department of Disabilities, Aging and Independent Living website with links.http://ddas.vermont.gov/ddas-programs/programs-cfc/

Choices for Care, 1115 Long-Term Care Medicaid Waiver Regulations. Agency of Human Services, Vermont Department of Disabilities, Aging and Independent Living. [February 9, 2009]http://dail.vermont.gov/dail-statutes/statutes-ddas-cfc-documents/cfc-regulations

Choices for Care 1115 Long-Term Care Medicaid Program Manual, Highest and High Needs Manual, Section 4.2: Adult Day Services. Vermont Department of Disabilities, Aging and Independent Living. [August 2013]http://ddas.vermont.gov/ddas-policies/policies-cfc/policies-cfc-highest/policies-cfc-highest-documents/cfc-high-manual-section-4-2

Choices for Care 1115 Long-Term Care Medicaid Program Manual, Moderate Needs Manual, Section 4.2: Adult Day Services. Vermont Department of Disabilities, Aging and Independent Living. [May 2009]http://ddas.vermont.gov/ddas-policies/policies-cfc/policies-cfc-moderate/policies-cfc-moderate-documents/sec-iv2-adult-day

Information Sources

Megan Tierney-WardAdult Services Division DirectorDepartment of Disabilities, Aging and Independent Living

VIRGINIA

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-virginia

Overview

Adult day care (ADC) centers are licensed by the Virginia Department of Social Services (DSS) and the State Board of Social Services prescribes service standards. Applicants for licensure must complete a pre-licensure orientation program that focuses on health and safety standards and residents' rights, offered through or approved by DSS. The Commissioner may, at his or her discretion, waive the orientation requirement or issue a license conditioned upon the owner's or administrator's completion of the required training. Applicants for licensure are exempt from the requirement for pre-licensure training if notified by DSS that such training is unavailable.

ADC providers can serve private pay participants and they can also enter into a contract with the Virginia Department of Medical Assistance Services (DMAS) to furnish adult day health care (ADHC) services to Medicaid-eligible individuals under the 1915(c) Elderly or Disabled Consumer-Direction (EDCD) waiver program. ADHC providers must meet the state's licensure requirements and adhere to the ADC center standards summarized in this profile. In addition, they must comply with requirements in the DMAS provider manual, also summarized in this profile under the relevant headings.

Definitions

Adult day care center means a licensed facility that provides supplementary care and protection during a part of the day to four or more aged, infirm, or disabled adults who reside elsewhere, except in: (1) a facility or portion of a facility licensed by the State Board of Health or the State Board of Mental Health, Mental Retardation and Substance Abuse Services; and (2) the home or residence of an individual who cares only for persons related by blood or marriage.

Adult day health care services are community-based day programs licensed by DSS as an ADC center providing a variety of health, therapeutic, and social services designed to meet the specialized needs of elderly and physically disabled participants who are at risk of being placed in a nursing facility. The purpose of ADHC services is to augment EDCD waiver participants' social support system in the community in order to avoid institutionalization. A day of ADHC services is defined as a minimum of 6 hours.

Parameters for Who Can Be Served

All participants must be age 18 years or older. The ADC center must develop a written statement of the purpose and scope of the services to be provided by the center, and a description of adults who may be accepted into the program as well as those whom the program cannot serve. Only persons who meet the admission criteria may be admitted to the center. Centers may be licensed to serve ambulatory and/or non-ambulatory participants. When centers can no longer meet participants' needs, plans must be made for their discharge. Participants can also be involuntarily discharged when their condition presents an immediate and serious risk to their or others' health, safety, or welfare.

Medicaid ADHC services may be offered to elderly and physically disabled waiver participants who have been assessed to be at risk of institutionalization. A center can admit participants who have skilled needs only if professional nursing staff are immediately available on-site to provide the specialized nursing care required. DMAS, or the designated pre-authorization contractor, has the responsibility and the authority to terminate ADHC services for Medicaid waiver participants for any of the following reasons:

  1. The service is not a critical alternative to prevent or delay institutional placement.

  2. The participant no longer meets nursing home level of care criteria.

  3. The participant's environment does not provide for her/his health, safety, and welfare.

  4. An appropriate and cost-effective plan of care cannot be developed.

Inspection and Monitoring

Initial licenses and renewals for an ADC center may be issued for periods of up to 3 successive years, unless sooner revoked or surrendered. Licensees must at all times afford the Commissioner reasonable opportunity to inspect their facilities, books, and records, and to interview their agents and employees and any person participating in such facilities.

ADC centers issued a license for a period of 6 months are inspected at least twice during the 6-month period, and at least one of these inspections is unannounced. ADC centers issued a license for a period of 1 year are inspected at least three times each year, and at least two of these inspections are unannounced. ADC centers issued a license for a period of 2 years are inspected at least twice each year, and at least one of those inspections is unannounced. For any ADC center issued a 3-year license, the Commissioner makes at least one unannounced inspection each year.

DMAS conducts ongoing monitoring to determine compliance with Medicaid provider participation standards and DMAS policies. Non-compliance with DMAS policies and procedures, as required in the provider's contract, may result in a retraction of Medicaid payment or termination of the provider agreement.

Required and Optional Services

All ADC and ADHC programs provide socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

Required and Optional Services Adult Day Care Adult Day Health Care
  Required     Optional     Required     Optional  
ADL Assistance X   X  
Health Education and Counseling        
Health Monitoring X   X  
Medication Administration X   X  
Nursing Services X   X  
Physical Therapy, Occupational Therapy, or Speech Therapy   X1   X2  
Skilled Nursing Services   X X  
Social Services     X  
Transportation   X X2  
  1. Facilities must arrange for specialized rehabilitative services by qualified personnel as needed by participants. All rehabilitative services rendered by a rehabilitative professional can be performed only upon written medical referral by a physician or other health care professional.
  2. ADHC centers are required to coordinate rehabilitative therapies. The center may arrange for individual rehabilitation treatment with an outpatient facility or independent rehabilitation provider. Rendering of the specific rehabilitative therapy is not included in the center's fee for services.
  3. ADHC centers are required to coordinate transportation but must also provide transportation when needed in emergency situations for any Medicaid-eligible participant to and from his or her home (e.g., if the primary caregiver has an accident and cannot transport the individual home). Any center which is able to provide individuals with transportation routinely to and from the center from their residence, can be reimbursed by DMAS based on a per-trip fee.

Medication Provisions

Unless it is contrary to the day care center's policy, participants may take their own medication if a physician has deemed them capable of doing so and has given written authorization for them to self-administer medications. The use of PRN (as needed) medications is prohibited unless certain conditions exist, including: (1) a participant is capable of determining when the medication is needed; (2) a licensed health care professional administers the medication; or (3) the participant's physician has provided detailed written or documented verbal instructions.

