State Assisted Living Policy: 1998

Publication Date

May 31, 1998

Robert L. Mollica, Ed.D.

National Academy for State Health Policy

This report was prepared under contracts #HHS-100-94-0024 and #HHS-100-98-0013 between the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, Office of Disability, Aging, and Long-Term Care Policy (ASPE) and the Research Triangle Institute. Additional funding was provided by American Association of Retired Persons, the Administration on Aging, the National Institute on Aging, and the Alzheimer's Association. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/_/office_specific/daltcp.cfm or contact the ASPE Project Officer, Gavin Kennedy, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201. His e-mail address is: Gavin.Kennedy@hhs.gov.

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.

Section I

Preface

Project Overview

Assisted living facilities are a rapidly expanding source of supportive housing with services. In the view of many, such facilities represent a promising new model of long-term care, one that blurs the sharp distinction between nursing homes and community-based long-term care and reduces the chasm between long-term care in one's own home and in an institution. In this model, consumer control and choice are central to the philosophy of "assisted living." Indeed, the ability of consumers to control both key features of the environment and to direct services, under a "negotiated" or "managed risk" model, and to receive care and supervision in a "home-like" setting are considered hallmarks of the philosophy of assisted living. Further, assisted living, at least conceptually, is distinguished by a flexible service arrangement, in which there is no set "package" of services but facilities provide services to meet scheduled and unscheduled needs of residents, allowing residents to "age-in-place."

Despite the growing interest in and expansion of places calling themselves assisted living facilities, relatively little is known about their actual role and performance and the degree to which they represent a viable option for frail and disabled elders. Indeed, there is not even agreement or information on the number of such facilities currently in operation. As a result, the Office of the Assistant Secretary for Planning and Evaluation (ASPE) of the U.S. Department of Health and Human Services is undertaking a national study of the role of assisted living. ASPE entered into a contract for a comprehensive study to be conducted by Research Triangle Institute (RTI), the Myers Research Institute, as well as its collaborators, Lewin, Inc., the University of Minnesota Long-Term Care Resources Center, and the National Academy for State Health Policy.

Purpose of the Study

The intent of the National Study of Assisted Living for the Frail Elderly is to determine where "assisted living" fits in the continuum of long term care and to examine its potential for meeting the needs of a growing population of elderly persons with disabilities. Within this broad objective, the study will address several specific goals, including:

To identify trends in demand for and supply of assisted living facilities;
To identify barriers to the development of assisted living and supply-demand factors that contribute to those barriers.

In addition, the study has further descriptive and "evaluative" goals:

To determine the extent to which the current supply matches the central philosophical and environmental tenets embodied in the concept of "assisted living" and to describe the key characteristics of the universe of assisted living facilities; and
To examine the effect of key features, particularly source, mix and privacy, on selected outcomes, including resident satisfaction, autonomy, affordability, and the potential to provide nursing-home level of care.

Overview of the Study Design

ASPE's approach to this study includes the following activities:

We will select and interview a purposive sample of lenders, developers and multi-facility owners.
We are conducting annual surveys of all state licensing agencies involved in assisted living, as well as of Medicaid agencies that provide funding for assisted living.
The study will draw a national probability sample of facilities. This will allow us to generalize our findings and make valid estimates about the status of assisted living facilities across the nation.
Using this sample, the study will describe the key characteristics of places holding themselves out to be "assisted living" facilities, based on a telephone survey of about 2,500 facilities.
We will also conduct a more in-depth telephone survey of about 200 facilities. In addition, we will select a sample of about 450 facilities that will be visited, with in-person interviews with administrators, staff and residents.
We also plan to interview families of residents with cognitive impairment and to conduct follow-up interviews at six months with residents who have been discharged or otherwise exited the facility.

Acknowledgment

The author thanks the many people in state agencies throughout the country who completed surveys and provided copies of statutes, regulations and reports needed to conduct this study. We also appreciate their willingness to review draft summaries of the material related to their state. This project is possible because of the support of dedicated professionals in state agencies who are willing to share their time and knowledge in this endeavor. We hope the information is helpful to states as policies on assisted living continue to emerge and develop over time.

Methodology

This study was designed to review, describe, and analyze state policy on assisted living. Two surveys were developed covering general licensing issues and Medicaid reimbursement policy. The surveys were mailed to state Aging, Health, and Medicaid agencies. The information was collected between January and March 1998. Copies of existing and draft regulations, where appropriate, were received from each state. Telephone interviews were conducted as necessary with state agency staff to clarify survey response information or to discuss key issues. The narrative describes state policy trends for licensing and reimbursing assisted living. Summaries of each state's policy and regulations covering assisted living and board and care are presented.

The Challenge Grows: What Is Assisted Living and Does It Differ from Board and Care?

Defining assisted living and differentiating it from board and care has proved a challenge in recent years. And a common definition or understanding of assisted living remains unlikely as state policy makers, regulators, legislators, consumers, and providers develop models that address local circumstances. In many states, there is considerable overlap between board and care and assisted living rules. Assisted living is both a generic concept and a specific model. Facilities and state regulators in states with board and care rules often use the terms assisted living and board and care synonymously and include the ability to age in place and offer higher levels of care under their board and care rules. A review of state polices finds that four states use assisted living and board and care interchangeably: Alabama, Rhode Island, South Dakota, and Wyoming. Yet other states describe assisted living as a specific model that has a consumer centered philosophy, apartment settings, residential environment, and a broad array of services which support aging in place.

Assisted living policy in other states generally differs from board and care rules in three primary areas:

Assisted living statutes/regulations often contain a statement of philosophy that emphasizes privacy, independence, decision-making and autonomy.
Assisted living is more likely than board and care to emphasize apartment settings shared by choice of the residents.
Assisted living allows facilities to provide or arrange nursing or health related services and to admit or retain residents who may meet the level of care criteria for admission to a nursing facility.

Some states have gone even further with their efforts to differentiate services. Washington state has developed Medicaid regulations which differentiate assisted living, residential care, and enhanced residential care. Assisted living contractors must offer private apartments and may provide limited nursing services. Enhanced adult residential care providers may provide limited nursing services while adult residential care contractors may not. Adult residential care and enhanced adult residential care providers are not required to offer private units with bathrooms and kitchens, while assisted living facilities are required to do so.

TABLE 1. Assisted Living and Board and Care: Washington

Component	Assisted Living	Enhanced Adult Residential Care	Adult Residential Care
Room and board	Yes	Yes	Yes
Personal care	Yes	Yes	Yes
Nursing services	Yes	Yes	No
Private unit	Yes	No	No
Private bathroom	Yes	No	No
Kitchen	Yes	No	No
Nurse delegation	Yes	No	No

States may create a new assisted living licensing category and retain older categories (e.g., residential care facilities, personal care homes) which allow shared bedrooms and limited services. Other states have consolidated categories and now have one general set of assisted living rules that might cover assisted living, board and care, multi-unit elderly housing, congregate housing and sometimes adult family or foster care (e.g., Maine, Maryland and North Carolina). Still others set core requirements for licensed facilities and require an additional license to offer limited nursing services or a higher level of care. To add to the variation, Wisconsin has changed its category from assisted living to residential care apartment complexes.

States also differ in their description of the focus of assisted living. Connecticut and Minnesota see assisted living as a service, and license the service provider (which may be a separate entity from the organization that owns or operates the building). Others states see assisted living as a building in which supportive and health related services are provided. The operator of the building is licensed, and services may be provided by the operator's staff or contracted to an outside agency.

Draft rules in Louisiana establish core rules and separate modules for assisted living facilities, personal care homes, and shelter care facilities. The modules contain separate requirements for administrators, staff training, and living units. The draft rules state that the purpose of the regulations is to promote the availability of appropriate services for elderly and disabled persons in a residential environment; to enhance the dignity, independence, privacy, choice, and decision-making ability to the residents; and to promote the concept of aging-in-place. This extends the principles of assisted living to other categories while requiring (1) more training for administrators and staff, and (2) apartment units in assisted living settings. Oregon, which was the first state to adopt principles of assisted living, and Washington have extended the principles to other categories of care.

Will There be Consensus?

Reaching consensus on a definition of assisted living can only occur if the federal government sets standards as they have for nursing facilities. However, federal standards are unlikely for several reasons. The federal government is not likely to become a major payer of assisted living. The expansion of Medicare managed care has generated expectations that assisted living can offer HMOs an excellent vehicle for managing rehabilitative services and providing a supportive environment for frail HMO members. Medicare HMO membership continues to grow, from 3.1 million in December 1996 to 5.7 million in May 1998, and the Congressional Budget Office projects enrollment will reach 15 million by 2007.

Although many experts predict coverage of assisted living through HMOs with Medicare risk contracts, it is the flexibility of the Medicare capitation payment which encourages HMOs to provide added or alternative services. Medicare HMOs are required to cover all regular Medicare benefits, and they may cover additional services. One of the attractions of Medicare HMOs is their coverage of additional services such as physical exams, prescription drugs outside a hospital, eye glasses, dental care, and others. But even if HMOs begin to cover services in assisted living, assisted living is not likely to become a regular Medicare benefit. As Congress and a Commission explore ways to protect the future of Medicare, further benefits, especially non-medical benefits, are not likely to become a regular covered benefit.

Second, Medicaid payments for assisted living are expanding, but, here again, assisted living is most often covered as a service under home- and community-based waivers. Personal care services in assisted living can also be covered under the state Medicaid plan, but assisted living itself is not covered. Room and board cannot be covered by Medicaid except in hospitals and nursing homes. States have the responsibility for setting provider standards, and regulations governing assisted living facilities participating in Medicaid remain a state responsibility. Further federal action through regulation is unlikely given the manner of Medicaid coverage, state options, and continuing state responsibility in this area.

Third, quality-of-care concerns could stir federal interest in assisted living but, historically, quality, standards, and monitoring have been a state responsibility. During the late 1970's and early 1980's Congressional hearings were held on the quality of care in board-and-care homes. Little federal action followed, and states retained licensing and monitoring responsibility. In the current political climate, government responsibilities are more likely to shift to states rather than flow from states to the federal government.

Without a major federal financial interest or a major change in federal-state responsibilities, there is little likelihood that federal action will be forthcoming in the near future. Assisted living will continue to be defined through legislation and regulation on a state-by-state basis and through marketing and advertising by facilities. The result is likely to be continued divergence, differences, and innovation as states develop definitions, licensing criteria, and standards that reflect the priorities and philosophy of each state.

The Role of the Market in Defining Assisted Living

Regulations set parameters for what is possible. Admission/retention criteria establish the maximum boundaries for tenants, and the services allowed define the maximum allowable package that may be delivered. Operators still determine which tenants may be admitted or retained and what services are provided. State regulations often specify that the residence must develop written policies concerning whom it will serve and what services it will provide. As a result, providers may choose not to offer all the services allowed by regulation. Companies that own or manage assisted living facilities and nursing homes may view the nursing facility as their primary line of business and develop assisted living as a referral source. While this policy may be a sound business strategy, it is not consumer or customer focused and does not maximize a resident's ability to age in place.

Despite broader rules, facilities may be successful at offering a limited service package. If competition is limited, and demand and occupancy are high, facilities can operate successfully offering limited services. The staffing requirements are easier to manage, and rates can be relatively low. As more facilities locate in an area and residents age and require more services, these facilities will have a more difficult time maintaining a lower service package. If, as residents leave, new residents are harder to attract, the residence will have to increase the service intensity to retain residents rather than allow a lower occupancy rate.

Existing Providers

Many providers may seek protection for the product they market today, while others will diversify and develop new products to keep pace with a changing market place. New assisted living licensing categories which require more privacy and autonomy may displace older shared occupancy models. Providers who build new facilities that reflect current consumer preferences face challenges for what to do with an existing facility. Can it be sold, rehabilitated, or converted to another use? If not, is the organization solvent enough to withstand its closing? As states develop policy, the interest and vision of those directly affected are likely to influence the direction of new public policy.

States can help nursing home owners deal with a changing market. Nursing homes can diversify their product mix, convert portions of a facility for other uses including assisted living, or provide in-home services. Although many states do not track nursing home conversions to assisted living, the survey responses from six states indicated that 72 nursing facilities have converted 2,428 beds to assisted living. Responses from seven additional states reported that a total of 117 facilities had converted to assisted living, but the number of nursing home beds involved was not known. The largest number of conversions has occurred in Iowa (24 facilities and 1,114 beds) and Kansas (38 facilities and 952 beds).

Legislation passed in Nebraska in 1998 provides $40 million in grants or loan guarantees to nursing homes to convert wings or entire facilities. The program will be administered by the Nebraska Department of Health. Grants will be made when conversion is considered efficient and economical. Grantees must agree to maintain specified occupancy levels of Medicaid beneficiaries for a period of ten years. The Department will develop rules specifying minimum occupancy rates, allowable costs, and refund methods. Grants may cover capital or one-time costs and operating losses for the first year to facilities that have participated in the Medicaid program for at least three years. Facilities must provide 20% of the cost of conversion. Facilities may convert existing space or construct additional space to include assisted living or other alternative services. Construction of a new assisted living facility may be funded if the nursing home beds are de-licensed and it is more cost effective to construct new space rather than convert old.

Living Unit Options

Single occupancy apartments or rooms dominate the private market. A survey of non-profit facilities conducted by the Association of Homes and Services for the Aging² found that 76% of the units in free-standing facilities and 89% of units in multi-level facilities were private (studio, one- or two-bedroom units). A similar survey by the Assisted Living Federation of America found that 79% of units in member facilities were studio, one- or two-bedroom units.

The issue that often creates conflict in policy development is the requirement for the living units. Older board-and-care rules allow shared rooms, toilets, and bathing facilities. Existing facilities that want to be licensed as assisted living would oppose rules requiring apartment-style units and single occupancy. Some states have grandfathered existing buildings or maintained separate board-and-care categories which allow shared rooms.

To some extent, market forces rather than minimum licensing standards will define the type of units built for and occupied by the private market. Older, shared room models will have a more difficult time competing for residents. However, older providers may increasingly seek low- income older people. As the upper-income market becomes saturated and more companies seek to serve low- and moderate-income elders, efforts to develop "affordable" models may compromise on single occupancy. Medicaid policy will play a critical role in shaping the market over time as it serves lower-income residents. Some facility operators contend that shared occupancy is the only way to develop affordable units. While historically, low Medicaid rates are cited as the reason for offering double occupancy, owner pricing policy also plays a role. Offering double occupancy allows an operator to set a higher price for single occupancy and scale prices by room size. The actual cost difference of single versus double occupancy units over the life of a mortgage is minimal. However, the revenue stream that can be generated by shared occupancy may be significant. Some providers contend that shared occupancy models actually require more staff time than single occupancy units because of the problems and conflicts between tenants that must be resolved. Under the guise of affordability, developers may market shared occupancy models to lower-income residents and single occupancy units to people who can afford to pay a higher rate.

Thus far, Medicaid policy in several states has recognized the importance of single occupancy in fulfilling the principles stated in their policy and developed a reimbursement level that allows facilities to contract with Medicaid at the market rate. Other states have required apartments but do not specify that apartment units can be shared only by choice. Whether Medicaid's role in maintaining the apartment and single occupancy threshold for low-income residents continues remains to be seen.

2. Ruth Gulyas. "The Not-for-Profit Assisted Living Industry: 1997 Profile." American Association of Homes and Services for the Aging. Washington DC. 1997. Also, "An Overview of the Assisted Living Industry: 1996." The Assisted Living Federation of America and Coopers and Lybrand. Washington, DC. 1996.

State Policy Developments

The rapid development of assisted living regulations and revision of board-and-care regulations continued in 1997 and during the first half of 1998. Thirty-three states have taken steps to implement an assisted living policy, and 11 others have instituted a process to study the issue.³ In 1997 and 1998, laws were passed in Florida, Indiana, Nebraska, and Oklahoma. Florida amended its existing statute to modify training requirements especially for facilities serving persons with Alzheimer's disease. Laws passed in Indiana create a disclosure requirement and direct the Department of Health to conduct a study of assisted living facilities.

Regulations were finalized in Delaware, Iowa, Kansas, Kentucky, Maine, Nebraska, Oklahoma, Tennessee, and Wisconsin. Draft regulations were issued in Hawaii, Louisiana, Maryland, and Vermont, and efforts to consolidate or revise regulations are now underway in Alabama, Arizona, New York, and Oregon. New Hampshire's rules sunset the end of 1998, and new rules will be developed.

Three states added assisted living to their Medicaid waivers: Kansas, Rhode Island, and Wisconsin, and waiver coverage is planned or under consideration in Connecticut, Delaware, Hawaii, Nebraska, New Hampshire, South Carolina, and Utah.

Proposed rules in Hawaii are still in the comment period. Iowa has created a certification process for assisted living, developing rules which certify facilities providing home-like environments and follow the principles of assisted living. Regulations in Kansas were finalized and a Medicaid Home and Community Based Services (HCBS) waiver has been approved that allows assisted living facilities to become providers of waiver services. Kentucky's regulations voluntarily certify facilities offering apartment or home-style housing units in assisted living residences. Regulations in Tennessee were effective in April 1998 and were developed by a 13 member task force headed by a state agency.

Four states are developing demonstration programs designed to test models for serving low-income residents. Two pilots are being conducted in Illinois, one by the Department of Public Aid (DPA) and another by the Department of Aging. The DPA program targets lighter-need nursing facility residents who are unable to remain in their homes or independent settings but do not need 24-hour nursing care. As participants in the project, contractors may convert nursing home units or free standing buildings to units that integrate housing, health, personal care, and supportive services in home-like residential settings. The program is consistent with the definition of assisted living used by the HCBS program.

The Illinois Department on Aging is testing a Community Based Residential Facilities service model. Services will be reimbursed as home care services through the Medicaid Home and Community Based Services Waiver or state funds. The pilot may include three facilities and serve no more than 360 people. The authorizing statute allows the programs to serve people with short or long term needs as a means of relieving family caregivers. Two facilities have been selected, including an Alzheimer's care facility. The Department may contract with a third program involving a nursing home seeking to convert its facility.

The Rhode Island legislature authorized the Housing and Mortgage Finance Agency (HMFA), working in collaboration with the Department of Human Services and the Department of Elderly Affairs, to implement a pilot program. The pilot can serve (in facilities certified and financed by the HMFA) up to 200 low- and moderate-income chronically impaired or disabled adults who are eligible for or at risk of entering a nursing home.

Louisiana agencies are designing a pilot program to test the feasibility of covering assisted living under Medicaid. The project will be implemented by the Department of Health and Hospitals. A task force was appointed to draft guidelines for the project. The project will include two assisted living facilities and use Medicaid waiver funds to pay for assisted living services. The bill defines assisted living as "a residential congregate housing environment combined with the capacity by in-house staff or others to provide supportive personal services, twenty-four-hour supervision and assistance, whether or not such assistance is scheduled, social and health related services to maximize residents' dignity, autonomy, privacy, and independence and to encourage facility and community involvement." One rural and one urban site will be selected through an RFP. Each facility may serve up to 30 Medicaid beneficiaries. Residents must be offered a chance to live in private quarters with a lockable door, bedroom, kitchenette, and bathroom.

Legislation authorizing a pilot program has passed in Connecticut. The bill authorizes Medicaid coverage for assisted living services in three cities with a maximum of 300 units.

To summarize state activity:⁴

Thirty-one states had existing regulations (22) or Medicaid provisions (9) using the term "assisted living" as of June 1998.
Six states have issued draft rules.
Twenty-eight states provide Medicaid reimbursement for services in assisted living or board-and-care.
- Nine states plan to add Medicaid coverage of services in assisted living facilities.
- Six of the twenty-eight states reimburse for services in board-and-care facilities.
Eleven states are studying assisted living.

Several states with existing policy have formed a task force to review the policy and make recommendations.
States may be counted in more than one category.

State Regulatory Models

Earlier NASHP studies of state assisted living policy described three approaches to categorizing state models that highlight particular features of state policy. Based on further policy developments, a fourth approach has been added to better define state approaches to licensing, unit requirements, and the service level. The approaches are:

Board-and-care/institutional,
New housing and services model,
Service model, and
Umbrella model.

Institutional models are based on older board-and-care regulations. They allow shared bedrooms without attached baths and either do not allow nursing home eligible residents to be admitted or do not allow facilities to provide nursing services. Two states, Alabama and Rhode Island, adopted "assisted living" as the name for their board-and-care licensing category. South Dakota and Wyoming re-named an existing category as assisted living and allowed a higher level of service to be provided without changing the unit requirements. Arkansas and Illinois are two states that do not allow anyone requiring nursing home services to be served in a board-and-care facility. Some states allow skilled nursing services to be provided for limited periods by a certified home health agency. The upgraded board-and-care approach recognizes that residents are aging-in-place and need more care to prevent a move to a nursing home. State policies have allowed these facilities to admit and retain people who need assistance with activities of daily living (ADLs) and some nursing services. Mutually exclusive level of care criteria have been revised to allow people who would qualify for admission to a nursing home to be retained. The model retains the minimum requirements for the building and units (usually multiple occupancy bedrooms with shared bathrooms and tub/shower areas).

The new housing and service model licenses or certifies facilities providing assisted living services which are defined by law or regulation. These models require apartment settings and allow facilities to admit and retain nursing home eligible tenants. Depending on the state, rules may allow some or all of the needs met in a nursing home to also be met in assisted living. Policies in states with this approach included a statement of philosophy that emphasizes resident autonomy and creates a prominent role for residents in developing and delivering services. By licensing the setting and services, states distinguish these facilities from board-and-care and have attempted to develop more flexible regulations. Examples of this approach to licensing can be found in Hawaii, Kansas, Oregon, and Vermont and Medicaid waiver standards in Arizona, North Dakota and Washington.

The service model focuses on the provider of service, whether it is the residence itself or an outside agency, and allows existing building codes and requirements--rather than new licensing standards--to address the housing structure. This model simplifies the regulatory environment by focusing on the services delivered rather than the architecture. Unfortunately, newer residential models serving frailer residents may not be as familiar to local building inspectors and code enforcement officials who may want to apply more institutional requirements than are needed. Service regulation approaches may include requirements that define which buildings (apartment units, minimum living space) may qualify as assisted living, but the licensing agency's staff do not otherwise apply their standards to the building's characteristics. The service model can be developed for apartment settings (Connecticut) or multiple settings (Texas Medicaid waiver program).

States using an umbrella model issue regulations for assisted living that cover two or more types of housing and services: residential care facilities, congregate housing, multi-unit or conventional elderly housing, adult family care, and assisted living. States representing this approach include Florida, Maine, Maryland, Louisiana, New Jersey, Maryland, New York, North Carolina, and Utah.

Elderly Housing or Assisted Living?

Assisted living can be regulated as a service in a purpose built facility and in elderly housing buildings. Purpose built facilities involve new construction or renovation of a building that is designed to serve frail residents. The term is clear as it refers to a building in which all the residents receive some level of care. Buildings which are built explicitly to operate as assisted living settings can be built to existing codes for multi-unit residential environments.

Assisted living may also be regulated as a service that can be provided in a conventional elderly apartment complex. To some extent, existing elderly housing buildings can also be considered assisted living. Because a significant percentage of, but not all, residents need service, the assisted living component may be considered a more comprehensive, organized service package provided in subsidized housing with a mix of residents, some of whom are impaired and others who function independently. In this setting, comparisons with in-home service programs and confusion between independent and dependent residents concerning the type of building they live in is more likely.

Questions can be raised about approaches that regulate the service rather than the setting. In some settings, differentiating assisted living from more common community based services programs becomes difficult. As a new trend, the term "assisted living" may be expected to mean something different from board-and-care or in-home-services models of care. Policy makers need to respond to aging-in-place that is occurring in conventional elderly apartment complexes since many residents have both health and personal care needs. The key question is: when does an apartment building become an assisted living residence? For residents who are receiving personal care and some nursing care, elderly housing may resemble buildings that were designed and built as an assisted living residence. For independent residents, it's an apartment building. Even if all the residents required some supportive services, many contend that the building would not constitute an "assisted living" site because of licensing and architectural characteristics.

Participants at a 1995 round table on assisted living discussed the environmental differences between conventional elderly housing and assisted living. Buildings designed and built as assisted living tend to have higher lighting levels in common spaces, more common spaces for activities and socialization, different flooring, small refrigerators raised above floor level, handicapped accessible bathrooms in every unit, roll-in showers, wider corridors with hand rails, two-way voice communication, and other features. Conventional elderly housing generally may not have been renovated to accommodate the decreasing independence of residents needing care.

The important factor is that residents receive the service they need to maximize functioning in the most independent and autonomous way possible. Whether the term "assisted living" is applied broadly or more narrowly may be a function of the presentation of the concept in a way that generates the level of political support to make the resources available. Regarding assisted living solely as a service, not a place, may omit setting important requirements for living units. In licensing or certifying assisted living as a service, however, state regulations can require that assisted living services be provided in buildings with apartments or private rooms and attached baths while still allowing state and local building codes to govern the structure itself. Connecticut, New Jersey (assisted living program category), and North Carolina (multi-unit housing category) are examples of this approach.

Connecticut licenses assisted living service agencies which provide assisted living services in managed residential communities. Living units in these communities are defined as a living environment belonging to a tenant(s) that includes a full bathroom within the unit including water closet, lavatory, tub or shower bathing unit, and access to facilities and equipment for the preparation and storage of food. The housing owner or operator does not need a license to manage the residential property.

New Jersey defines assisted living as "a coordinated array of supportive personal and health services, available 24 hours per day to residents who have been assessed to need these services including residents who require formal long term care." In this state, assisted living services can be provided in three settings: assisted living residences, comprehensive personal care homes, and assisted living programs. The assisted living program model is provided in elderly housing projects. New Jersey wanted a model that was suitable for urban environments, assuming that limited land availability and high costs limit new construction in major cities. To develop its assisted living program model, the state funded a two-year pilot project in a large elderly housing site. Prior to the pilot, residents who needed assistance received one meal in a congregate dining room, one or two hours of housekeeping a week, laundry, and shopping.

As part of the pilot, personal care, additional meals, medication assistance, and escort services to doctors appointments were added, and wellness and health education programs (flu shots, health fair, guest lectures, referrals to podiatrists, dentists, and physicians) were available to all tenants. In addition, a health clinic was established using a vacant apartment that was staffed by a geriatrician and a geriatric nurse practitioner two and a half days a week. Security guards were used to implement a 24 hour emergency response capacity. Twenty-four hour, on-site staff coverage was not identified as a need. Twenty-five percent of the participants met the nursing home admission criteria. The evaluation found the program was cost effective, consumer centered, and worthwhile.

Based on the results, regulations were drafted and issued for public comment. The New Jersey rules now refer to assisted living residences (purpose built facilities), comprehensive personal care homes (previously licensed homes which meet new standards), and assisted living programs which are services provided to residents in publicly subsidized housing sites. These regulations took effect January 1, 1997.

North Carolina has developed requirements for registration and disclosure for a category of assisted living residences called multi-unit assisted housing with services. Services in these settings are arranged by housing management but provided by a licensed home care or hospice agency and not the housing provider, unless the housing management company is also licensed as a home care agency. The disclosure statement describes the services which may be arranged, the cost of services, tenant admission/retention criteria, a list of service providers, a grievance procedure, and any financial relationships between service providers and the housing management. This category seems to formalize but not alter the existing in-home delivery system serving residents in elderly housing sites.

While the primary vehicle for reimbursing care in residential settings in North Carolina is through the Medicaid state plan, the combination of rules and Medicaid funding create some interesting contrasts. North Carolina reimburses assisted living residences in adult care homes and multi-unit assisted housing with services models. Personal care in adult care homes is reimbursed as a state plan service while the Medicaid HCBS waiver may cover eligible residents in multi-unit assisted housing with services settings. Participants must meet the nursing home level of care criteria while adult care home residents must have ADL impairments. It has not been determined whether residents in subsidized elderly housing sites which register as multiunit assisted housing with services settings will be eligible for both programs.

States designing policies to facilitate aging-in-place must recognize the importance of meeting unscheduled needs for personal care, especially during the night, holidays, and weekends. In terms of capacity to serve frail residents, these are key variables. Whether services are provided directly by the building management or through a contract to serve all residents with a community agency (certified home health agency, licensed home care agency) is less significant than the availability of 24-hour staffing capacity and the ability to meet unscheduled needs for assistance with activities of daily living. Issues of cost are also significant. A certified home health agency may have a higher cost structure in order to maintain its Medicare certification which adds to the cost of delivering services. Home health agencies which have created home care subsidiaries can deliver a similar level of care with lower costs.

Assisted Living Philosophy

Assisted living in many states represents a more consumer focused model which organizes the setting and the delivery of service around the resident rather than the facility. States which emphasize consumers use terms such as independence, dignity, privacy, decision-making, and autonomy as a foundation for their policy. Statutes, licensing regulations, and Medicaid requirements in twenty-two states, up from 15 states in 1996, contain a statement of their philosophy of assisted living. (See table in appendix.) States which have adopted or proposed this philosophy are Arizona, Delaware, Florida, Hawaii, Illinois (demonstration program), Iowa, Kansas, Kentucky, Louisiana (draft), Maine, Maryland, Massachusetts, Nebraska, New Jersey, New Mexico, Oregon, Rhode Island, Utah, Vermont, Virginia, Washington and West Virginia. Massachusetts includes their language in a section that allows the Secretary of Elder Affairs to waive certain requirements for bathrooms as long as the residences meet the stated principles.

Oregon's definition states that: "Assisted living promotes resident self-direction and participation in decisions that emphasize choice, dignity, privacy, individuality, independence and home-like surroundings." Florida's statute states the purpose of assisted living is "to promote availability of appropriate services for elderly and disabled persons in the least restrictive and most home-like environment, to encourage the development of facilities which promote the dignity, individuality, privacy and decision-making ability...." The laws also state that facilities should be operated and regulated as residential environments and not as medical or nursing facilities. The regulations require that facilities develop policies which allow residents to age-in-place and which maximize independence, dignity, choice, and decision-making of residents.

New Jersey amended its rules to emphasize the values of assisted living and introduce managed risk. Facilities must provide and coordinate services "in a manner which promotes and encourages assisted living values." These values are concerned with the organization, development, and implementation of services and other facility or program features so as to promote and encourage each resident's choice, dignity, independence, individuality, and privacy in a home-like environment. The values promote aging-in-place and shared responsibility.