The center must have a written policy for medication management that addresses methods of administering medication. Prescription and non-prescription medications, including physician's samples, can be given to a participant only with written or verbal authorization from the physician or prescriber or the physician's authorized agent. All staff responsible for medication administration must be licensed by the state to administer medications or must successfully complete the most current medication training program developed by DSS and approved by the Board of Nursing. They must also complete the current approved refresher course every 3 years.

Medicaid ADHC centers must employ or contract with a registered nurse (RN) who is responsible for administering prescribed medications, supervising participants who self-administer medication, or generally supervising staff who are certified through the Board of Nursing in medication management and administering medications.

Staffing Requirements

Adult Day Care

Type of Staff. The ADC center must employ a director whose responsibilities include, but are not limited to, the following areas: program content; programmatic functions, including orientation, training, and scheduling of all staff who directly supervise participants, whether or not the director personally performs these functions; and management of the supervision provided to all staff who directly supervise participants, whether or not the director individually supervises such staff.

If the director is not routinely present in the center at least 51 percent of the weekly hours of operation, there must be an officially designated assistant director who has the qualifications of the director and who must assume responsibility in the director's absence. During the center's hours of operation, one adult on the premises must be in charge of the center's administration. This person must be either the director or a staff member appointed by the licensee or designated by the director. At least one staff member trained in first-aid and cardiovascular pulmonary resuscitation (CPR) must be on the premises during the center's hours of operation and on field trips. At least one staff member must be assigned responsibility for overall selection, supervision, and orientation of volunteers. In the event the center provides skilled health care services to meet participants' needs, the provider of health care must be licensed, certified, or registered as required by law.

Staffing Ratios. At least two staff persons must be on duty at the center and on field trips at all times when one or more participants are present. Both of these staff persons must be at least 18 years of age and one of them must be at least 21 years of age. There must be a minimum of one staff person on duty providing direct care and supervision for every six participants, whether at the center or on field trips. All staff persons who work directly with participants and who are counted in the staff-to-participant ratio must be at least 18 years of age.

The staff-to-participant ratio is to be calculated for the center rather than for a room or activity. The number of any additional staff persons required depends upon: (1) the program and services the center provides; (2) the participants' functional level; and (3) the facility's size and physical layout. Volunteers may be counted in the staff-to-participant ratio if both of the following criteria are met: (1) they have the same qualifications as compensated employees and meet the same training requirements; and (2) for each volunteer, at least one compensated employee is also counted in the staff-to-participant ratio.

Adult Day Health

Type of Staff. The ADHC center must employ a director who is responsible for overall management of the center's programs and supervision of its employees; an activities director, who is responsible for directing recreational and social activities for the participants; and program aides, who are responsible for overall care of the participants (activity of daily living [ADL] assistance, social/recreational activities, and assistance with the management of the individual's care plan). In the absence of the director, the center must designate the activities director, a RN, or a therapist to supervise the program. The director can also serve as the activities director if he or she has the qualifications for that position. The ADHC center may use one person to fill more than one professional position as long as the requirements for both positions and other staffing requirements are met.

The ADHC provider must also employ or contract with a registered nurse who is licensed to practice nursing in the Commonwealth of Virginia. The RN is responsible for administering to and monitoring the health needs of the participants, and for the planning and implementation of the care plan involving multiple services where specialized health care knowledge is needed.

The nurse must be present a minimum of 8 hours each month at the center, or more, depending on the number of participants in attendance and according to their medical and nursing needs. Although DMAS does not require that the RN be a full-time staff position, a RN must be available, either in person or by telephone, to the center's participants and staff during all times that the center is in operation.

Staffing Ratios. The number of staff required for an ADHC center depends upon the level of care required by its participants. Each ADHC center is required to employ sufficient interdisciplinary staff to adequately meet participants' health, maintenance, and safety needs. The center must provide at least two staff members awake and on duty at all times when there are Medicaid waiver participants in attendance, and maintain a minimum staff-to-participant ratio of at least one staff member to every six participants (waiver program and other participants). However, DMAS reserves the right to require an ADHC center to employ additional staff if, on review, DMAS staff find evidence of unmet participant needs. Volunteers may be included in the staff-to-participant ratio only when they have the same qualifications and meet the same training requirements as paid staff, and for each volunteer there must be at least one paid employee also included in the staff-to-participant ratio.

Training Requirements

Prior to working directly with participants, all staff must receive training in: (1) their individual responsibilities in the event of fire, illness, injury, and other emergencies; (2) standard precautions; and (3) participant rights. Staff who work with participants must receive at least 24 hours of training no later than 3 weeks after starting employment; part-time staff must receive the training no later than 6 weeks after starting employment.

Staff training must cover a range of topics including: (1) needs of the center's target population (for example, those with dementia, a developmental disability, and/or depression); (2) the purpose and goals of the ADC center; (3) behavioral interventions, behavior acceptance and accommodation, and behavior management techniques; (4) how to safely and appropriately help participants perform ADLs, including use of good body mechanics; and (5) confidential treatment of personal information about participants and their families. The required 24 hours of training can be accomplished through a variety of methods including, but not limited to, formal lecture, observation, self-study of material provided by the center, supervised practice, and audiovisual training.

On an annual basis, employed staff who are primarily responsible for the direct care of the participants must attend at least 8 contact hours of staff development activities that must consist of in-service training programs, workshops, or conferences relevant to the needs of the population they serve. These staff development activities must be in addition to first-aid, CPR, or orientation training. The director must complete 24 hours of continuing education annually to maintain and develop skills. This training must be in addition to first-aid, CPR, and orientation training.

No additional training requirements were specified for Medicaid ADHC providers.

Location of Licensing, Certification, or Other Requirements

Code of Virginia, Title 63.2, Chapter 17: Licensure and Registration Procedures. [July 1, 2014]http://www.dss.virginia.gov/files/division/licensing/adcc/intro_page/code_regulations/code/2014_code_of_virginia.pdf

General Procedures and Information for Licensure. Virginia Department of Social Services, Division of Licensing Programs. [July 17, 2013]http://www.dss.virginia.gov/files/division/licensing/adcc/intro_page/code_regulations/regulations/final_gp_reg_071713.pdf

Standards and Regulations for Licensed Adult Day Care Centers. Virginia Department of Social Services, Division of Licensing Programs. [July 17, 2013]http://www.dss.virginia.gov/files/division/licensing/adcc/intro_page/code_regulations/regulations/final_adcc_reg_071713.pdf

12 Virginia Administrative Code, 30-120-940: Adult day health care services. [May 19, 2014]http://leg1.state.va.us/cgi-bin/legp504.exe?000+reg+12VAC30-120-940

Elderly or Disabled with Consumer Direction Waiver Services Provider Manual. Chapter II: Provider Participation Requirements [July 18, 2014] and Chapter IV: Covered Services and Limitations [October 31, 2011]. Department of Medical Assistance Services.https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/ProviderManual

To access the two chapters listed above, click on the Elderly or Disabled with Consumer Direction Waiver Services manual from the drop-down list provided under the heading Accessing Provider Manuals. This will take you to a Table of Contents for that particular manual.

Information Sources

The websites listed above are the only source of information for this profile. It was not possible to find state agency staff to review the profile.

WASHINGTON

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-washington

Overview

Washington has two types of adult day services (ADS): adult day care (ADC) and adult day health (ADH) and does not license either. ADC and ADH centers that contract with the Washington State Department of Social and Health Services--or a Department designee such as an Area Agency on Aging (AAA)--to serve Medicaid waiver program participants must comply with specific contracting requirements in the state's administrative code, which are described in this profile.

Washington covers both types of ADS through two Medicaid waiver programs--the 1915(c) Community Options Program Entry System (COPES) and the 1115 Roads to Community Living program--and under non-Medicaid programs funded with state and federal dollars.

A COPES-eligible participant may receive ADC services on some days and adult day health services (ADHS) on different days if the service plan documents which level of service is to be provided on which days. However, core services must be provided on all days that ADH skilled services are provided. Participants receiving services from the Department in an adult family home, boarding home, or other licensed community residential facility may not receive COPES-funded ADC, but may receive Medicaid ADHS when the skilled nursing or rehabilitative services are approved by the participant's case manager as part of the participant's service plan.

ADC or ADH centers that receive Senior Citizens Services Act or Respite Care funding must provide the same services that are required for centers contracting with Medicaid. An AAA that elects to provide ADS using Senior Citizens Services Act or Respite Care funding must contract with an adult day center that meets all administrative and facility requirements. The AAA may require additional services by contract.

Definitions

Adult day services is a generic term for ADC and ADHS. An ADS program is a community-based program designed to meet the needs of adults with impairments through individual care plans. This type of structured, comprehensive, non-residential program provides a variety of health, social, and related support services in a protective setting. By supporting families and caregivers, an ADS program enables the person to live in the community.

Adult day care is a supervised daytime program providing core services for adults with medical or disabling conditions that do not require the intervention or services of a registered nurse (RN) or licensed rehabilitative therapist.

Adult day health is a supervised daytime program providing skilled nursing, rehabilitative therapy services, and psychological or counseling services, in addition to the core services provided in ADC programs.

Adult day center means an ADC or ADH center.

Parameters for Who Can Be Served

Medicaid has different eligibility criteria for ADC and ADH care. These criteria indicate the parameters for who can be served in these settings.

Adult Day Care. Adults with medical or disabling conditions that do not require the intervention or services of a RN or licensed rehabilitative therapist but who need one or more of the following services: personal care, routine health monitoring with consultation from a RN, general therapeutic activities, or supervision and/or protection for safety.

The ADC center must offer and provide core services on site that meet the level of care needed by the participant as assessed by the department case manager for waiver program participants but do not exceed the scope of services that the ADC center is able to provide.

Adult Day Health. ADHS are only appropriate for adults with medical or disabling conditions that require the intervention or services of a RN or licensed rehabilitative therapist acting under the supervision of the participant's physician.

Individuals cannot be served if their needs exceed the scope of authorized services that the ADH center is able to provide or if they are not capable of participating safely in a group care setting.

Provisions Applicable to Both Adult Day Care and Adult Day Health. Discharge policies must include specific criteria that establish when a participant is no longer eligible for services and under what circumstances the participant may be discharged for other reasons. Unless the discharge is initiated by the participant's department or authorized case manager, the center must notify in writing the participant and his/her representative, if applicable, and his/her case manager of the specific reasons for the discharge. Discharge may occur due to participant choice, other criteria as defined in the center's policy, such as standards of conduct or inappropriate behavior, or changes in circumstances making the participant ineligible for services.

Inspection and Monitoring

The department, or an AAA, or other department designee, must determine that the ADC or ADH center meets the applicable requirements and any additional requirements for contracting through a COPES or other Medicaid provider contract. The determination process includes an on-site inspection. If a center is contracting for both ADC and ADH, requirements of both ADS must be met.

The AAA or other Department designee monitors the adult day center at least annually to determine continued compliance with ADC and/or ADH requirements and contracting requirements.

Required and Optional Services

All ADS programs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

Required and Optional Services Adult Day Care Adult Day Health
  Required     Optional     Required1     Optional  
ADL Assistance X   X  
Health Education and Counseling X   X  
Health Monitoring X   X  
Medication Administration   X2 X  
Nursing Services X3   X  
Physical Therapy, Occupational Therapy, or Speech Therapy       X4  
Skilled Nursing Services     X  
Social Services X3   X  
Transportation   X5   X5
  1. Psychological or counseling services are an additional required service for ADH providers. They include assessing for psychosocial therapy need, dementia, abuse or neglect, and alcohol or drug abuse; making appropriate referrals; and providing brief, intermittent supportive counseling.
  2. ADC must also provide medication management that does not require a licensed nurse. (NOTE: We did not find a definition of medication management in the regulations and were unable to locate a state agency staff person to define the term.)
  3. Services may be provided by consultation.
  4. Providers must offer at least one of the three skilled rehabilitation therapies.
  5. Providing transportation is optional. Assisting with arranging transportation is required.

Medication Provisions

ADC and ADH providers must develop written policies that are explained and accessible to all staff, contractors, volunteers, and participants. Medication policies must describe: (1) under what conditions licensed program staff will administer medications; (2) how medications brought to the program by a participant are to be labeled; (3) how non-prescription medications, such as aspirin or laxatives, are to be used; and (4) how the administration of medications will be entered in participant case records.

Medication policies must be consistent with laws governing medication administration and staff must be trained to observe medication usage and effects and to document and report any concerns or difficulties with medications.

Participants who need to take medications while at the center and who are able to self-medicate, must be encouraged, and are expected to bring and take their own medications as prescribed. Some participants may need assistance with their medications, and a few may need to have their medications administered by qualified program staff. In order for center staff to administer any prescribed medication, there must be a written authorization from the participant's authorizing practitioner stating that the medication is to be administered at the program site.

Washington permits certified nursing assistants, who meet specific education and training and work experience requirements, to be endorsed as medication assistants. Medication assistants can administer oral, topical, and inhalant medications under the direct supervision of a designated RN who is on site and immediately accessible during the medication assistant's shift. The RN must assess the resident prior to the medication assistant administering medications or treatments and determine whether it is safe to do so.

The RN must retain (i.e., must not delegate) the judgment and decision to administer medications. Medication assistants may not accept telephone or verbal orders from a prescriber; calculate medication dosages; inject any medications; administer medications through a tube; administer any Schedule I, II, or III controlled substance; or perform any task that requires nursing judgment.