Although the philosophy of assisted living is increasingly found in state policy, facilities must take additional steps to operationalize it. Aspects of assisted living that might be considered to convert philosophy to action include the living units required or provided, whether living units may be shared by choice, use of a shared-risk process to develop a service plan and training for facility staff on the principles of assisted living. Eight of the twenty-two states with a statement of the philosophy of assisted living also require apartment units. Rules in four states have mixed requirements, allowing bedrooms in some arrangements and apartments in new construction. Fifteen of the states allow sharing (apartments or bedrooms) only by choice of the residents. Ten states use a shared risk process for developing tenant service agreements or service plans. Connecticut, which licenses assisted living service agencies and not facilities, does not have a statement of philosophy, but residences must offer apartments, and sharing is allowed only by choice. Two other states, Ohio and Oklahoma (draft rules), have a shared-risk provision and no statement of philosophy. Four states include a philosophy of assisted living but do not address the remaining areas which would operationalize the philosophy. Eleven states require that the training curriculum for staff must cover the principles of assisted living.

Resident Agreements

State rules often include requirements for agreements or contracts with residents. The scope of the agreement varies but usually includes provisions dealing with services, fees, resident rights and responsibilities, occupancy, and move-out or discharge issues.

The agreements include a description of the fee or charges to be paid, the basis of the fee or what is covered, who will be responsible and the method, and time of payment. Refund policy is also covered by agreements in many states. Rules covering agreements specify the amount of advance notice tenants must be given when rates are changed. A thirty-day notice is usually required. Policies governing the management of resident funds, when applicable, may also be included in resident agreements.

Service provisions generally describe the services to be provided that are covered by the basic fee and any additional services that might be available. Maryland's rules require disclosure in the agreement of the level of care that the facility is licensed to provide and the level of care needed by the resident at the time of admission. Wisconsin requires that the qualifications of staff who will provide services are included in the agreement and whether services are provided directly or by contract. The resident agreement in Colorado includes a care plan which outlines functional capacity and needs.

Resident rights and the provisions that allow staff to inspect living quarters, with the resident's permission, are also required by some states. Other states require that a copy of residents' rights provisions must be provided to each resident, without including it as part of the resident agreement. Grievance procedures may also be included in the agreement or provided separately to residents.

Terms of occupancy may also address provision of furnishings and the policy concerning pets. Other terms often include admission policy and descriptions of the reasons for which a resident may be involuntarily moved as well as the time frame and process for informing the resident and arranging for the move. Policies concerning shared occupancy must be included in agreements under Maryland's rules as well as procedures which will be followed when a resident's accommodations are changed. The changes could be due to relocation, change in roommate assignment, or an adjustment in the number of residents sharing a unit. Agreements may also include the facility's "bed hold" policy when residents temporarily enter a hospital, nursing home, or other location.

Agreements in Colorado must disclose whether the facility has an automatic sprinkler system.

Rules in Maine do not allow the resident agreement to contain any provision for discharge which is inconsistent with state rules or law or imply a lesser standard of care than is required by rule or law. Agreements in Maine must also include information on grievance procedures, tenant obligations, resident rights, and the facility's admissions policy.

Kansas requires that citations of relevant statutes and copies of information on advance medical directives, resident rights, and the facility's grievance procedure must be given to residents before an agreement is signed.

Kansas specifies that the agreement must be written in clear and unambiguous language in 12 point type. Draft rules in Maryland direct that the agreement must be a clear and complete reflection of commitments agreed to by the parties and the actual practices that will occur in the facility. The language must be accurate, precise, easily understood, legible, readable, and written in plain English. Wisconsin's rules require that the format of agreements make it esay to readily identify the type, amount, frequency, and cost of services.

Most state rules do not address revising or updating resident agreements. However, Alabama includes the period covered by the agreement. Wisconsin's rules provide that agreement must be reviewed and updated when there is a change in the comprehensive assessment, or at the request of the facility or the resident. Updates are otherwise made as mutually agreed by the parties.

Unit Requirements and Privacy

Privacy is primarily measured by the type of unit, the ability of residents to lock their doors, and the behavior of staff. States which have based their policy on privacy have emphasized apartments with attached bath. Autonomy is promoted by the availability of cooking facilities within the unit. Of the states that have established or proposed assisted living policy in this area, the following require apartments: Arizona, Connecticut, Hawaii, Kansas (draft), Louisiana (draft), Minnesota, New Jersey,⁵ North Dakota, Oregon, Vermont (draft), Wisconsin andWashington. (Note: States in italics require apartments under the Medicaid program rather than the state's licensing requirements).

Thirty-one states have rules that allow two people to share a unit or bedroom, and eleven of these states allow sharing of units only by choice of the residents. Several of these states have multiple licensing categories, and the two-person limit may apply to only one of the categories. Fifteen states have licensing categories that allow four people to share a room; five states allow three people to share units, and one state allows up to five people to share a room.

Washington requires private apartments shared only by choice. New Jersey's policy requires apartments for newly constructed units but allows two people to share an apartment. Florida now has two types of assisted living, one which allows up to four people to share a bedroom, and extended congregate care, which requires private apartments, private rooms or semi-private rooms or apartments, shared by choice of the residents. Massachusetts allows two people to share a room or apartment. Kentucky's statute requires apartments or home-style units. A home-style unit is a private room with a semi-private bathroom and use of kitchen facilities.

States which have developed a multiple-setting assisted living model vary the requirements by the setting. New York allows sharing for board-and-care facilities participating in the Medicaid program but requires apartments in the "enriched housing category," which includes purpose-built residences and subsidized housing.

New Mexico's Medicaid assisted living waiver covers two types of facilities offering "home-like" environments which are either units with 220 square feet of living and kitchen space (plus bathroom) or single or semi-private rooms in adult residential care facilities; however, rooms may be shared only by choice.

Regulations in Maine allow residential care facilities and congregate housing projects to operate as assisted living. Residential care facilities may offer shared rooms, and congregate housing projects are typically built as elderly housing projects. North Carolina allows up to four residents to share a room in adult care residences, but the multi-unit assisted housing with services category contains apartments in elderly housing projects. Texas covers assisted living services through Medicaid to residents in three settings: assisted living apartments (single occupancy); residential care apartments (double occupancy allowed); and residential care non-apartments (double occupancy rooms). Utah also establishes separate requirements based on the units offered rather than the setting. Facilities offering apartments must be single or double occupancy with a bathroom, living room, dining space, and kitchen facilities. Facilities may also provide double occupancy rooms. Virginia's new rules for assisted living also build on board-and-care requirements which allow four people to share a room.

Shared rooms, toilet facilities, and bathing facilities are the rule among states with board-and-care regulations. Board-and-care rules generally allow bedrooms shared by 2-4 residents and bathrooms shared by 6-10 residents. Board-and-care and/assisted living rules in Alabama, California, Colorado, Idaho, Nevada, New Hampshire, New Mexico, New York, South Dakota, Utah, and Wyoming limit sharing of units to two residents. South Dakota requires a toilet room and lavatory in each room. Three people may share a room in West Virginia. A few states do not specify a limit on the number of people sharing a room.

Four people may share a room under board-and-care rules in Delaware, Georgia, Indiana, Iowa, Michigan, Mississippi, Missouri, Nebraska, Pennsylvania, Rhode Island, South Carolina, and Virginia.

TABLE 2. State Policy Concerning Living Units¹

Assisted Living Rules		Shared Rooms
Apartment Units	Multiple Settings	Assisted Living Rules	Board-and-Care
Arizona (Medicaid)2	Alaska	Arizona	Arkansas
Connecticut	Delaware	Alabama	California
Hawaii (draft)	Florida	Nebraska	Colorado
Illinois (pilot)	Iowa	Rhode Island	Georgia
Kansas	Kentucky	South Dakota	Idaho
Louisiana (draft)	Maine	Virginia	Indiana
Minnesota (Medicaid)	Maryland (draft)	Wyoming	Michigan
New Jersey	Massachusetts		Mississippi
North Dakota (Medicaid)	New Mexico (Medicaid)		Missouri
Oregon	New York (Medicaid)		Montana
Vermont (draft)	North Carolina		Nevada
Washington (Medicaid)	Oklahoma		New Hampshire
Wisconsin	Utah		Ohio
	Texas (Medicaid)		Pennsylvania
			South Carolina
			West Virginia

The first two columns describe the policy of existing or draft assisted living regulations that require apartments or license multiple settings (apartment units and rooms). The last two columns list states whose policy addresses only bedrooms through assisted living or board-care regulations.
Arizona's new regulations require apartments in assisted living centers (facilities with eleven or more units) and allow shared rooms in assisted living homes (<10).

Space requirements under board-and-care rules typically require 80 or 100 square feet for single units and 60 or 80 square feet per resident in shared units. Alabama requires 130 square feet for double units, and New Hampshire requires 140 square feet. Several states with assisted living rules that require apartments do not specify a square footage (Connecticut, New Jersey), while Arizona, Oregon, and Washington require at least 220 square feet of living space, not including closets or bathrooms.

Table 2 presents state policy concerning living units. States that allow shared units generally have developed policy that broadens the scope of residential options and may create two or more types of buildings, each with different requirements (eg., Florida, New York, Texas, Utah). The table may also be expressed as a continuum. On one end are residences that offer single occupancy units with kitchenette and skilled services to residents. On the other end are residences that provide shared units without cooking capacity to residents who cannot receive skilled services in an assisted living setting. While a state's policy sets the parameters for what may be offered and provided, the actual practice may be more narrow. Shared units may be allowed, but the market may produce very few or no projects that offer shared units. Further, facilities constructed prior to the development of assisted living may offer shared units while most, if not all, newly constructed buildings have private units.

5. New Jersey's rules require apartment settings for all new construction but allowed existing Personal Care Homes with shared rooms to convert to assisted living.

Tenant Policy or Admission/Retention Criteria

State policy on the level of need that may be served in assisted living varies widely. States have set very general criteria while others are very specific. The criteria can be grouped in five areas:

General,
Health related conditions,
Functional,
Alzheimer's disease and dementia, and
Behavioral.

Eighteen states have general criteria that require that the resident's needs can be met by the facility. Initially this domain was included to identify states using only this general criteria. Draft regulations in Hawaii and Vermont rely primarily on these criteria. Wisconsin also uses this threshold but limits the amount of services any resident can receive to 28 hours a week. Other states allow facilities to admit and retain residents whose needs can be met but include other limits as well. In effect, the requirement is used in combination with others that screen out residents with certain conditions and set expectations that any facility admitting residents with allowable service needs must be capable of meeting those needs.

A table comparing admission/retention criteria in the appendix summarizes the provisions of state regulations. Some states use general criteria (such as a resident must have stable health conditions or cannot need 24-hour nursing care). These criteria may be interpreted to mean that anyone needing a feeding tube, sterile wound care, or ventilator care could not be served.

Twenty-six states use criteria that specify that residents must not need 24-hour nursing care. Four states (Arizona, Kansas, New Jersey, and Vermont) specify that 24-hour care can be provided if the facility meets certain criteria (e.g., they are licensed to do so, or a care plan has been approved by the licensing agency). Nine states do not allow residents who need hospital or nursing home care to be served, and rules in eight states specify that facilities may provide part time or intermittent nursing care. States may specifically cite conditions or services that may not be met. For example, ten states include prohibitions against serving anyone with stage III or IV ulcers. Eight do not allow anyone who is ventilator dependent to be served or anyone needing naso-gastric tubes. Fourteen states specify that persons with a communicable disease may not be admitted or retained.

Criteria dealing with functional and Alzheimer's disease are less frequent. Six states require that residents are ambulatory, and five require that residents can evacuate without assistance. Four states specify that residents may not be totally bedfast and other states allow this level of care under specified conditions. Four states specify that facilities can admit people with mild dementia; however, most states allow people with dementia to be served without specifying it in their regulations. Facilities in twenty states cannot admit or retain people who are a danger to themselves or others, and people who need restraints are specifically excluded by regulations in nine states.

While state rules apply uniformly, actual practice may vary within the same state. State rules define the conditions that residents may or may not have in order to be admitted or retained in an assisted living residence. But these standards are not required for each residence. Individual residences are generally allowed to establish their own standards within state parameters, and residences are required to inform prospective tenants what the policy is and what conditions would trigger "move out." For example, Massachusetts' rules allow residences to meet personal care needs. At a minimum residences must offer support for bathing, dressing, and ambulation but are not required to offer assistance with other ADLs. Most other states allow, but do not require, residences to serve people with ADL needs.

Hawaii and Vermont are posed to join Oregon among the states with the broadest policies. Oregon's regulations generally do not limit whom facilities may serve. The rules contain "move out" criteria that allow residents to choose to remain in their living environment despite functional decline as long as the facility can meet the resident's needs. Facilities may ask residents to leave if the resident's behavior poses an imminent danger to self or others, if the facility cannot meet the resident's needs or if services are not available, if the resident has a documented pattern of non-compliance with agreements necessary for assisted living, or for not-payment.

Draft rules in Hawaii would require that each facility develop admission policies and procedures which support the principles of dignity and choice. The policies include a listing of services available, the base rates, services included in the base rates, services not provided but which may be coordinated, and a service plan and contract. Facilities must also develop discharge policies and procedures which allow 14 days notice for discharge based on behavior, on needs that exceed the facility's ability to meet them, or on the resident's established pattern of non-compliance. The rules do not specify who may be admitted and retained. Rather each facility may use its professional judgement and the capacity and expertise of the staff in determining who may be served.

New rules in Vermont allow residents to be moved if they pose an immediate threat to others or have needs that cannot be met by the residence. A resident may, but is not required to, be moved if he or she requires 24-hour, seven day a week, on-site nursing care, or if he or she is bedridden more than 14 days, is consistently and totally impaired in four or more ADLs, has cognitive decline severe enough to prevent making simple decisions, has stage III or IV pressure sores or multiple stage 2 sores, has medically unstable conditions, and/or has special health problems and a regimen of therapy that cannot be implemented appropriately in the setting. Facilities that want to serve people with these conditions must notify the licensing agency and describe how it will meet the person's needs. The licensing agency determines whether the plan is appropriate.

Regulations in Arizona, Delaware, Kansas, Maine, Nebraska and New Jersey are also flexible, allowing a high degree of impairment. Arizona sets requirements for different supplemental licensing levels. Facilities providing supervisory care services may serve residents needing health or health-related services that are provided by a home health agency or licensed hospice agency.

Additional requirements allow facilities in Arizona providing personal care services to serve residents who require continuous nursing services, are bedbound or have Stage III or IV pressure sores. Residents requiring continuous nursing services may be served if nursing services are provided by a private duty nurse, a hospice agency, or if the facility is a foster care home operated by a licensed nurse. These facilities may serve someone who is bedbound or has stage III or IV pressure sores if a physician authorizes residency and nursing services are provided by a private duty nurse or hospice agency, a licensed nurse, or home health agency, and the facility is meeting the resident's needs. These facilities may not admit residents unable to direct their care.

Facilities in Arizona must have a supplemental license to provide directed care services to serve people with Alzheimer's disease who are not able to direct their care. This license requires policies that ensure the safety of residents who may wander, that control access and egress, and that provide appropriate training for staff.

Two groups of consumers cannot be served in Delaware--unless the attending physician certifies that despite the presence of the following factors, the consumer's needs may be safely met by a service agreement developed by the agency, the attending physician, a registered nurse, the consumer or his/her representative if the consumer is incapable of making decisions and other appropriate health care professionals:

Consumers whose medical conditions are unstable to the point that they require frequent observation, assessment and intervention by a licensed professional nurse, including unscheduled nursing services, and
Consumers who are bedridden for 14 consecutive days.

Facilities may not serve residents who need transfer assistance from more than one person and a mechanical device, unless special staffing arrangements have been made, or residents who present a danger to self or others or engage in illegal drug use.

Kansas also has very broad criteria. Each facility develops admission, transfer, and discharge policies which protect the rights of residents. Facilities may not admit or retain people with the following conditions unless the negotiated service agreement includes hospice or family support services which are available 24-hours a day or similar resources:

Incontinence where the resident cannot or will not participate in management of the problem;
Immobility requiring total assistance in exiting the building;
Any ongoing condition requiring two person transfer;
Any ongoing skilled nursing intervention needing 24-hour a day care for an extended period of time; or
Any behavioral symptom that exceeds manageability.

Rules in Maine encourage aging in place and have very flexible policies to do so. In its licensing application, facilities must describe who may be admitted and the types of services to be provided. Facilities may discharge tenants who pose a direct threat to the health and safety of others, damage property, or whose continued occupancy would require modification of the essential nature of the program. The rules also require facilities to permit reasonable modifications at the expense of the tenant or other willing payer to allow persons with disabilities to reside in licensed facilities. Facilities must make reasonable accommodations for people with disabilities unless they impose an undue financial burden or result in a fundamental change in the program.

Maine's rules apply differently depending on the setting: congregate housing, adult family care, or residential care facility. Residential care facilities may only provide nursing services with their own staff to residents who do not meet the nursing home level of care. Residents who meet nursing home admission requirements can be served, but nursing services must be provided by a licensed home health agency. Congregate housing programs may receive a license to provide nursing and medication administration services by registered nurses employed by the program.

In Nebraska, anyone needing complex nursing interventions or whose conditions are not stable and predictable can be admitted if:

The resident, or the resident's designee if the resident is not competent, the resident's physician or the registered nurse agree that admission or retention is appropriate;
Care is arranged through private duty personnel, a licensed home health agency, or a licensed hospice agency; and
The resident's care does not compromise the facility operations or create a danger to others in the facility.

Complex nursing interventions are defined as those requiring nursing judgement to safely alter standard procedures in accordance with the needs of residents, which require nursing judgement to determine how to proceed from one step to the next, or which require a multidimensional application of the nursing process. Facilities will be able to develop their own admission and retention policies within state guidelines.

New Jersey's rules allow, but do not require, assisted living residences to care for people who:

Require 24 hours, seven day a week nursing supervision,
Are bedridden longer than 14 days,
Are consistently and totally dependent in four or more ADLs,
Have cognitive decline that interferes with simple decisions,
Require treatment of stage three or four pressure sores or multiple stage two sores,
Are a danger to self or others, or
Have a medically unstable condition and/or special health problems.

Assisted living in New Jersey is not appropriate for people who are not capable of responding to their environment, expressing volition, interacting, or demonstrating independent activity. Each resident receives an assessment and a care plan by a registered nurse. The admission agreement has to specify if the residence will retain residents with one or more of these characteristics and the additional costs which may be charged.

New Jersey officials report that, although the experience is limited, no complaints have been made about the level and quality of care and monitoring surveys have not detected any violations. Licensing applications show a bell-shaped curve with most facilities selecting 3-4 conditions which they will serve. A few on either end will not serve people with any of the eight criteria while a similar number will serve people meeting all eight criteria.

Oregon and other states have developed assisted living as the equivalent of nursing home care, at least for people at lower acuity levels. The New Jersey regulations require that at least 20% of the occupants meet the nursing facility admission criteria within three of years licensing.

Tenant admission/retention criteria often result from compromises reached with trade associations. In Massachusetts and Tennessee, state home-care associations supported requirements that all skilled services must be provided by a certified or licensed home health agency. However, most of the controversy over admission/retention criteria has been sparked by drawing the line between nursing home and assisted living. State respondents reported consistent, though varied, opposition from nursing home operators to allowing people who need skilled services to be served in assisted living facilities. In at least one state, an association objected to the ability of these facilities to provide personal care. As a result of the policy formulation and legislative process, a number of compromises have emerged. States typically include a general statement that residents must have stable health conditions and do not need 24-hour, skilled nursing supervision. A number of states have specified which conditions may or may not be treated in an assisted living residence.

Nursing home providers participating on a Maryland task force created to recommend policy on assisted living sought upper limits on admission/retention criteria, but the task force adopted a policy which allows residents to remain as long as the care is appropriate to the person's needs. Draft regulations in Maryland do not allow programs to serve anyone who, at the time of admission, requires one or more of a number of listed conditions (see state summary). However, programs may request a waiver to care for residents with needs that exceed the licensing level if they can demonstrate that they can meet the residents' needs and that others will not be jeopardized. Programs are licensed based on their level of service. Waivers for Level I and Level II programs may not be granted for more than 50% of the licensed bed capacity. Level III programs may not receive waivers for more than 20% of capacity or 20 beds, whichever is less.

Utah's facilities may not serve anyone who requires inpatient hospital care or 24-hour continual nursing care that will last more than fifteen calendar days or people who cannot evacuate without physical assistance of one person. Written acceptance, retention, and transfer policies are required of each facility. Facilities may not accept anyone who is suicidal, assaultive, or a danger to self or others, has active tuberculosis or other communicable disease that cannot be adequately treated at the facility or on an outpatient basis or that may be transmitted to other residents through general daily living. Physicians' statements are required to document the resident's ability to function in the facility and to confirm that the resident's health condition is stable and free from communicable disease. They are also required to list the following: allergies; diets; current prescribed medications with dose, route, time of administration and assistance required; physical or mental limitations; and activity restrictions.

Florida's regulations for "admissions" are very detailed. New residents must:

Be able to perform ADLs with supervision or assistance (but not total assistance);
Be free from signs and symptoms of communicable diseases;
Not require 24-hour nursing supervision;
Be capable of taking their own medication or may require administration of medication and the facility has licensed staff to provide the service;
Not have bed sores or stage II, III, or IV pressure ulcers;
Be able to participate in social activities;
Be capable of self-preservation;
Not be bedridden;
Be non-violent; and
Not require 24-hour mental health care.

Additional criteria affect continued residency. In regular assisted living facilities, people who are bedridden more than seven days or develop a need for 24-hour supervision may not be retained. In Extended Congregate Care facilities, a higher level of care, residents may not be retained if they are bedridden for more than fourteen days. Residents may stay if they develop stage II pressure sores but must be relocated for stage III and IV pressure sores. Residents who are medically unstable, become a danger to self or others, or experience cognitive decline to prevent simple decision making may not be retained. People who become totally dependent in four or more ADLs (exceptions for quadraplegics, paraplegics, and those with muscular dystrophy, multiple sclerosis, and other neuro-muscular diseases if the resident is able to communicate his or her needs and does not require assistance with complex medical problems) may not be retained. State officials are planning to undertake a review of the criteria to evaluate their impact.

Tennessee's new regulations allow residences to retain for 21 days but not admit anyone requiring: intravenous or daily intramuscular injections of feedings; gastronomy feedings; insertion, sterile irrigation and replacement of catheters; sterile wound care; or treatment of extensive stage 3 or 4 decubitus ulcers or exfoliative dermatitis; or who, after 21 days, require four or more skilled nursing visits per week for any other condition.

In Washington, residents may be required to move when their needs exceed the services provided through the contract with the state agency or when the resident requires a level of nursing care that exceeds what is allowed by the boarding home license.

Although Wyoming expanded their regulations to allow skilled services, they do not allow residents who wander or need wound care, stage II skin care, are incontinent, need total assistance with bathing and dressing, or need continuous assistance with transfer and mobility in order to be served.

Negotiated Risk

Sixteen states have adopted or proposed a negotiated risk process to involve residents in care planning and to respect resident preferences which may pose risk to the resident or other residents. Washington provides for negotiated risk agreement that is developed as a joint effort between the resident, family members (when appropriate), the case manager, and facility staff. The negotiated risk document specifies that the agreement's purpose is to "define the services that will be provided to the resident with consideration for preferences of the resident as to how services are to be delivered." The agreement lists needs and preferences for a range of services and specific areas of activity under each service. (See table.) A separate form is provided to document amendments to the original agreement. Signature space is provided for the resident, family member, facility staff, and case manager. If assistance with bathing is needed, the process allows the resident to determine and choose what assistance will be provided, how often, and when. It allows residents to preserve traditional patterns for eating and preparing meals and engaging in social activities. The negotiated service agreement operationalizes a philosophy that stresses consumer choice, autonomy, and independence over a facility-determined regimen that includes fixed schedules of activities and tasks that might be more convenient for staff and management of an efficient "facility." It places residents ahead of the staff and administrators and helps turn a "facility" into a home.

The process allows the participants to identify a need and determine with what tasks the residents themselves wish to receive help. For example, if the resident has difficulty bathing, the resident may prefer help getting to the bathroom and unfastening clothing. Yet a resident may prefer to undress and get into the tub and bath herself/himself even though the staff member and perhaps a family member feel the resident may be placed at risk of falling. The risk is expressed but the final decision to bathe rests with the resident.

TABLE 3. Washington Negotiated Service Agreement Areas

Nursing	Health monitoring, nursing intervention, supplies, services coordination, medication, special requests
Personal service	Toileting, bathing, AM preparation, ambulation, PM preparation, hygiene
Food service	Dietary, eating
Environmental	Safety, housekeeping, laundry
Social/emotional	Family intervention, information/assistance, counseling, orientations, behavior management, socialization
Administration	Business management, transportation
Special needs

Values assume a prominent role in shaping policy in several states. Many states use values language developed in Oregon. The Oregon definition says that "assisted living promotes resident self direction and participation in decisions that emphasize choice, dignity, privacy, individuality, independence and home-like surroundings." Each facility must have written policies and procedures which incorporate the above principles. Services plans are reviewed for the extent to which the resident has been involved, and the resident's choices as well as the principles of assisted living are reflected.

New Jersey defines managed risk as the process of balancing resident choice and independence with the health and safety of the resident and other persons in the facility or program. If a resident's preference or decision places the resident or others at risk or is likely to lead to adverse consequences, such risks or consequences are discussed with the resident and, if the resident agrees, a resident representative. A formal plan to avoid or reduce negative or adverse outcomes is negotiated. The rules provide that choice and independence may need to be limited when the resident's individual choice, preference, and/or actions place the resident or others at risk. The managed risk process requires that staff identify the cause for concern, discuss the concern with the resident, seek to negotiate a managed risk agreement that minimizes risk and adverse consequences and offers possible alternatives while respecting resident preferences, and document the process of negotiation or lack of agreement and the decisions reached.

Ohio added managed risk provisions to its residential care facility rules in 1996. The rules allow facilities to enter into agreements with residents to share responsibility for making and implementing decisions affecting the scope and quantity of services provided by the facility.

Services

States seeking to facilitate aging-in-place and to offer consumers more long-term-care options allow more extensive services. These states view assisted living as a person's home. In a single family home or apartment in an elderly housing complex, older people can receive a high level of care from home health agencies and in-home service programs. Several states extend that level of care to assisted living facilities.

The extent and intensity of services generally follows state admission/retention criteria. Services can be provided or arranged that allow residents to remain in a setting. Mutually exclusive resident policies, which prohibit anyone needing a nursing home level of services from being served in board-and-care, have been replaced by "aging-in-place" provisions. However, drawing the line has been controversial in many states. Opponents of assisted living legislation in Tennessee initially opposed allowing personal care to be provided. In many states, some nursing home operators see assisted living as competition for their "patients" and oppose rules which allow skilled nursing services to be delivered outside the home or nursing home setting.

Most states require an assessment and the development of a plan of care that determines what services will be provided, by whom and when. Residents often have a prominent role in determining what they will receive from the residence and what tasks they will do for themselves. A key factor in assisted living policies is the extent of skilled nursing services.

Arizona has three service levels that allow supervisory care services, personal care services, and directed care services. Residents in facilities with a supervisory care license may receive health services from home health agencies. Facilities with a personal care services license can provide intermittent nursing services and administer medications. Other health services may be provided by outside agencies. Directed care service facilities provide supervision to ensure personal safety, cognitive stimulation, and other services for residents who are unable to direct their care.

Alaska's regulations also require that tenant contracts spell out the services and accommodations that will be provided and that reflect the diversity and availability of providers in the state. Intermittent nursing services are allowed for residents who do not require 24-hour nursing care, and supervision and tasks approved by the Board of Nursing may be delegated to unlicensed staff.

Connecticut allows client teaching, wellness counseling, health promotion and disease prevention, medication administration, and skilled services to clients with chronic but stable conditions. Draft legislation in Illinois would allow intermittent health services (medication administration, dressing changes, catheter care, therapies). Kentucky's statute does not specifically mention nursing services in a listing of services but includes the phrase "is not limited to" which may allow other services to be added when regulations are prepared.

Facilities in Florida may provide limited nursing services (e.g., medication administration and supervision of self-administration, applying heat, passive range of motion exercises, ice caps, urine tests, routine dressings that do not require packing or irrigation, and others), and intermittent nursing services (e.g., change of colostomy bag and related care, catheter care, administration of oxygen, routine care of an amputation or fracture, prophylactic, and palliative skin care).

Facilities in Florida may not provide oral or nasopharyngeal suctioning, assistance with tube feeding, monitoring of blood gasses, intermittent positive pressure breathing therapy, intensive rehabilitation services for a stroke or fracture or treatment of surgical incisions which are not clean and free from infection, and any treatment requiring 24-hour nursing supervision. Washington has developed a list of skilled services that may and may not be delivered by licensed nurses and unlicensed staff. Nursing services are differentiated by licensing category. RNs or LPNs may provide insertion of catheters, nursing assessments, and glucometer readings. Unlicensed staff may provide the following under supervision of an RN or LPN: stage-one skin care, routine ostomy care, enema, catheter care, and wound care. Changes in the nurse practice are pending in the legislature which would allow greater delegation.

Hawaii's draft regulations require facilities to provide nursing assessment and health monitoring; medication administration; services to assist with ADLs; support, intervention and supervision for residents with behavior problems; opportunities for socialization; meals; laundry; and housekeeping. Facilities must also provide or arrange for transportation and ancillary services for medically related care (physician, pharmacist, therapy, podiatry, home health, and others).

In keeping with its admission/retention criteria, New Jersey's rules allow levels of skilled care that are specifically barred in many states (e.g., stage III or IV pressure sores, ostomy care, 24hour nursing supervision). Oregon's policy allows a wide range of delegation under which nurses must train unlicensed staff for each resident receiving delegated services. Further, there are no explicit discharge criteria based on service needs.

Legislation in Massachusetts, as in other states, does not allow 24-hour nursing services. However, skilled services may only be provided by a certified home health agency on a part-time or intermittent basis. Medical conditions requiring services on a periodic, scheduled basis are allowed. In addition, residents may "engage or contract with any licensed health care professional and providers to obtain necessary health care services...to the same extent available to persons residing in private homes." The Massachusetts statute only allows skilled nursing services to be provided by a certified home health agency. As a result, registered nurses, if hired by an assisted living facility, presumably, would not be allowed to deliver skilled care. The initial draft of state regulations did not allow skilled services to be received for more than 90 days in a one-year period. The attorney general's office reviewed the draft and advised that such limits may conflict with fair housing rules. The 90-day limit was removed.

The Massachusetts statute specifies a minimum level of personal care services that must be provided (bathing, dressing, ambulation) and requires that tenant agreements include the services which will be provided and those which will not be provided. Facilities certified under the law may offer a broader range of personal care services. Alabama's rules mandate personal care for bathing, oral hygiene, hair, and nail care but do not require assistance with eating, dressing, or toileting.