Staffing Requirements

Adult Day Care

Type of Staff. Minimum staffing requirements include an administrator/program director, an activity coordinator, a consulting registered nurse, and a consulting social worker.

Adult Day Health

Type of Staff. Minimum staffing requirements include an administrator, a program director, a registered nurse, an activity coordinator, a physical therapist, occupational therapist, or speech therapist, and a social worker. The administrator and program director may be the same person.

The following requirements apply to both adult day care and adult day health providers.

Staff selection is dependent on participants' needs, program design, and contracting requirements. Providers must have the proper balance of professionals and paraprofessionals or non-professionals to adequately meet participants' needs. Services must be delivered by those with adequate professional training. A staff person can have multiple functions, such as an administrator who is also responsible for providing nursing services or social services.

An administrator must be on site to manage the center's day-to-day operations during hours of operation. If the administrator is responsible for more than one site or has duties not related to adult day center administration or service provision, a program director must be designated for each additional site and must report to the administrator. A nurse or personnel trained in first-aid and cardiovascular pulmonary resuscitation (CPR) must be on site whenever participants are present. Providers may use a range of staff under contract or consulting from a larger parent organization or from a private entity to provide services.

Volunteers may be individuals or groups who desire to work with participants and must take part in program orientation and training. Volunteers and staff must mutually determine the duties of volunteers. Duties to be performed under the supervision of a staff member must either supplement staff in established activities or provide additional services for which the volunteer has special talents. Volunteers will be included in the staff ratio only when they conform to the same standards and requirements as paid staff, meet the job qualification standards of the organization, and have designated responsibilities.

Staffing Ratios. Staffing levels in adult day centers will vary based upon the number of participants and the care provided but must be sufficient to serve the number and functional levels of participants, meet program objectives, and provide access to other community resources. When there is more than one participant present, there must be at least two staff members on the premises, one of whom is directly supervising the participants.

All centers must have written policies regarding staff-to-participant ratios. The ratio must be a minimum of 1:6. Staff counted in the ratio are those who provide direct service to participants. As the number of participants with functional impairments, skilled nursing, or skilled rehabilitative therapy needs increases, the required staff-to-participant ratio must be adjusted accordingly. To ensure adequate care and safety of participants, the center must have provisions for qualified substitute staff.

Training Requirements

The following requirements apply to both adult day care and adult day health providers.

All new employees, contractors, and volunteers must receive an orientation. At a minimum, all staff, contractors, and volunteers must receive quarterly in-service training and staff development that meets their individual training needs to support program services.

Staff, contractors, and volunteers must receive training about documentation, reporting requirements, and universal precautions. At a minimum, one staff person per shift must be trained and certified in CPR. Staff and volunteers must receive training on all applicable policies and procedures.

Location of Licensing, Certification, or Other Requirements

Washington Administrative Code, Title 388, Chapter 71-0702 through 71-0776: Home and Community Services and Programs--Adult Day Services. [June 24, 2014]http://app.leg.wa.gov/wac/default.aspx?cite=388-71&full=true#388-71-0702

Information Sources

Staff in the Aging and Long-Term Support Administration Home and Community Services

Sarah MillerDirectorSenior Living and Community ServicesLeadingAge Washington

WEST VIRGINIA

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-west-virginia

Overview

The state licenses medical adult day care (ADC) centers as a special type of ambulatory health care center. The West Virginia Department of Health and Human Resources, Office of Health Facility Licensure and Certification, Assisted Living Program, is the office responsible for maintaining oversight of medical ADC centers. A medical ADC program maintained and operated by a nursing home, hospital, or other licensed health care facility must comply with the standards in the medical ADC licensing rule; compliance must be evaluated independently from compliance with other licensure standards. Sharing of staff, space, physical facilities, and equipment may be permitted only if the requirements of each applicable rule are satisfied in full.

The medical ADC center licensure rule does not apply to programs carried out by a licensed behavioral health center unless the program routinely offers medical treatment services in addition to behavioral health services. The rule also does not apply to ADC programs that are primarily social and recreational in nature, but that may occasionally offer medical screening clinics. These programs are neither licensed nor certified, and the only funding source for such programs is the Department of Veterans Affairs (VA) and grants to local senior centers.

West Virginia Medicaid does not cover medical ADC directly.

Definitions

Medical adult day care center is an ambulatory health care facility that provides an organized day program of therapeutic, social, and health maintenance and restorative services, and whose general goal is to provide an alternative to 24-hour long-term institutional care to elderly or disabled adults who are in need of such services by virtue of physical and mental impairment. The center must operate from 4 to 14 hours per day, 5 days per week, during times that encompass a normal work week for participants' caregivers.

Specialized services offered to participants in addition to regular medical ADC services include physical therapy, occupational therapy, speech therapy, and services specifically targeted to special populations such as individuals with Alzheimer's disease, developmental disabilities, traumatic brain injury, mental illness, and HIV/AIDS.

Parameters for Who Can Be Served

The licensee may not admit to the medical ADC center individuals requiring ongoing or extensive nursing care nor admit or retain individuals requiring a level of service that the center is not licensed to provide or does not provide. The licensee must seek immediate treatment for a participant or may refuse to admit or retain a participant if there is reason to believe that the participant may suffer serious harm, or is likely to cause serious harm to himself, herself, or to others, if appropriate interventions are not provided in a timely manner. If a participant has care needs that exceed the level of care for which the center is licensed or can provide, the licensee must inform the participant, or his or her legal representative, of the need for discharge from the center.

Inspection and Monitoring

The Secretary conducts at least one inspection of a medical day care center prior to issuing an initial license, and conducts periodic unannounced inspections at least once every 12 months to determine the center's continued compliance with the licensing rule.

The VA inspects ADC providers annually.

Required and Optional Services

All medical ADC programs provide socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

Required and Optional Services   Medical Adult Day Care  
  Required     Optional  
ADL Assistance X  
Health Education and Counseling    
Health Monitoring/Health-Related Services X  
Medication Administration X  
Nursing Services X  
Physical Therapy, Occupational Therapy, or Speech Therapy   X  
Skilled Nursing Services    
Social Services    
Transportation   X

Medication Provisions

A prescription--written or verbal order from a professional authorized by state law to prescribe medications--is required for altering, discontinuing, administering or self-administering prescription and over-the-counter medications, treatments, and therapies. A licensed health care professional must determine whether or not a participant is capable of self-administration of medications or requires supervision of self-administration of medications.