Rules governing residential care facilities in Ohio will limit skilled services to 120 days with exceptions for diets, dressing changes, and medication administration.

Missouri's rules governing residential care facilities allow advanced personal care services to be provided which include residents with a "catheter or ostomy, require bowel or bladder routines, range of motion exercises, applying prescriptions or ointments and other tasks requiring a highly trained aide."

Iowa's legislation allows health related care which are services provided by a registered nurse, a licensed practical nurse, or home care aide and services provided by other licensed professionals as defined by rule. Health related and personal care services can be provided on an intermittent and part-time basis, which is defined as up to 35 hours a week of personal care and health related services on a less than daily basis, or up to 8 hours personal care and health related services provided 7 days a week for temporary periods not exceeding 21 days.

Because of its funding source, New York allows for skilled nursing, home health aide, and therapies. Regular Medicaid state plan services have been included in a capitated rate to include the full range of Medicaid long-term care services that can be delivered in the home.

In Utah facilities must arrange for necessary medical and dental care although medication administration of prescription drugs is allowed. Maine's revised policy allows skilled services to be provided by a residential care facility or a congregate housing program. Previous policy required skilled services to be provided by a licensed home health agency.

State policy generally specifies the range of allowable services but facilities are not required to provide the full range of services allowed under the law. Facilities are usually authorized to determine which services will be provided. Combined with facility-based admission/retention policies, facilities may offer a very light, moderate, or heavy level of care. Owners of assisted living facilities who also own nursing homes may develop assisted living as a "feeder" system for their nursing homes and set policies which require residents to "move out" when they develop multiple ADL impairments or require nursing services. Although state regulations frequently explicitly support aging-in-place and resident involvement in care planning decisions, facility specific policies may be developed which limit the potential impact of assisted living to serve residents with higher levels of need.

Provisions for Residents with Alzheimer's Disease and Dementia

Twenty six states reported that they have specific requirements for facilities serving people with dementia or Alzheimer's disease. Requirements address one or more of the following: disclosure requirements, staffing patterns and staff training, activities, environmental provisions, and admission/retention criteria. Staff training accounts for the special provisions in the majority of these states. Idaho's rules include a definition of Alzheimer's facilities. The rules define special care facilities as those that "are specifically designed, dedicated, and operated to provide the elderly individual with chronic confusion, or dementing illness, or both, with the maximum potential to reside in an unrestrictive environment through the provision of a supervised life-style which is safe, secure, structured but flexible, stress free and encourages physical activity through a well developed activity and recreational program. The program constantly strives to enable residents to maintain the highest practicable physical, mental or psychosocial well-being."

Arizona licenses directed care facilities which means programs and services, including personal care services, provided to persons who are incapable of recognizing danger, summoning assistance, expressing need or making basic care decisions. Regulations in most other states do not define special care facilities.

Disclosure

Disclosure requirements are included in state regulations in nine states. These provisions typically require that facilities advertising themselves as operating special care facilities or units, or that care for people with Alzheimer's disease, describe in writing how they are different. The regulations may require a description of the philosophy of care, admission/discharge criteria, the process for arranging a discharge, services covered and the cost of care, special activities available, and differences in the environment.

A voluntary disclosure process has been adopted in California under which facilities offering special services for people with Alzheimer's Disease disclose information concerning their program. A consumer's guide has been developed which alerts family members to several key questions that should be asked. The areas include the philosophy of the program and how it meets the needs of people with Alzheimer's, the pre-admission assessment process used by the facility, the transition to admission, the care and activities that will be provided, staffing patterns and the special training received by staff, the physical environment, and indicators of success used by the facility.

Admission/Retention Criteria

Eight states have admission/retention criteria that directly reference people with Alzheimer's disease. Tennessee does not allow people in the later stages of the disease to be served. People with Alzheimer's disease may be served only after a multi-disciplinary team determines that care can be provided safely. The determination must be reviewed quarterly.

Florida allows people with Alzheimer's disease to be retained in facilities with an extended congregate care license if they can make simple decisions and if they do not have a medical condition requiring nursing services. Georgia also requires that residents must be able to make simple decisions. California's criteria allows people with Alzheimer's disease to be admitted who are not able to respond to verbal instructions. Vermont's draft rules allow but do not require facilities to serve people who cannot make simple decisions.

Washington state has included separate requirements for boarding homes providing special dementia care units or services to people with dementia. Boarding home staff must be qualified to serve people with dementia, and homes must have sufficient staff to monitor and care for residents as well as an alarm or monitoring system to alert staff when a resident leaves the building or enclosed outside area. Boarding homes with dementia units must design floor and wall surfaces to augment orientation and provide access to secured outside space. Units must meet other requirements concerning doors that restrict egress, are alarmed, and release automatically during a fire or power failure. Officials are evaluating whether dementia care units are consistent with the state's assisted living model.

Idaho requires that residents of specialized care units be evaluated by their primary care physician for the appropriateness of placement into the unlocked specialized care unit/facility prior to admission. Residents cannot be admitted without a diagnosis of Alzheimer's disease or related disorder. Residents must be at a stage in their disease such that only periodic professional observation and evaluation is required. Residents in these units must be re-evaluated quarterly. Residents who require physical or chemical restraints cannot be admitted.

Facilities in South Dakota that admit or retain residents with cognitive impairments must have the resident's physician determine and document if services offered by the facility continue to enhance the functions in ADLs and identify if other disabilities and illnesses are impacting on the resident's cognitive and mental functioning.

Staffing and Training

Twenty states have regulations that address training requirements for staff in facilities serving people with Alzheimer's disease. In Maine, all new employees in facilities with Alzheimer's/ Dementia Care Units must receive a minimum of eight hours classroom orientation and eight hours of clinical orientation. The trainer must have experience and knowledge in the care of individuals with Alzheimer's disease or other dementia. The facility's regular orientation covers resident rights, confidentiality, emergency procedures, infection control, the facility's philosophy of Alzheimer's disease/dementia care, and wandering/egress control. The eight hours of classroom orientation includes the following topics: a general overview of Alzheimer's disease and related dementias, communication basics, creating a therapeutic environment, activity focused care, dealing with difficult behaviors, and family issues.

Florida has recently implemented new training rules for staff in facilities serving people with Alzheimer's disease. The rules require four hours of initial training in areas of the disease in relation to the normal aging process; diagnosing Alzheimer's disease; characteristics of the disease process; psychological issues including resident abuse; stress management and burn-out for staff, families and residents; and ethical issues. An additional four hours is required on medical information, behavior management, and therapeutic approaches. Direct care staff must participate in four hours of continuing education each year.

Core training and Alzheimer's disease training may be obtained from persons approved by the Department of Elder Affairs or the Department staff. The rules contain a sliding fee for training that varies with the percentage of residents supported by public funds.

New rules in Arizona will require a special license to service people who are unable to direct their own care. These facilities are required to have services that are appropriate to people with Alzheimer's disease, including cognitive stimulation, encouragement to eat meals and snacks, and supervision to ensure personal safety. Staff must receive 12 hours of additional training or demonstrate skills in and knowledge of Alzheimer's disease, communicating with residents, providing services including problem solving, maximizing functioning and life skills training for those unable to direct care, managing difficult behaviors, and developing and providing social, recreational and rehabilitative activities.

Staff in specialized care units for Alzheimer's/dementia residents in Idaho must complete an orientation/continuing training program that includes information on Alzheimer's and dementia, symptoms and behaviors of memory impaired people, communication with memory impaired people, resident's adjustment, inappropriate and problem behavior of residents and appropriate staff response, activities of daily living for special care unit residents, and stress reduction for special care unit staff and residents. Staff must have at least six additional hours of orientation training, and four hours of the required twelve hours per year of continuing education must be in the provision of services to persons with Alzheimer's disease.

Draft rules in Texas contain special requirements for administrators and a combination of orientation, on-the-job supervision and in-service education (see state summary).

Vermont's ongoing training requirements include communication skills for residents with Alzheimer's disease and other dementias. South Dakota's rules require that all staff members attend an annual in-service training in the care of the cognitively impaired and those with unique needs.

Activities

Survey responses from 12 states indicated that state rules address activities for people Alzheimer's disease. Regulations in Maine, Nevada, and California require activities that address gross motor skills, self care, social activities, crafts, sensory enhancement, outdoor, and spiritual activities. Draft rules in Texas propose activities that encourage socialization, cognitive awareness (crafts, arts, story telling, reading, music, discussion, reminiscences and others), selfexpression and physical activity in a planned and structured program.

In Idaho, services in specialized care units for residents with Alzheimer's disease include habilitation services, activity program and behavior management according to the individualized plan of care.

Environment

Draft rules in Nebraska's would have required facilities serving special populations must provide an environment that conforms to their special needs to enhance quality of life, reduce agitation and difficult behaviors, and promote safety. The accommodations include offering secured outdoor space; high visual contrasts between floors, walls, and doorways in resident areas; lighting which minimizes glare; plates and eating utensils which provide visual contrast between the plate, food and the table; and chairs that allow for gliding. These provisions were not included in the final regulations.

Delaware's rules require that facilities have policies designed to prevent residents from wandering away from the grounds.

Facilities serving people with Alzheimer's disease in South Dakota must have exit alarms. California operated a three-year demonstration program to test the feasibility of serving people with Alzheimer's disease in Residential Care Facilities for the Elderly (RCFEs). Seventy-five percent of California's residential care facilities have six or fewer beds. Prior to the demonstration, RCFEs could serve people with mild or moderate dementia who require protective supervision as long as they can make their needs known and can follow instructions. The pilot was approved to test whether people with more advanced dementia who were required to transfer to nursing facilities could be served in RCFEs. The independent study variables were special staff training, resident activities, and the use of either locked or secured (alarmed) perimeters. No facilities were willing to participate as a control group without using the interventions. Staff in both groups received 25 hours of training in residential care, normal aging, Alzheimer's disease, managing problem behaviors, recreational activities, communication, medication use and administration, medications used for disruptive behavior, ADLs, and staff stress and burn-out.

Six facilities were selected to participate in the demonstration, three with locked or secured perimeters and three with alarms or other signal devices to alert staff when people were leaving the facility or the grounds.

In April 1994, the California Department of Social Services issued a report with recommendations based on findings from the demonstration program. The report found that both models reduced acting-out behavior, diversion of staff time from direct care, and incidents of wandering. The report recommended a separate licensing category for RCFEs specializing in care of people with moderate to severe dementia. However, the report concluded that RCFEs should not be allowed to serve people with serious medical conditions which would require staffing patterns that would significantly raise costs. Examples of conditions which the study found should not be allowed in RCFEs included urinary catheters, colostomies, ileostomies, tracheostomies, tube feeding, contractures, bedsores, and intravenous injections. Because of the demands of residents, the report recommended at least two staff be on duty at all times. Other recommendations included training in dementia care, pre-admission assessment and reassessments to determine suitability for admission and retention, family meetings, continued standards for the use of "chemical restraints," and increased frequency of monitoring by regulatory staff (quarterly rather than annually).

The report found that the staff-to-resident ratio was more important than the size of the facility and that requirements for specialty staff included in the legislation were not necessary. Beyond requiring one awake staff and two persons at all times, the report suggested that staffing patterns should reflect resident needs for assistance with planned activities and supervision. However, the report did emphasize the need to require adequate outdoor space for resident use. Regulations should specify standards for the amount of space and other physical characteristics based on the size of the facility.

The report concluded that the use of locked or alarmed perimeters had no impact on medication use and reduction in physical or verbal behaviors (kicking, biting, throwing, screaming, threatening harm) or agitation (pacing, repeated movements, hand wringing, rapid speech). The study was limited by sample problems. Baseline measures showed significant differences among residents in each facility (higher or lower wandering, medication use). The report suggested that increasing the time staff spent with residents and increasing resident social interaction may contribute to a reduction in problem behaviors. While outcomes were similar for both alarmed and secured models, the study found high satisfaction among family members and some reduction in disruptive behaviors.

During 1995, legislation (Chapter 550 of the Acts of 1995) was passed that allows RCFEs that serve people with Alzheimer's disease to develop secure perimeters. The law allows facilities to install delayed egress devices on exterior doors and perimeter fence gates. Resident supervision devices, wrist bracelets which activate a visual or auditory alarm when a resident leaves the facility, may also be used. Facilities must provide interior and exterior space for residents to wander freely, must receive approval from the local fire marshal, and must conduct quarterly fire drills. Facilities with delayed egress devices must be sprinklered and contain smoke detectors, and the devices must deactivate when the sprinkler system or smoke detectors activate. The devices must also be able to be deactivated from a central location and when a force of 15 pounds is applied for more than two seconds to the panic bar. In addition facilities shall permit residents to leave who continue to indicate such a desire, and staff must ensure continued safety. Reports must be submitted when residents wander away from the facility without staff. Delayed egress devices may not substitute for staff.

Requirements for Assisted Living Facility Administrators

Regulations in five states do not describe any requirements for the administrators of assisted living facilities or assisted living service agencies. Half the states require that administrators must be at least 21 years of age, six states specify 18 as the age requirement, one state uses 19, and one 25. Seventeen states do not specify an age requirement.

In addition to age, state rules typically set standards for education and training. Eighteen states require a high school diploma or G.E.D., and seven include advanced degree requirements which sometimes vary with the level of care offered by the facility. Ten states have experience requirements, and thirteen identify specific abilities or knowledge that an administrator must have. Licensing or certification of administrators is required by seventeen states. Twenty-two states have an annual requirement for CEUs or hours of in-service training. The number of hours range from six to 40 per year. Finally, twenty-five states include criminal background checks in their requirements for administrators. (See appendix.)

Staff Training Requirements

State regulations typically require on orientation for new staff and annual in-service training. Training requirements can be very general or specific. Ten states require direct care staff to successfully complete an approved course. Other states specify the areas to be covered during training, some specify the number of hours to be spent in training, and many states include requirements for both topic areas and number of hours. Training requirements can be grouped into five domains:

Direct care,
Health related,
Knowledge areas,
Safety and emergency issues, and
Process.

Thirty-five states require training on resident rights, the most common of all issues described in state rules. Direct care skills are covered as training in personal care or direct care skills (26 states), as areas that are appropriate or related to the tasks or duties of staff (17 states), and more generally as tasks necessary to meet the needs of consumers (13 states). There is considerable overlap between these areas as fifteen states require training in two or all three of the areas. Other direct care areas included nutrition/food preparation (18), dementia or Alzheimer's care (15), mental health and emotion needs (16), general requirements (13), principles of assisted living (12), housekeeping/sanitation (14), hygiene (11), and training related to the use of restraints (7).

Safety and emergency issues are also important components of training in these facilities. Thirty-three states require training in fire, safety, and emergency procedures. Twenty-three cover first aid, while 15 require CPR training. Infection prevention and control is also required in 24 states.

The most common health related topics were medication administration and assistance (23 states) and observation or reporting skills (14 states). Preventive or restorative nursing services and basic nursing skills is required in three states.

Fewer states address aging process (11), communication skills (9), assessment skills (8), psychosocial needs (6), care plan development (5), and death and dying (4).

Quality Assurance and Monitoring

Developing outcome measures is a major focus in the health care system and interest in similar measures has appeared in long-term care services. Seventeen states indicated that they are either developing outcome measures for assisted living or were interested in doing so: Alabama, Florida, Idaho, Iowa, Kansas, Maine, Massachusetts, Minnesota, New Jersey, New York, North Carolina, Oregon, Texas, Utah, Vermont, Washington, and West Virginia.

The initiative has gained attention in part as a result of the work of Keren Brown Wilson, President of Assisted Living Concepts, who developed a paper on this area for the American Association of Retired Persons. Based on her work, officials in the Washington Aging and Adult Services Division developed a review guide that operationalizes the principles of assisted living and the concepts of outcome measures and which tested an outcome-based approach to monitoring quality in assisted living facilities. Using this approach, the inspector--prior to monitoring visits--reviews existing information and prepares a plan for the visit. This includes reviewing the files for complaint history, reviewing DOH inspections reports, checking for information from the long-term care ombudsman program, and contacting the case manager to determine whether any concerns have been raised by clients and whether any clients have special needs. The reviews include visits with a sample of Medicaid residents.

During the visit, the monitor meets with the residence administrator who informs the residents of the visit. The monitor compares the list of the residents to the list maintained by the department. Staff provide an escorted walk-through of the residence to evaluate the home-like quality of the facility and observes activities, interactions between staff and residents, laundry areas, availability of a public telephone, posting of resident's rights as well as the numbers for filing complaints. Based on the size of the facility, a sample of residents is selected for interviews, including at least one resident who receives "limited nursing services" and a resident who does not have a person that can intervene on his/her behalf. The monitor reviews a sample of the negotiated service agreements and notes who was involved in developing the agreement, the extent of the resident's needs, and the agreed upon service plan and ensures that the services required to meet the needs have been delivered. A staff member introduces the monitor to the residents included in the sample. The interviews are held to determine what services were provided, if they were adequate to meet the resident's need, and if they were delivered according to the preferences of the resident.

Direct interviews with residents are the central source of information concerning quality of care. Residents are asked about a range of issues that include the appropriateness of and satisfaction with the service received. Residents are asked to identify what services are being received, whether they are received when and in the manner that is needed, who decided when the services would be delivered, whether any needed services are not being received, and any limitations that need to be addressed.

Residents are asked if they feel as though they are treated with dignity and respect, to describe their daily routine, to discuss who makes decisions about routine activities (getting up and going to bed, eating meals, taking baths) and how well the residence respects the resident's preferences.

Privacy issues are addressed by asking whether the mail is opened, how a person makes personal phone calls, whether service needs have been discussed in front of others. Questions are also asked about support for personal relationships and the maintenance of a home-like environment. (Do you like the way your room is arranged and decorated? Are your personal possessions safe? Is the housekeeping satisfactory?) Other areas covered include understanding and perception of the rules, adequacy of health care services, and the resident's sense of well-being. Monitors also make observations about the resident's living area and appearance and, if concerns are observed, first checks the person's preferences and choices before a conclusion is reached.

When negative outcomes are observed, the monitor conducts a more focused and detailed review of the residence in the problem areas to determine whether the facility's administration, policy, procedures or practices are contributing to the outcome. Additional activities include expanding the sample of residents interviewed, more detailed record reviews, and a review of the minutes of the resident council meetings. Monitors will also review the records of residents who have left the residence as well as activity schedules and menus.

Monitors talk with staff and the administrator to discuss observations from the review and to obtain the provider's perspective on service delivery. Monitors may contact family members or case managers before completing a report. The report covers the physical environment; resident's rights concerning privacy, dignity, and choice as well as the awareness of rights; and service delivery.

Other models: Under Connecticut's rules, assisted living services agencies (ALSAs) are required to establish a quality assurance committee that consists of a physician, a registered nurse, and social worker. The committee meets every four months and reviews the ALSA's policies on program evaluations, assessment and referral criteria, service records, evaluation of client satisfaction, standards of care, and professional issues relating to the delivery of services. Program evaluations are also to be conducted by the quality assurance committee. The evaluation examines the extent to which the managed residential community's policies and resources are adequate to meet the needs of residents. The committee is also responsible for reviewing a sample of resident records to determine whether agency policies are followed, services are provided only to residents whose level of care needs can be meet by the ALSA, care is coordinated and appropriate referrals are made when needed. The committee submits an annual report to the ALSA summarizing findings and recommendations. The report and actions taken to implement recommendations are made available to the state Department of Health.

Oregon's rules require providing for ongoing monitoring by the state Senior and Disabled Services Division staff or its designee, usually an area agency on aging. The staff review the service plans of residents for compliance. Written outcome measures covering functional abilities, psycho-social well-being, stability of medical conditions, and client/family satisfaction are examined.

Nearly final rules in Vermont will require facilities to develop quality improvement programs that identify indicators to be used to monitor performance and describe how monitoring will occur. An internal quality committee will be formed that includes the director, a licensed nurse, one other staff member, and others as needed or desired. Committees will meet quarterly and residents are to be able to provide input on satisfaction and review of any quality improvement plans.

Facilities must allow survey staff access to resident assessments and service plans and outcome measures that reflect planned and actual events related to functional abilities, psycho-social well being, stability of medical conditions, and resident satisfaction. Assisted living residences must establish and maintain a written quality assurance plan and a listing of all residents who moved from the facility since the last monitoring visit.

Role of the Ombudsman Program

In addition to the survey and inspection activities of the state licensing agency, additional monitoring is possible through the state ombudsman program and home and community based case management agencies. Thirty-four states indicated that the ombudsman program monitors care in assisted living and board-and-care facilities. The role is similar to that performed in nursing homes and focuses on receiving and investigating complaints.

Nineteen states indicated that case managers monitor Medicaid beneficiaries receiving services in these facilities. The role of case managers was described in various terms and included observing and monitoring care, ensuring that services were delivered in accordance with a negotiated service agreement, and monitoring the assessment process. Quality of care problems are reported to the licensing agency in several states. Case managers are mandatory reporters of abuse and neglect in Alabama.

Certificate of Need (CoN)

Six states have certificate of need requirements for assisted living: Connecticut, Illinois, Kentucky, Missouri, New Jersey, and New York. Three states (Arkansas, North Carolina, and North Dakota) have a moratorium on licensing new facilities. North Carolina's moratorium has exceptions for counties in which the average occupancy rate is above a specified threshold. New York, which reimburses assisted living as a Medicaid service, limits the number of contracted units to 4,200 and removes 4,200 beds from the nursing home facility bed need estimates. New Jersey retains a CoN requirement but provides an expedited review. Legislation passed in Connecticut repealing the CoN requirement was awaiting action by the Governor at the time this paper was published.

The certificate of need process was designed to allocate scarce health care resources by controlling the supply, and therefore utilization, of hospital and nursing home care. In today's more service rich environment, certificate of need in long-term care limits consumer choices and protects existing providers. State experience suggests that it is impossible to measure the appropriate supply of nursing homes. The supply of nursing homes ranges from 19.2 beds per thousand elderly in Nevada to as high as 72.9 beds per elderly residents in North Dakota. Applying certificate of need measures in an era in which extensive home care and assisted living services are available further weakens an already flawed policy.

A certificate of need requirement for nursing homes assumes that a given service, e.g., nursing homes, is the only appropriate choice for an individual. If we could measure the number of people who needed a particular service, states could regulate supply to meet the measured need. However, many people have needs that can be met in more than one setting. The same individual may qualify for and enter a nursing home, remain at home with home care and home health services, remain at home and attend an adult day care program, move to an adult foster care program, or move to an assisted living residence. With this overlap of services, measuring the need for one service, nursing home or assisted living, fails to acknowledge the availability of other existing and/or potential resources. Not only are certificate of need programs unable to accurately measure this overlap, it would limit the choices available to consumers. The value of certificate of need was its ability to control spending. However, other mechanisms have evolved in the health care arena e.g., managed care, that have taken on this responsibility. While controls are not yet needed in Medicaid spending on assisted living, other approaches should be devised to anticipate growing demand over time.

Consumer Guides and Report Cards

Five states (Colorado, Massachusetts, Montana, Pennsylvania, and Washington) have developed consumer guides to assisted living facilities for consumers in their states. Agencies in Alaska, Delaware, Minnesota, Nevada, New Jersey, North Carolina, and Vermont are developing consumer guides. The guides may list individual facilities and note the fees, services, and accommodations available while others describe assisted living and contain questions to be asked or information consumers should know as they consider assisted living.

As in the managed health care system, assisted living report cards are also an interest of policy makers. Report cards would identify and measure key characteristics of facilities that would assist consumers in selecting the most appropriate facility and create incentives for facilities to maintain or improve quality of care. Two states, Iowa and Vermont, indicated that they were developing report cards, and ten states are interested in developing these tools: Michigan, Minnesota, Mississippi, Montana, New Jersey, New Mexico, New York, North Carolina, Utah, and Virginia. Report cards are contingent on developing aspects of assisted living that are measurable and commonly accepted as measures of quality. To be fair and meaningful, measures such as length of stay, resident turnover rates, reason for discharge, and location after discharge may require adjustments to reflect the functional and cognitive status of residents. Without adjustments for acuity, facilities that serve "lighter need" residents may measure more favorably than those that promote aging-in-place or admit residents with greater health and functional needs.

Building Codes

The NASHP survey asked which level of government determines the building code requirements and which codes were used. Usable responses were received from 37 states. State agencies determine which codes will be used in fifteen states. Local government agencies make this determination in seven states, and both state and local agencies are responsible in fifteen states.

TABLE 4. Level of Government and Building Codes

State			Local		State and Local
AL ID IN KS MI	MO NE NJ OH RI	TN UT VT VA WY	AS CT DE MN	MS OR TX	CA CO FL IA MA	NY MT NV NM NY	PA SC SD WA WV

Six states indicated that they use the BOCA code, while nine use the Uniform Building Code, and three use the Standard or Southern Building code. Ohio uses the Ohio Basic Building Code. The remaining states did not indicate which codes were used.

Policy Priorities

The survey asked state respondents to list three top issues facing public policy makers with regard to assisted living. The responses covered a broad range of areas: financing, regulation, quality of care, services, staff training, and the future and direction of assisted living. Policy makers are searching for ways to make assisted living accessible and affordable. Sixteen states identified a range of issues related to affordability. Several are interested in developing public funding for low-income residents or funding ways to make it affordable to residents whose income is too high to meet Medicaid eligibility requirements and too low to pay privately.

A number of general regulatory issues were raised such as whether and how to regulate assisted living, transitioning from licensing to an accreditation model, and dealing with unlicensed facilities. One respondent noted that greater consistency in the application of regulations by survey staff was needed, and another state is seeking ways to improve dealing with facilities that consistently have violations of rules that are not severe enough to warrant termination of the license. The role of the Fair Housing regulations and ADA were cited as a concern.

States also support but express concern about many of the main tenants of assisted living. How do you balance safety and maximum autonomy and independence? What levels of care are appropriate? How should state policy facilitate or deal with aging in place, and what are the best ways to monitor facilities serving residents with a mix of health and functional needs? The needs of residents with Alzheimer's disease and control of access issues were mentioned by four states.

A number of policy makers dealt with quality in stating their priorities. States are searching for the right level of oversight, developing outcome measures, dealing with abuse and neglect, and handling facilities that admit residents that they are not staffed to serve appropriately.

Several respondents were concerned about the lack of consensus about the definition of assisted living and the potential for medicalizing what is now seen as a social or home-like model of care. Another was concerned that over time the more flexible approach to regulation might give way to more prescriptive regulation. Precedents in licensing and regulating nursing homes were mentioned. Concerns that the spiraling growth of facilities and the emerging dominance by a limited number of chains may undermine what has until now been a "consumer-driven" market were described. A few states were concerned about recruitment and retention of enough trained staff as the number of facilities expands. While states worry about over-supply, some seek to stimulate development in rural areas where the supply has been far slower to develop.

Appropriate training for administrators and staff was cited by three states. Several states are focusing on medication management and the training of staff administering medications. Regulations in most states allow administration of medications and many allow unlicensed staff to administer medications under nurse delegation procedures.

Among the issues related to services, state respondents listed integration of services, linkages between assisted living and other Medicaid waiver services, and the coordination of home health services and assisted living services as areas to explore.

Negotiated service agreements are another area that differentiates assisted living from board-and-care rules, yet states are concerned that consumers do not understand these procedures and may not use them to their full advantage. The need for an effective assessment process and the offering of meaningful activities to residents were also cited.

A few states were interested in exploring how assisted living could serve people with chronic mental illness or adults with physical disabilities.

Public Subsidies

Public policy concerning subsidies for elders in residential settings has paralleled the emergence of new residential long-term care models. Subsidies for low-income older persons may be provided through the federal Supplemental Security Income program (SSI), through state supplements to the federal SSI program, or through Medicaid. Many states have created living arrangements under a state supplement to the federal SSI payment for residential settings. These supplemental payments cover room and board and sometimes personal care. The payment standards typically were created years ago before the emergence of assisted living and the higher level of care provided in assisted living and, more frequently, in board-and-care settings. SSI payments developed primarily for "board," rather than "care," are quite low in relation to the fees in assisted living facilities. Many observers contend they are low in relation to the actual cost of meeting the increasing needs of low-income board-and-care residents. States are now developing policies which combine SSI and Medicaid to provide an appropriate level of service and to encourage aging in place.

The Social Security Administration publishes an annual report describing each state's living arrangements and the amount of the state supplement. Individual states may use a specific term to refer to their supplement and some use the term SSI to refer to both the federal payment and any state supplement. The federal payment in 1998 is $494 a month and is adjusted each January based on the cost of living. For the purposes of this section, references to SSI payments above $494 a month mean that the state supplements the federal payment.

Medicaid Reimbursement

States may fund services in assisted living or board-and-care settings through Home and Community Based Services (HCBS) waivers or as a regular state plan service. States most often use the Home and Community Based Services Waiver (1915 (c)). However, a few states use Medicaid state plan services, typically personal care. The two forms of coverage differ in three important ways:

First, waiver services are available only to beneficiaries who meet the state's nursing home level of care criteria; that is, they would be eligible to enter a nursing home if they applied. Nursing home eligibility is not required for beneficiaries using state plan services.

Second, states set limits on the number of beneficiaries that can be served through waiver programs. The limits are defined as expenditure caps that are part of the cost neutrality formula required for approval. Waivers are only approved if the state demonstrates that Medicaid long- term care expenditures under the waiver will not exceed expenditures that would have been made in the absence of the waiver. States do not receive federal reimbursements for any waiver expenditures that exceed the amount stated in the cost neutrality calculation. In contrast, state plan services are an entitlement, meaning that all beneficiaries who meet the eligibility criteria must be served. Federal funding continues to match state expenditures without any cap.

Finally, under home and community based waiver service programs, states may use the optional eligibility category that allows beneficiaries with incomes less than 300% of the federal Supplemental Security Income (SSI) benefit ($494 a month) to be eligible and receive all Medicaid services. In the absence of this provision, people who live at home and have too much income to quality for Medicaid would be forced to spend down their income and assets to qualify, often by needlessly entering an expensive nursing home. Using the optional eligibility approach, states can pay for assisted living and other services to give people options to nursing home admission. Tenants who meet the nursing home criteria can become eligible for Medicaid without spending their excess income. They may retain the income to pay the room and board costs while Medicaid covers the services. In contrast to the more generous eligibility option available under 1915 (c) home and community based services waivers, beneficiaries are eligible under the regular Medicaid state plan if they receive SSI or meet the state's medically needy standards.