Participants must be allowed to self-administer their own medication provided their attending physician has certified, in writing, that they are capable of doing so. Medications and treatments that are not self-administered must be administered only by a nurse or physician. The same person who prepared the doses for administration must administer drugs to those participants who do not self-administer their medication. All participants receiving services in the center have a right to be free from unnecessary or excessive medication. Medication must not be used for the staff's convenience, as a substitute for a program, or in quantities that interfere with the participant's treatment program.

Staffing Requirements

Type of Staff. The center must employ a center director, or designate one of the professional staff members as the center director. The director is responsible for ensuring compliance with all applicable laws, and ensuring the adequacy and appropriateness of services delivered to the participants. The director, or a responsible employee designated in writing and with the authority to make decisions in the director's absence, must be present and in charge of the center at all times.

The center must employ or contract with a registered nurse (RN) who must be in the center a minimum of 8 hours per week to provide oversight of nursing services and participant care. If licensed practical nurses are employed, they must work under the supervision of the center's RN. Other required staff include a qualified activity director to be responsible for planning and implementing an activity program to meet the needs of all participants. If the center prepares meals on site, the director must designate a staff member to serve as food service supervisor. Prior to assuming these duties, this individual must receive specialized training in food management and preparation, including the preparation of therapeutic diets.

Volunteers used in the program must serve as an adjunct to staff and must possess qualifications and experience appropriate to the services they render.

Staffing Ratios. The center must maintain a sufficient number of staff at all times to meet the care and service needs of all participants. A minimum staffing level of one full-time staff member involved in direct services provision for each six participants must be maintained. Additional staff must be added to meet participants' needs. Volunteers must not be used to meet the required staff ratio unless they are professionally trained and/or certified in a health occupation and receive the same orientation and training as other staff. If a participant experiences a poor outcome related to a lack of supervision or unmet care needs, the Secretary may require the licensee to add staff.

Training Requirements

The licensee must provide training to new employees prior to scheduling them to work unsupervised and no later than within the first 14 days of employment and annually thereafter. Training must include at a minimum: (1) emergency procedures and disaster plans; (2) the center's policies and procedures; (3) participant rights; (4) confidentiality; (5) abuse prevention and reporting requirements; (6) complaint procedures; (7) specialty care based on individualized participant needs and service plans; (8) the provision of group and individual participant activities; (9) infection control, and (10) needs of the elderly and disability populations.

Training of at least 2 hours' duration on Alzheimer's disease and other dementias is also required and must include: (1) basic understanding about Alzheimer's disease and other dementias; (2) communication approaches and techniques for use when interacting with persons with Alzheimer's disease or other dementias; (3) prevention and management of problem behaviors; and (4) activities and programming appropriate for persons with dementia.

New employees must have a minimum of 5 days supervised on-the-job training, volunteers must receive orientation to the program and training on the specific tasks to be performed prior to working with participants, and the director must participate in 8 hours of training annually related to the operation of a center. All employees must have current first-aid and cardiovascular pulmonary resuscitation training.

Location of Licensing, Certification, or Other Requirements

West Virginia Code of State Rules, Title 64, Series 2: Licensure of Medical Adult Day Care Centers. Office of Health Facility Licensure and Certification, Department of Health and Human Resources. [July 1, 2009]http://apps.sos.wv.gov/adlaw/csr/ruleview.aspx?document=2549

West Virginia Bureau of Senior Services website: Medicaid Aged and Disabled Waiver, Personal Options.http://www.wvseniorservices.gov/Portals/0/pdf/brochure-PersonalOptions.pdf

Information Sources

Karen BillResource CounselorWest Virginia Bureau of Senior Services

Kelly W. HogsettCEOSarahCare Adult Day ServicesBarboursville, West Virginia

WISCONSIN

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-wisconsin

Overview

The state has voluntary certification standards for adult day care (ADC) and family ADC. Certification is mandatory for providers who serve one or more participants receiving Medicaid funding. The Wisconsin Division of Quality Assurance is responsible for certifying ADC facilities. When ADC and family ADC certification standards differ, they are described separately in this profile. The ADC standards include additional provisions for ADC programs located in a multi-use facility.

Medicaid covers ADC and family ADC under several 1915(c) waiver programs and under Family Care, a 1915(b)/(c) managed long-term care program. Individual Family Care managed care organizations (MCOs) can specify additional requirements for providers or choose to contract with ADC programs with particular features, services, and competencies; for example, by selectively contracting with ADC providers that offer more services than required by certification standards.

Family Care participants who require more assistance than a family ADC provider can furnish would typically be offered ADC providers instead. If a participant needs assistance that neither a family ADC nor an ADC provider can furnish, then the MCO must use other services, such as personal care, to meet the participant's needs, but they must not duplicate what is provided under ADC.

Definitions

Adult day care means the provision of services for part of a day in a group setting to adults who need an enriched social or health supportive experience, or who may need assistance with activities of daily living (ADLs), supervision, and/or protection. Services may include personal care and supervision, provision of meals, medical care, medication administration, transportation, and activities designed to meet physical, social, and leisure time needs.

Family adult day care is ADC furnished for part of a day for small groups of no more than six adults in a provider's home.

Multi-use facility means an ADC setting that is typical of or strongly resembles the locations where adults in that community customarily congregate for social, recreational, or association activities (e.g., clubs, church halls, private homes, lodges, restaurants). The building is consistent with the environment in terms of size, architectural style, and type (urban versus rural) and would be attractive and inviting to members of that community. The setting, programs, and physical environment must enhance the dignity and individual respect of participants.

Parameters for Who Can Be Served

Both ADC and family ADC providers may serve severely impaired individuals, defined as those having any impairment that results in an inability while attending the program to perform three or more ADLs (e.g., mobility, dressing, eating, toileting, hygiene) without assistance, supervision, or prompting. The impairment may be physical or cognitive in nature.

Inspection and Monitoring

The division conducts on-site inspections once every 2 years to ensure that providers meet applicable certification standards.

Required and Optional Services

All ADC and family ADC programs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

Required and Optional Services Adult Day Care   Family Adult Day Care  
  Required     Optional     Required     Optional  
ADL Assistance X     X
Health Education and Counseling        
Health Monitoring   X   X
Medication Administration   X   X
Nursing Services   X   X
Physical Therapy, Occupational Therapy, or Speech Therapy     X   X
Skilled Nursing Services        
Social Services   X   X
Transportation   X   X

Medication Provisions

If participants are responsible for managing their own medications, the individual service plan must indicate this and participants can set up and label their medications as they wish.

The self-administration of medications may be supervised by a staff member who may prompt the participant and observe him/her taking the medication. When medications are self-administered (whether supervised or not), the medication list must be reviewed and updated annually by the prescribing practitioner (i.e., physician, physician's assistant, or nurse practitioner).

If staff administer participants' medications, non-licensed staff must consult with the prescribing practitioner or pharmacist about each medication to be administered.