TABLE 5. Difference in Medicaid Coverage

Issue	State Plan Service	1915(c) Waivers
Entitlement	States must provide services to all beneficiaries who qualify for Medicaid	States limit spending for waiver services
Functional criteria	Beneficiaries must need the service covered	Must meet the state's nursing home level of care criteria
Income	Must be SSI or otherwise eligible for Medicaid	State may set eligibility up to 300% ($1482) of the federal SSI payment standard ($494)

Available since 1981, HCBS waivers afford States the flexibility to develop and implement creative alternatives to institutionalizing Medicaid-eligible individuals.⁶ States may request waivers of certain Federal rules which impede the development of Medicaid-financed community-based treatment alternatives. The program recognizes that many individuals at risk of institutionalization can be cared for in their homes and communities, preserving their independence and ties to family and friends, at a cost no higher than that of institutional care. Waivers are initially granted for three years and may be renewed for five years.

HCFA has streamlined the waiver process. A pre-printed application allows states to simply check off essential aspects of its application. Assisted living has been added as a service on the pre-print although states may submit their own definition of the services, subject to approval. Some states reimburse waiver services--such as personal care, homemaker, chores, and others--in an assisted living setting rather than assisted living services. Waiver services may be provided statewide or may be limited to specific geographic subdivisions.

To gain approval, states must assure HCFA that, on average, it will not cost more to provide home and community-based services than providing institutional care would cost. The Medicaid agency also must provide and document certain other assurances, including that there are safeguards to protect the health and welfare of recipients.

6. Portions of the following have been taken from HCFA's description of the waiver program which is available at its web site (http://www.hcfa.gov).

Current State Activity: Use of Waivers and State Plan Services

Describing coverage of assisted living by state Medicaid programs, like many aspects of assisted living, is complex. Coverage can be presented by licensing terms (assisted living or board-and-care), current and planned coverage, and source of coverage (Medicaid state plan or waiver services).

By June of 1998, 28 states covered services in assisted living and board-and-care facilities and nine more planned to do so. Twenty states reimbursed services in facilities licensed as assisted living or designated as assisted living by Medicaid, and eight states covered personal care services in board-and-care facilities that are sometimes considered assisted living. The eight states planning to add coverage will license assisted living facilities.

When presented by type of coverage and current and planned coverage, the number of states totals 37, although Maine and Vermont are counted twice. Maine, which licenses several categories of assisted living, covers services in residential care facilities under its state plan. Services in congregate housing can be covered by a Medicaid waiver. Vermont presently covers care in residential care facilities under its waiver and plans to add assisted living when draft regulations are final.

Twenty-two states now have an assisted living licensing category, although not all the states reimburse services for Medicaid beneficiaries. Other states reimburse for services in facilities licensed as board-and-care facilities, and still others have created assisted living as a Medicaid reimbursed service even though the state may not have an assisted living licensing category (Minnesota, New Mexico, New York, Texas, Washington). The table below presents the three categories of arrangements states have implemented: those with assisted living as a licensing category or a term developed by Medicaid; those that cover services in board-and-care facilities; and those that do not use Medicaid to pay for services in either assisted living or board-and-care facilities.

States that use or plan to use Medicaid reimbursements for assisted living are divided among three categories: states with approved waivers; states planning to seek waiver approval for assisted living; and states using the state plan to pay for care. Board-and-care reimbursement is divided between states using the waiver and those using state plan services.

TABLE 6. Medicaid Reimbursement Arrangements

Assisted Living						Board-and-Care¹		No Coverage (14)
Waiver (18)			Pending (9)		State Plan (4)	Waiver (5)	State Plan (2)	No Coverage (14)
AK AZ FL IA KS ME²	MD MN NJ NM ND OR	RI SD TX VA WA WI	CT DE HI IL LA	NE NH UT VT²	ME² MA NY NC	CO GA MT NV VT²	AR MO	AL CA KY ID IN	MI MS OH OK PA	SC TN WV WY

These states do not have a licensing category named assisted living.
Maine, using a broad definition of assisted living, uses the state plan and an HCBS waiver. Vermont covers services in residential care facilities and plans to add coverage for assisted living when its new rules take effect.

Although 28 states cover services in assisted living or board-and-care, total participation is just over 40,000 beneficiaries and waiver participation is very low in many states. States using personal care under the state plan to cover care have higher participation rates than states using the waiver. For example, roughly half of all Medicaid beneficiaries nationwide in assisted living or other residential care settings are in North Carolina, and another 25% are in Missouri and New York. Waiver participation is much lower. In 1998, Nevada had approximately 52 recipients participating in the waiver. New Jersey, which is approved for 1,500 participants, has 119 participants. Oregon, Virginia, and Washington have 1,400-1,500 each, and New York has approximately 2,100 participants. It is not clear why participation is low although observers speculate that primary referral sources and eligibility assessors may not be familiar with this new model. Facilities themselves may be slow to sign contracts with Medicaid over concern for the rate of payment or fears that additional regulations will be imposed and future increases may not be adequate. Further work is necessary to determine whether these or other factors contribute to the slower than expected participation rates.

State Approaches to Reimbursement

As in any reimbursement system, the amount of the payment and the approach to reimbursement create incentives for provider behavior. Five primary approaches are used by states in setting rates for assisted living and/or board-and-care services:

Flat rates,
Flat rates that vary by type of setting,
Tiered rates,
Case mix rate systems, and
Care plan or fee-for-service based rates.

Table 7 summarizes the rate-setting approaches used by states that reimburse assisted living services.

TABLE 7. State Rate-Setting Approaches

Flat Rates		Vary by Setting	Tiered Rates	Case Mix	Care Plan
Colorado Florida Georgia Maine Maryland Massachusetts Nevada	New Mexico North Carolina Rhode Island South Dakota Virginia Vermont²	Alaska¹ New Jersey¹ Texas	Arizona Delaware² Florida¹ Oregon Washington Wisconsin Vermont²	Maine¹ Minnesota New York North Carolina¹	Arkansas Iowa Kansas Missouri Montana North Dakota

Alaska, Florida, New Jersey, and North Carolina are exploring new rate-setting approaches. Maine plans to implement a case mix system in 1998 for residential care facilities. Note that Florida, Maine, and North Carolina appear under more than one category.
Delaware and Vermont are also developing tiered rate systems as waivers are developed for new assisted living regulations.

1. Flat Rates

As in the health care system, flat rates in the assisted living system create incentives for facilities to admit tenants who need lighter care. Facilities receive the same monthly payment regardless of the level of care and staff assistance needed. Facilities may tend not to admit tenants with multiple impairments in activities of daily living.

Thirteen states currently use flat rate reimbursements. Florida, which is exploring a tiered payment system, pays facilities $1350 a month, a fee that includes a service payment and a room and board component. Massachusetts uses Group Adult Foster Care (GAFC), which is listed as a Medicaid state plan service, to reimburse for services to Medicaid recipients in assisted living. The service payment averages $33.70 per day for Medicaid recipients. The program was developed prior to passage of the assisted living legislation and combines two approaches: services in conventional elderly housing projects and purpose-built assisted living sites.

Massachusetts, recognizing that high development costs create barriers for low-income residents, is the only state that has set a separate SSI payment for assisted living of $924 a month. This payment is considerably higher than the community standard (the payment for an aged person living alone in the community) or the board-and-care standard. The increased rate reflects the higher real estate and development costs in the state and provides access for Medicaid recipients to many market rate and mixed-income developments.

The state Medicaid agency prefers to retain coverage of assisted living through the GAFC program as a state plan service rather than as a waiver service. Although spending would be capped under the waiver, the state plan approach allows Medicaid to serve people who are frail but are not eligible to enter a nursing home following a tightening of the level of care criteria.

Four states--Colorado, Nevada, South Dakota, and Georgia--cover services in licensed board-and-care settings that are sometimes referred to as assisted living. Colorado's Medicaid rules limit room and board charges for Medicaid recipients to $448 a month. Effective July 1998, the Medicaid rate for services will be $29.88 a day ($896.40 a month). The rate covers oversight, personal care, homemaker, chore, and laundry services. The total monthly rate for an SSI recipient is $1344.40.

In Nevada, personal care services are reimbursed through a Medicaid HCBS waiver in group residential settings if the resident meets the SSI eligibility criteria. Facilities receive a total payment of approximately $1000 a month which includes $781 from SSI for room and board and $9.09 a day ($277.20 a month) for personal care.

The SSI payment, including state supplement, in South Dakota for assisted living facilities is $910 per month. Residents retain a personal needs allowance of $30 a month. If the Department of Social Services determines that a Medicaid eligible individual also needs medication administration, the facility receives $150 per month through the Medicaid HCBS waiver for a total payment of $1,030 per month.

Georgia has implemented a small Medicaid HCBS waiver that reimburses two models of personal care homes: (1) group homes serve 7-24 people, and (2) family homes serve 2-6 people. Group homes which are more comparable to assisted living, are reimbursed at $23.49 per day. Family homes, also called assisted living, are called adult foster care in other states.

Under its assisted living regulations, North Carolina licenses adult care homes, family care homes, group homes for the developmentally disabled, and multi-unit assisted housing with services. All are considered variations of assisted living under state law although some observers would consider adult care homes as a board-and-care model.

North Carolina uses a modified flat rate with add-ons for tenants with specific ADL impairments. In 1998, the SSI payment for room and board is $893 a month (plus a $43 personal needs allowance), and the state covers personal care in adult care homes as a Medicaid state plan service. Providers receive a flat rate for basic personal care. Residents with extensive or total impairments in eating, toileting, or both eating and toileting qualify for a higher rate. In 1998, the basic payment is $8.07 a day which assumes each resident receives one hour of personal care a day. Providers receive higher payments for residents with extensive or total impairments in three specific ADLs: eating, toileting, or both. The rate for residents with extensive or total impairments in eating is $16.00 per day, toileting $10.87 per day, and impairments in both eating and toileting are reimbursed at $18.80 per day. These three payment levels include the basic rate of $8.07 per day. Eligibility for the added payment is based on an assessment by the adult care home which is then verified by a county case manager. North Carolina is developing a case mix payment system using assessment data and cost report data for tenants in adult care homes.

TABLE 8. North Carolina Medicaid Rates--Monthly (1998 data)

	Basic Rate	Eating	Toileting	Eating and Toileting
Room and board	$893.00	$893.00	$893.00	$893.00
Personal care	$242.70	$480.00	$326.10	$564.00
Total	$1135.70	$1373.00	$1219.10	$1457.00

2. Flat Rates that Vary by Setting

Flat rates that vary by setting generally reflect a state's preference for apartments and private occupancy without excluding facilities offering rooms or shared occupancy. However, unless the reimbursement also takes into account the differing service needs of the residents, the total amount of the payment may be more important to provider participation than the differential rates facilities receive based on the type of units offered (apartments or rooms) or occupancy arrangements (private or shared).

In some cases, varying rates by setting may reflect differences in the average acuity level of residents in each setting. For example, a state may reimburse for services in conventional elderly housing buildings and purpose-built assisted living facilities. Generally, tenants in elderly housing sites are less impaired than those in purpose-built assisted living facilities. Unlike purpose-built assisted living facilities, elderly housing sites typically do not have 24-hour staffing and the capacity to meet the unscheduled needs of tenants. Elderly housing facilities, therefore, receive a lower rate than purpose-built assisted living facilities with 24-hour staffing.

Texas has developed flat rates that vary by location rather than acuity. Separate service rates are based on the setting and the number of occupants. Single occupancy assisted living apartments receive $29.39 a day for services. Residential care units receive $22.96 a day for double occupancy and $18.99 a day for non-apartment, double occupancy models. The SSI rate for room and board is $11.88 a day for all settings.

New Jersey licenses assisted living as a service provided in a range of settings. Rates have been developed for each of three settings rather than level of service or other factor. Newly constructed assisted living residences receive $571 for room and board and $1800 a month for Medicaid services. Comprehensive personal care homes receive $571 for room and board and $1500 a month for services. Assisted living programs (subsidized housing) receive $1200 a month for services. Residents are charged a percentage of their income for rent with the remaining amount subsidized by the project. State officials plan to review the methodology and develop a new rate structure.

TABLE 9. New Jersey Rate Schedule

	Assisted Living Residences	Assisted Living Programs	Personal Care Homes
Room and board	$571.55	NA	$571.55
Medicaid waiver services	$1800.00	$1200.00	$1500.00
Total	$2371.55		$2071.55

3. Tiered Rates

Tiered Rates Based on Acuity Levels

Tiered rates have been developed to more fairly reimburse facilities for the care provided to frailer residents. Tiered systems usually include 3-5 tiers based on the type, number, and severity of ADL and/or cognitive or behavioral impairments. They create incentives to serve higher acuity tenants who are more likely to enter a nursing home.

Arizona has developed three rate classes based on the needs of the resident. Ohio was also planning to use a service rate structure with five tiers ranging from $200 to $1400 a month that varies based on the number and type of ADL impairments, skilled nursing needs, and behavior needs. The room-and-board payment was proposed to be $700 a month. The service rate was developed after consultation by the Department of Aging with assisted living providers.

TABLE 10. Oregon Reimbursement Categories

Impairment Level	Service Priority	Service	R&B	Total Rate
Level V	Service priority A or priority B and dependent in the behavior ADL.	$1643.48	$420.70	$2064.18
Level IV	Service priority B or priority C with assistance required in the behavior ADL.	$1330.48	$420.70	$1751.18
Level III	Service priority C or priority D with assistance required in the behavior ADL.	$1016.48	$420.70	$1437.18
Level II	Service priority D or priority E with assistance required in the behavior ADL.	$767.48	$420.70	$1188.18
Level I	Service priority E or F or priority G with assistance required in the behavior ADL.	$579.48	$420.70	$1000.18

Oregon reimburses facilities using five levels based on the type and degree of impairments of residents. The total rate includes a room and board payment of $420.70 and a service rate. The levels are assigned based on a service priority score determined through an assessment. ADLs include eating/nutrition, dressing/grooming, bathing/personal hygiene, mobility, bowel and bladder control, and behavior. Service priority ratings are assigned based on the number and type of impairments in ADLs. Service priority A is assigned to people who are dependent in 3-6 ADLs; priority B those dependent in 1-2 ADLs. (See table.) About 60% of the Medicaid residents are in Level IV.

Vermont has developed a unique three-tiered system that was developed using MDS 2.0 and assessment data. Residents receive a score in five areas: ADLs, bladder and bowel control, cognitive and behavior status, medication administration, and special programs (behavior management, skin treatment, or rehabilitation/restorative care). Residents are assigned to a level (1 or 2) based on the extent of ADL impairments. Scores of 6-18 are assigned to level 1 and scores between 19-29 are assigned to level 2. The four remaining areas are rated, and additional points are assigned. The payment tier is determined by combining the ADL level and the additional points. Payment rates have not been devised. The Department of Aging and Disability has piloted the classification system and will be developing rates for each tier.

TABLE 11. Vermont Payment Areas and Scoring System (proposed)

Area	Maximum Points	Factors
ADLs	29	Eating, toileting, mobility, bathing, dressing
Continence	13	Bladder and bowel
Cognitive/behavior status	65	Sleep pattern, wandering, danger to self/others
Medication	5	Administration
Special programs	49	Mood, behavior, cognitive loss. Skin: Turning/repositioning, nutrition or hydration, dressings, ulcer care, surgical wound care. Rehab: range of motion, skin brace assistance, transfer, walking, dressing/grooming, eating/swallowing, prosthesis care, communication.