If an adult day center employs a registered nurse (RN), that nurse may set up and label medications and delegate to ADC staff the responsibility to administer them to participants. The ADC RN may delegate medication setup and labeling to a licensed practical nurse.

If the adult day center has a nurse, the nurse can review participants' medications provided by residential care facilities36 to determine their safety. If the nurse feels the medication's integrity is compromised, the nurse may decide the medications are unusable and require the medications to come in a package provided by the pharmacy.

Staffing Requirements

Adult Day Care

Type of Staff. A program director is required. The program director must be knowledgeable about the specific disabilities of the persons being served by the ADC program, including the physical and psychological aspects of these disabilities, the types of functional deficits that result from these disabilities, and the types of services the program must provide to meet the participants' needs resulting from these disabilities.

Staffing Ratios. At least one staff member over the age of 18 years must be on the premises at all times when participants are present. There must be a minimum of one staff person for each eight non-severely impaired participants and a minimum of one staff person for each four severely impaired participants at the ADC site. The ADC program must provide sufficient staff time and staff expertise to implement the program and participants' service plans. Volunteers may be counted as part of the staff-to-participant ratio if they have signed a written job description and meet the same standards and training requirements as employees.

Family Adult Day Care

Type of Staff. The provider must be knowledgeable in the same areas as an ADC program director (see above).

Staffing Ratios. At least one person over the age of 18 years, designated by the provider, must be on the premises at all times when participants are present; no participant may be designated as in charge. The total number of persons served at any one time must not exceed six; this includes adult family members or others for whom the provider may be responsible. The maximum number of participants by care level for any one provider or staff person is shown in the following table.

  Severely Impaired     Not Severely Impaired     Total  
3 0 3
2 2 4
1 4 5
0 6 6

The provider must not care for children other than his/her own when participants are present. Volunteers must be under the supervision of the provider.

Training Requirements

The ADC program must have and implement a written plan for providing orientation and training to staff members. All ADC staff who interact with participants, and volunteers who are included as part of the staff-to-participant ratio, must complete an orientation within the first 2 weeks of employment, which includes: (1) an explanation of participant rights; (2) an explanation of the ADC program's policies; (3) training in recognizing and responding appropriately to medical and safety emergencies; (4) an explanation of established emergency and evacuation procedures, including the proper use of the fire extinguisher; and (5) an explanation of the program's procedure related to standard precautions, prior to exposure to potentially infectious material.

Within 90 days of employment, all employees who provide care to participants must have received training on the following topics, if they are pertinent to their job responsibilities: (1) the needs and abilities of the participants served; (2) the physical and psychological aspects of each participant's disabilities; (3) the techniques required to provide personal care to participants--bathing, grooming, walking, and feeding, etc.; and (4) the interpersonal communication skills needed to relate to participants, including an understanding of the independent living philosophy; respecting participant rights, needs, and uniqueness; respecting age; cultural and ethnic differences; confidentiality; and other relevant topics.

After the first year of employment, all employees who have responsibility for direct care or program activities, including the program director, must receive 10 hours of continuing education annually. The ADC program must provide orientation, training, and supervision to volunteers.

After the first year of operation, family ADC providers must have 5 hours of continuing education annually in topics pertinent to their job responsibilities.

Location of Licensing, Certification, or Other Requirements

Adult Day Care Certifications Standards Checklist, Department of Health Services, Division of Quality Assurance. [July 2008]http://www.dhs.wisconsin.gov/forms1/F6/F60947.pdf

Family Adult Day Care Certifications Standards Checklist, Department of Health Services, Division of Quality Assurance. [July 2008]http://www.dhs.wisconsin.gov/forms1/F6/F62611.pdf

Medication Setup in Assisted Living and Adult Day Care, Wisconsin Department of Health Services website. [May 4, 2012]http://www.dhs.wisconsin.gov/rl_DSL/Publications/12-007.htm

Wisconsin Department of Health Services has the following web pages on adult day care that provide multiple links to information.http://dhfs.wisconsin.gov/rl_DSL/AdultDayCare/AdultDCintro.htm

http://www.dhs.wisconsin.gov/rl_dsl/AdultDayCare/ADCinqResp.htm

http://www.dhs.wisconsin.gov/rl_DSL/AdultDayCare/ADCnodMemo.htm

Information Sources

Colette AndersonResearch TechnicianBureau of Assisted Living

Diane PooleChiefPolicy and Federal RelationsOffice of Family Care ExpansionWisconsin Department of Health Services

WYOMING

This state profile also available at: /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-wyoming

Overview

The Wyoming Department of Health licenses adult day care (ADC) facilities. Medicaid covers ADC under its 1915(c) Long-Term Care waiver program for the Elderly and Physically Disabled and under the Wyoming Home Services program, which is funded solely with state funds. Both programs require ADC providers to be licensed.

Definitions

Adult day care facility means any facility, not otherwise certified by the Department of Health, engaged in the business of providing activities of daily living (ADLs) assistance and supervision services based on a social model to four or more persons age 18 years or older with physical or mental disabilities.

Adult day care is a community-based group program designed to meet the needs of adults with physical and mental disabilities through an individual care plan. It is a structured, comprehensive program that provides a variety of health, social, and related support services in a protective setting during any part of a day but for less than 24 hours. ADC helps its participants to remain in the community and prevents inappropriate or premature institutionalization, enabling families and other caregivers to continue caring for an impaired individual at home.

Medicaid defines adult day care as services encompassing both health and social needs to ensure the optimal functioning of the individual, which are furnished for 4 or more hours per day, on a regular schedule, for 1 or more days per week (as specified in an individual care plan) but for less than 24 hours each day.

Parameters for Who Can Be Served

The parameters for who can be served are contained within the state's definition of the target population: (1) adults who require assistance with ADLs and instrumental ADLs; (2) adult with physical problems that require health monitoring and supervision on a regular basis; (3) adults with significant memory loss and cognitive impairment; and (4) adults who require assistance in overcoming the isolation associated with functional limitations or disabilities.

A facility may refuse to serve adults with communicable disease, adults who are actively alcoholic or addicted to drugs, adults with a history of violence to self or others and/or whose behavior is not manageable within the group setting, and adults whose need for care requires more time and skill than the individual program is able and qualified to provide. Providers may discharge participants if the program can no longer meet their needs.

Inspection and Monitoring

The Survey Division of the Wyoming Department of Health, Division on Aging, performs initial and annual renewal on-site licensure evaluation surveys to determine compliance with State of Wyoming rules and regulations for ADC facilities. The Survey Division may also conduct an on-site inspection at any time at its discretion, for example, in response to a complaint. Complaints are triaged to determine how quickly an inspection needs to be scheduled.

Licenses are normally issued for 1 year from July 1-June 30. If issued after July 1, they are in effect from the date of issue until the next June 30 date. New providers are initially given a provisional license until the Survey Division can conduct a survey, which may not occur for several months.

Required and Optional Services

All ADC programs furnish socialization, social activities, nutrition services, and supervision to ensure safety. They also monitor participants' health and functioning at a basic level to determine if the program can continue to meet participants' health and functional needs. The table below lists additional required and optional services.

Required and Optional Services Adult Day Care
  Required1     Optional  
ADL Assistance X  
Health Education and Counseling X  
Health Monitoring    
Medication Administration   X
Nursing Services    
Physical Therapy, Occupational Therapy, or Speech Therapy      
Skilled Nursing Services    
Social Services    
Transportation   X
  1. Additional required services are support and education for families and other caregivers.

Medication Provisions

Participants may keep and take their own medicine provided that their physicians have deemed them capable of doing so and have authorized self-administration in writing. The facility must ensure that participants do not have access to other participants' medicine.

If a physician has deemed a participant incapable of self-administering medicine, each staff person who administers the medicine must be authorized to do so by the Wyoming Nurse Practice Act. To administer medicine means to read the label, to open the container of medicine, to remove the prescribed dosage, and to give it to the person for whom it is prescribed. Persons authorized to administer medicine under the Act include licensed physicians, registered nurses, licensed practical nurses, and physicians' assistants.

Staffing Requirements

Type of Staff. The director, or an adult appointed or designated by the director, is responsible for the day-to-day operation and management of the facility. The program director is responsible for the facility's program. If the program director is present in the facility fewer than 4 hours per day, there must be an officially designated assistant program director who will assume responsibility in the absence of the program director.

At least one staff person who has certification in first-aid issued within the past 3 years by an appropriate provider must be on the premises at all times during the hours of operation, and at least one employee or staff member who has current certification in cardiovascular pulmonary resuscitation (CPR) issued through the American Red Cross or the American Heart Association must be on the premises at all times during the hours of operation. The CPR certificate must be renewed every 2 years.

All volunteer personnel must be under the individual supervision of a director, program director, assistant program director, or designated staff person.

Staffing Ratios. There must be a minimum of one staff person on duty providing direct care and supervision for every six participants. The number of additional staff persons required depends upon the program and services the facility provides and the functional level of the participants. If volunteers meet all the personnel and health requirements for staff persons, they may be counted in the staff-to-participant ratio.

Training Requirements

Before assuming job responsibilities or within 1 week of hire, all staff persons must receive job orientation training. The orientation must include training specific to the staff's assigned responsibilities, as well as training on more general topics, including: (1) the purposes of the ADC facility; (2) state procedures for addressing abuse and neglect; (3) confidentiality of personal information; (4) employee responsibilities; (5) capabilities and special needs of the elderly and disabled; (6) the facility activity schedule; and (7) record-keeping responsibilities.

All staff must be trained in the appropriate procedures for handling emergencies before job responsibilities are assumed, including, at least, fire, illness, or injury, and lost or missing person emergencies.

All staff primarily responsible for the direct care of participants must attend at least 8 hours of staff development activities annually, which must consist of in-service training programs, workshops, or conferences related to ADC or gerontology, provided that both subject areas are addressed during the year.

Location of Licensing, Certification, or Other Requirements

Wyoming Department of Health website: Adult Day Care Facility--Wyoming Licensure Information.http://www.health.wyo.gov/ohls/Wyoming_Adult_Day_Care.html

Wyoming Rules and Regulations, Chapter 7: Rules and Regulations for Program Administration for Adult Day Care Facilities. Department of Health, Aging Division. [July 20, 1999]http://soswy.state.wy.us/Rules/RULES/3633.pdf

Wyoming Rules and Regulations, Chapter 2: Rules and Regulations for Licensure of Adult Day Care Facilities. Department of Health, Health Quality Program. [April 20, 2000]http://soswy.state.wy.us/Rules/RULES/3979.pdf

Information Sources

Tim ErnstDeputy AdministratorWyoming Department of HealthAging Division, Community Living Section

Lee Grossman, MPAWaivers and Home Care Services CoordinatorWyoming Department of HealthDivision of Healthcare Financing

NOTES

  1. In 2012, the average number of participants served daily in ADS centers was 185,300, which is smaller than the total enrollment because some participants did not attend each weekday. Long-Term Care Services in the United States: 2013 Overview. National Center for Health Statistics. Available at http://www.cdc.gov/nchs/data/nsltcp/long_term_care_services_2013.pdf.

  2. The majority of individuals with these disabilities are served through the IDD service system, which offers key services needed by this population, such as habilitation. Some ADS programs that serve elderly persons and working-age adults with physical disabilities also serve individuals with IDD if they can meet their needs.

  3. For information about Medicaid reimbursement rates, see Adult Day Services/Adult Day Health: Financial Viability and Scope of Services Provided Under Medicaid Waivers, at http://www.leadingage.org/uploadedFiles/Content/Members/Provider_Types/Adult_Day/Adult_Day_Services_Adult_Day_Health_Medicaid.pdf.

  4. Lousiana is the only state that defines adult day care as a service only for persons with IDD. The state licenses only ADHC for the aged/disabled population.

  5. Adult day services is the term preferred and used by the National Adult Day Services Association, in part because the term "day care" is generally understood to be a service for children.

  6. Wyoming conducts joint inspections when administratively feasible and appropriate.

  7. Saucier, P. Truven Health Analytics data presented at the American Health Insurance Plans National Conference on Medicaid, Washington, DC, October 1, 2014.

  8. California's 1115 waiver program is a managed care program that covers health services and LTSS. In counties where a Medi-Cal Managed Care Plan exists, Community-Based Adult Services are available only to individuals who are enrolled in a Medi-Cal managed care organization. In counties without a Medi-Cal Managed Care Plan, Community-Based Adult Services are available through Medi-Cal fee for service.

  9. Programs that admit and retain individuals with these conditions are generally those that serve persons with intellectual and other developmental disabilities.

  10. The additional terms agreement is being updated in 2014 to reflect current language in the rules of the Idaho Administrative Procedure Act (IDAPA), which was updated in 2013.

  11. Not all providers accept DHR/ORS participants.

  12. IDOA is the primary third-party payer.

  13. Maine has three non-Medicaid programs that support the provision of adult day services: Adult Day Services, In-home and Community Support Services, and Respite Care for Adults with Alzheimer's Disease or Related Disorder.

  14. Personal Support Services, also known as personal care services, are assistance with ADLs and instrumental ADLs, and health maintenance activities provided in a participant's residence by a home health aide, certified nursing assistant, or personal support specialist, as appropriate, in accordance with an authorized plan of care. If a waiver participant qualifies for personal support services, the time spent in an ADS program is counted as personal support services.

  15. At the time this summary was written, no ADS participants were using night programs.

  16. The is an Authorized Agent of the Department, responsible for medical eligibility determinations, care plan development, and authorization of covered services.

  17. SCA is an organization that has the capacity to provide Care Coordination to eligible participants, and has met the MaineCare provider enrollment requirements of the department. In addition to Care Coordination, the SCA is responsible for administrative functions, including but not limited to, maintaining participant records, submitting claims, conducting internal utilization and quality assurance activities, and meeting the reporting requirements of the department.

  18. Funding sources include Title III Older Americans Act, Caregiver Support Funds, State Funds-Service Incentive Grants, and private foundation grants. Because of limited funding, priority for services is based on how much help a senior needs to perform daily tasks and how many needs are unmet. Seniors with critical unmet needs, such as personal care tasks (e.g., bathing, dressing, etc.), meal preparation and food shopping, and transportation to medical appointments, receive higher priority.

  19. The Health Promotion and Prevention level is expected to be eliminated when revised MassHealth regulations are promulgated this year.

  20. The phrase "must work toward developing" is used so providers have flexibility with regard to staffing. The state did not want to require dementia ADC providers to hire the named staff, but to work towards having them if participants required their services.

  21. All waiver program participants aged 65 or older must receive services through one of two managed care organizations--Minnesota Senior Care Plus or Minnesota Senior Health Options.

  22. Alternative Care is also part of a demonstration program--Minnesota Long Term Care Realignment Section 1115 waiver--receiving federal financial participation since December 2013.

  23. Exceptions to licensure requirements include: (1) any adult day care program operated by a person in which care is offered for no more than 2 hours per day; (2) any adult day care program maintained or operated by the Federal Government except where care is provided through a management contract; (3) any person who cares solely for persons related to the provider or who has been designated as guardian of that person; and (4) any adult day care program which cares for no more than four persons unrelated to the provider.

  24. The state uses the term adult day service rather than adult day services. To ensure consistent and grammatically correct usage throughout the report, this profile uses the term adult day services.

  25. Habilitation is defined as services that develop and/or retain the participant's capacity for independence, self-care, and social and/or economic functioning.

  26. Formerly known as the Home and Community-Based Care program for the Elderly and Chronically Ill.

  27. Medicaid State Plan adult medical day program participants are those who do not meet the waiver program's nursing facility level of care eligibility requirement.

  28. New York regulations refer to nursing homes as residential health care facilities. To avoid confusion, this profile uses the term nursing home(s).

  29. Licensing and other regulations use the term adult day care, whereas state staff and providers prefer the term ADS, which is used in this profile.

  30. Adult training facilities serve individuals with developmental needs, such as those with a physical disability such as blindness, visual impairment, deafness, hearing impairment, speech or language impairment, or a physical handicap; a mental illness; a neurological disability such as cerebral palsy, autism, or epilepsy; an intellectual disability; or a traumatic brain injury.

  31. The Medicaid program in Tennessee is called TennCare. The program CHOICES now encompasses a previous Medicaid 1915(c) waiver program that was called the Elderly and Disabled Home and Community-Based Services waiver program.

  32. The CHOICES program covers ADC services only for participants who are age 21 years or older; the services are limited to 2,080 hours per calendar year per participant.

  33. DADS provides DAHS as a Medicaid State Plan service. On September 1, 2014, most of the individuals receiving Medicaid-funded DAHS from DADS began receiving this service from the Health and Human Service Commission's 1115 managed care waiver program--Star+Plus. DADS continues serve some Medicaid recipients under the State Plan who are not mandatory enrollees in managed care, such as persons with intellectual and other development disabilities, and individuals who for various reasons do not consistently remain eligible for Medicaid.

  34. This program is referred to by different names depending on the area of Utah in which it is offered. It may be called The Alternatives Program (TAP) or Home and Community-Based Alternatives.

  35. Small base grants (about $8,000 per year per provider) are furnished to 14 sites. The funds are subject to the state's legislative budget approval process.

  36. Wisconsin has three types of residential care facilities: community-based residential facilities, residential care apartment complexes, and adult family homes.

STATE RESIDENTIAL CARE AND ADULT DAY CARE REGULATION AND POLICY

This report was prepared under contract #HHSP23320100021WI between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and the Research Triangle Institute. For additional information about the study, you may visit the DALTCP home page at http://aspe.hhs.gov/office_specific/daltcp.cfm or contact the ASPE Project Officer, Emily Rosenoff, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, SW, Washington, DC 20201. Her e-mail address is: Emily.Rosenoff@hhs.gov.

Reports Available

FULL REPORT

Executive Summary   /regulatory-review-adult-day-services-final-report-2014-edition-executive-summary

Full HTML Version   /daltcp/reports/2014/adultday14.cfm

Full PDF Version   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-december

SEPARATE STATE PROFILES[NOTE: These profiles are available in the full HTML and PDF versions, as well as each state available as a separate PDF listed below.]

Alabama   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-alabama

Alaska   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-alaska

Arizona   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-arizona

Arkansas   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-arkansas

California   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-california

Colorado   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-colorado

Connecticut   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-connecticut

Delaware   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-delaware

District of Columbia   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-district-columbia

Florida   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-florida

Georgia   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-georgia

Hawaii   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-hawaii

Idaho   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-idaho

Illinois   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-illinois

Indiana   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-indiana

Iowa   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-iowa

Kansas   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-kansas

Kentucky   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-kentucky

Louisiana   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-louisiana

Maine   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-massachusetts

Maryland   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-maryland

Massachusetts   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-massachusetts

Michigan   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-michigan

Minnesota   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-minnesota

Mississippi   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-minnesota

Missouri   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-missouri

Montana   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-montana

Nebraska   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-nebraska

Nevada   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-nevada

New Hampshire   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-new-hampshire

New Jersey   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-new-jersey

New Mexico   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-new-mexico

New York   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-new-york

North Carolina   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-north-carolina

North Dakota   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-north-dakota

Ohio   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-ohio

Oklahoma   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-oklahoma

Oregon   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-oregon

Pennsylvania   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-pennsylvania

Rhode Island   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-rhode-island

South Carolina   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-south-carolina

South Dakota   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-south-dakota

Tennessee   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-tennessee

Texas   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-texas

Utah   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-utah

Vermont   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-vermont

Virginia   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-virginia

Washington   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-washington

West Virginia   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-west-virginia

Wisconsin   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-wisconsin

Wyoming   /pdf-report/regulatory-review-adult-day-services-final-report-2014-edition-wyoming

Files
adultday14-CT.pdf (pdf, 57.04 KB)
Topics
Regulatory Policy, Analysis, & Guidance | Long-Term Services & Supports (LTSS) | Home- & Community-Based Services (HCBS) | Disability
Populations
People with Disabilities | Older Adults