TABLE 12. Vermont Rating System (proposed)

Tier 1		Tier 2		Tier 3
Level	Points	Level	Points	Level	Points
1	0-30	1	31-59	1	60+
		2	0-35	2	36+

Tiered Rates with Geographic Variations

Washington has developed a unique approach to developing rates. The state initially offered contractors a flat per diem rate of $47.37 a day in 1995 consisting of $27.06 for services and $20.31 for room and board. In 1995, the state Aging and Adult Services Administration (AASA) initiated development of a tiered rate structure based on three levels of care needs. AASA sought information from facilities on rate related costs. Working with assisted living facilities and the state Housing Finance Agency, model rates were constructed based on staffing, operations, and capital costs. The model assumed an average size facility of 60 units and variations in levels of care. Each level of care assumed residents would receive some nursing services though not every resident necessarily receives such services. Nursing services are differentiated by licensing category. RNs or LPNs may provide insertion of catheters, nursing assessments, and glucometer readings. Unlicensed staff may provide the following under supervision by an RN or LPN: stage-one skin care, routine ostomy care, enema, catheter care, and wound care. Unlicensed staff may provide assistance with transfer, mobility, hygiene and incontinence.

The process set the rate for nursing costs in King County at $15.16 a day for Level 1 residents, $21.24 for Level 2 residents, and $27.82 for Level 3 residents. Operating costs were $32.28, $32.72, and $33.16 respectively. Capital costs were $8.30, $8.36, and $8.44 respectively. Capital costs varied because of changing assumptions about occupancy rates across levels. In addition, a capital add-on was created for new construction. The rates are increased for new facilities by $4.49 a day in King County. (See Table 13).

The methodology sets upper limits that facilities may charge to Medicaid residents. Since Medicaid may only reimburse for services, the room and board portion of the rate is paid by the resident from his or her social security, pension, or SSI benefit. Residents who rely solely on SSI will pay $14.79 a day for room and board. The rates in the table represent total rates that include $14.79 per day for room and board.

TABLE 13. Washington Rate Structure

Level I				Level II			Level III
Component	King County	MSA	Non-MSA	King County	MSA	Non-MSA	King County	MSA	Non-MSA
Nursing	$15.16	$13.44	$12.75	$21.24	$18.72	$17.75	$27.82	$24.47	$23.21
Operations	$32.28	$29.97	$30.24	$32.72	$30.35	$30.65	$33.16	$30.73	$30.78
Capital	$8.30	$7.95	$6.94	$8.36	$8.01	$6.99	$8.44	$8.09	$7.06
Total	$55.74	$51.36	$49.93	$62.32	$57.07	$55.39	$69.41	$63.29	$61.05
Add-on	$4.49	$4.08	$4.34	$4.49	$4.08	$4.34	$4.49	$4.08	$4.34
Total	$60.23	$55.44	$54.26	$66.81	$61.15	$59.72	$73.90	$67.37	$65.38

Under the new system, case managers use a comprehensive assessment to measure the person's level of need. Three sections of the assessment are used to determine the payment level: health status, psychological/social/cognitive status, and functional abilities and supports. A three-step process is used to determine the appropriate rate. Six ADLs are weighted and measured: eating, toileting, bathing, ambulation, body care, and transfer. Eating, toileting, bathing and ambulation are assigned a weighted value of 2, while body care and transfer a given a value of 1. Residents must be substantially or totally impaired in an ADL to receive a score. Scores of 0-4 are assigned to level 1; 5-10 level 2.

The second step measures speech, sight, hearing, disorientation, memory impairment, impaired judgement, wandering, disruptive behavior, and medication administration. Ten points are assigned to people who have impairments in speech, sight, and hearing. Points are assigned based on the number of medications and a weighting which gives higher scores as the number of medications increase. In addition, points are assigned for disorientation (12), memory impairment (16), impaired judgement (17), wandering (15) and disruptive behavior (20).

Step three combines the scores from each section to arrive at a payment level. A computer program reviews the assessment and determines the residents "level" and payment amount. Prior to the new system, a survey of facilities showed that Medicaid residents were "light care" and had relatively fewer ADL impairments. Since its implementation in January 1996, very few complaints have been received. While some facilities were worried that their rates might be reduced, most responded to the incentives created and began seeking residents who required higher levels of care.

4. Rates Linked to Nursing Home Case Mix Systems

Several states have adopted, or are developing, systems based on their nursing home case mix methodology approach. Like tiered rate approaches, the case mix approach also creates incentives to serve more impaired tenants by linking reimbursements to levels of care needs, but case mix approaches have more groupings. In addition, the case mix approach requires extensive functional and health data on residents. Both tiered rates and case mix rates are subject to "category creep" or "gaming;" that is, a tendency for facilities to interpret assessment data to support payment of the next higher rate or to request an adjustment because the resident has become more impaired and requires more staff support than upon admission. States may use an assessment by an independent case management agency to determine the original payment level. Subsequent requests to adjust the payment level can be reviewed by either the case management agency or the state agency before being approved.

Minnesota and New York have modeled their reimbursement rates on their case mix system for paying nursing homes. In New York, the service reimbursement is set at 50% of the resident's Resource Utilization Group (RUG) which would have been paid in a nursing home. The state has created RUG rates for 16 geographic areas of the state. The reimbursement category is determined through a joint assessment by the Assisted Living Program and the designated home health agency or long-term home health care program. The assessment and the RUG category are reviewed by the Department of Social Services' district office. The residential services (room, board, and some personal care) are covered by SSI, which also varies by region. In 1998, the SSI rates are $827 to $857 a month.

Service rates in Minnesota are negotiated between the client and the provider with caps based on the client's case mix classification. Service rates under the Alternative Care program, a state funded program for people who do not meet the Medicaid eligibility criteria, cannot exceed the state's share of the average monthly nursing home payment. The client pays for room and board (raw food costs only; meal preparation is covered as a service). The room and board payment standard under the SSI and state supplemental payment is $667 a month less a $54 personal needs allowance. To determine cost effectiveness, costs for assisted living and all other waiver services are combined. Residences receive a payment for assisted living services, and any other waiver services used are billed by the provider directly to the county.

TABLE 14. Minnesota Case Mix Categories and Maximum Statewide Rate Limits for Assisted Living and All Other Waiver Services--Effective 10/1/971

Case Mix	Assisted Living Monthly Limits	Total Maximum Payment2		Description
Case Mix	Assisted Living Monthly Limits	AC Program	Elderly Waiver Program	Description
A	$684	$1072	$1429	Up to 3 ADL dependencies3
B	$771	$1209	$1612	3 ADLs + behavior
C	$871	$1356	$1820	3 ADLs + special nursing care
D	$962	$1507	$2010	4-6 ADLs
E	$1023	$1654	$225	4-6 ADLs + behavior
F	$1029	$1663	$2217	4-6 ADLs + special nursing care
G	$1105	$1786	$2382	7-8 ADLs
H	$1249	$2020	$2693	7-8 ADLs + behavior
I	$1300	$2102	$2803	7-8 + needs total or partial help eating (observation for choking, tube or IV feeding & inappropropriate behavior)
J	$1380	$2320	$2974	7-8 + total help eating (as above) or severe neuro-muscular diagnosis or behavior problems
K	$1546	$2500	$3333	7-8 + special nursing

The maximum rate limits vary by region of the state but cannot exceed the maximum statewide limits.
Rates include assisted living and all other waiver services which the residence is responsible for providing or arranging but are billed by the provider to the county. The residence does not receive payment for the non-assisted living waiver services.
ADLs include bathing, dressing, grooming, eating, bed mobility, transferring, walking, and toileting.

The total cost of all waiver services, including assisted living, may not exceed 75% of the average nursing home payment for the case mix classification. Under the HCBS waiver, rates for assisted living services are capped at the state share of the average nursing home payment and the total costs, including skilled nursing and home health aide, cannot exceed 100% of the average cost for the client's case mix classification.

The average statewide rate for assisted living services ranges from $684 a month for case mix A to $1595 for case mix K. About 70% of the participants were assessed as Category A and 96% fall between A and D. The Alternative Care program rates for all services including assisted living range from $1072 to $2500 a month. The Medicaid waiver statewide maximum rates for assisted living services and all other waiver services for elderly recipients ranged from $1429 a month to $3333 a month depending upon the case mix classification. Rates in a particular county could be higher or lower than the averages.

5. Care Plan and Fee-for-Service Rates

A few states use a system that is more like an in-home service system. This approach has three components: an assessment, a care plan, and the payment. Rates are determined by the number of hours of service identified in a care plan or a point system based on the assessment. For example, Kansas considers assisted living facilities as providers of home care services, and they are reimbursed on a fee-for-service basis. This approach may be cumbersome for some facilities to implement. Facilities are used to receiving a regular monthly payment and providing services as needed by the tenant pursuant to a plan of care. If the services are reimbursed fee-for-service, facilities must track service delivery and prepare and submit bills to the payment agency. Depending on the pricing structure, assisted living facilities may not be set up to prepare and submit itemized bills for each increment of service delivered to a tenant.

Service delivery in assisted living facilities is also very different from the delivery pattern of in-home service programs. Participants in home-care programs typically receive services in block authorizations, e.g., two hours of care, five days a week. Assisted living tenants typically receive services in 15-minute increments at various times during each day of the week including nights and weekends when home care programs usually do not offer services. Tracking, aggregating, and billing become cumbersome and time consuming, especially for facilities used to charging one, all-inclusive fee for services. However, the pricing structure of many facilities includes a basic package of services with additional charges based on the increments of service used by tenants. Facilities with this policy for market-rate or private-pay tenants may be better able to participate in the fee-for-service approach.

In Missouri, personal care and advanced personal care services are reimbursed as a Medicaid state plan service in residential care facilities. The payment varies by resident based on an assessment and a plan of care completed by a case manager from the Division of Aging. Facilities are reimbursed at an hourly rate for the number of hours authorized in the plan of care. The maximum payment is $1700 a month which is tied to the state's Medicaid nursing home costs. The actual number of hours authorized ranges from 5-6 hours to 70 or 80 hours a month. The average number of hours authorized is 25-30 hours a month. The payment rate is $10.07 an hour for personal care aides, $14.61 for advanced personal care aide services and $25.00 an hour for nursing visits. No more than one nursing visit a week can be authorized. Very few residents receive advanced personal care and nursing visits.

The room and board rate is paid through the federal SSI payment and a state "cash grant" or SSI supplement payment. Type I facilities receive a combined payment of $645 a month and Type II facilities receive a combined payment of $752 a month. With an average personal care payment of $302.10, the total payment would equal $947 in Type I facilities and $1054 in Type II facilities. Type I facilities provide room and board, supervision and protective oversight. Type II facilities also provide personal care and supervision of diets and health care.

Montana and North Dakota use payment systems that have elements of a tiered methodology but lack the structure and limited number of payment levels of tiered approaches. However, payment is based on an assessment. Assessment data in Montana is converted to points and the facility receives so much per point. The Medicaid waiver reimburses adult foster care home and personal care facilities between $520 and $1800 a month depending on the level of care needed by residents. State agency field staff complete the assessment and determine the payment rate. In addition to the room-and-board component, the basic service payment for residents is $520 a month. Additional payments are calculated based on ADL and other impairments. Points are calculated for each impairment. The functions measured are: bathing, mobility, toileting, transfer, eating, grooming, medication, dressing, housekeeping, socialization, behavior management, executive cognitive functioning, and other. Each function is rated:

With aides/difficulty: Individual needs consistent availability of mechanical assistance or expenditure of undue effort;
With help: Individual requires consistent human assistance to complete the activity, but the individual participates actively in the completion of the activity;
Unable: individual cannot meaningfully contribute to the completion of the task.

Each point equals $33 a month. For example, a resident consistently needing help with toileting would be scored a two and would earn $66 a month for that impairment. Residents with severe impairments, totally dependent in more than three ADLs can receive $44 a month for each point. The room and board payment under SSI is $564 a month. The total payment (services and room and board) ranges from $1084 to $2363 a month, although very few participants have been approved at the highest rate.

North Dakota uses a rate classification system that is derived from a point system measuring a person's level of service need. Systems in Montana and North Dakota have some similarities to tiered systems, but they do not have as defined a structure or a limited number of categories as the tiered approaches. The amount of payment varies widely based on the number and type of impairments which have more in common with care plan and fee for service systems.

Discussion

States face a number of major challenges in developing payment methodologies for assisted living and other residential care services, including: (1) defining and distinguishing types of services, (2) finding existing models to replicate or seeking new models for payment approaches, and (3) dealing with the unique challenges and opportunities of developing payment approaches for people with differing needs when Medicaid cannot pay for room and board.

The extent to which low-income older people will gain access to this important alternative to nursing homes depends in large part on the extent to which states cover services in assisted living facilities and on the willingness of facilities to accept the rates set by state Medicaid programs. States continue to work on developing methodologies for setting rates. No single approach has yet emerged, although the trend is toward methodologies that reflect variations among tenants. As the private assisted living market expands, state policy concerning rates will determine the extent to which residents with low-incomes have access to this residential option. Rates must be high enough to encourage facilities to contract with Medicaid yet lower than the cost of a nursing facility. The experience in New Jersey, Oregon, and Washington suggests that states can set rates to meet these criteria. As the supply expands, facilities may be more willing to contract with Medicaid in order to maintain acceptable occupancy levels.

Comparing rates across states is difficult because of significant differences in the definition of assisted living and admission/retention criteria among states. States that do not allow tenants who meet the nursing home level of care criteria to live in assisted living cannot develop rates that compare to Medicaid nursing facility rates. States that allow higher levels of care will need higher rates than states that limit the provision of health services.

Seeking New Models

States exploring assisted living reimbursement methodologies have no existing models to replicate. Nursing home methodologies include both room and board and service costs and generally have higher acuity residents than assisted living. Residential care facility models typically have been limited to SSI standards that cover room and board and limited service costs. Assisted living often provides more intensive services and a more home-like environment. Providing access to such services for older persons with low incomes will require enhancements to the services and room and reimbursements beyond those typically provided in other residential settings.

In terms of acuity levels and service utilization, the best comparable cost data may come from in-home services provided under home- and community-based waiver programs. Waiver programs require that participants meet the level of care criteria for placement in a nursing home. While expenditure data is available for state plan services, assessment data is not collected, and the population is not likely to be comparable to people in nursing homes. However, using in-home services as a model would have to recognize significant differences between payment approaches and utilization patterns under in-home services and assisted living. As described above, reimbursing for in-home service units may overstate the amount of service utilized by a tenant because of the time increments required. On the other hand, in-home utilization may be constrained by the times during which it is available, state funding limits, or the lack of in-home workers. Because staff are on-site at all times, assisted living is able to offer more intermittent services in smaller time increments. In addition, assisted living provides more services during the evening and weekends when in-home services are generally not available. Since the perfect system is not likely to emerge, these differences in utilization patterns and payment approaches may tend to offset one another. As long as the populations are comparable, utilization in traditional in-home services programs may be the best current source of comparable reimbursement data.

Separating Room-and-Board from Service Costs

States have a long tradition of dealing with incentives created by reimbursement policy. Some of that experience guides rate setting as new models emerge. States have set rates for nursing homes and prohibited facilities from collecting additional payments from residents or family members. Facilities complained that Medicaid rates were too low and forced them to charge higher rates to private pay residents. Rates in the private assisted living market currently range from under $1,500 to over $3,500 a month. The reimbursement approach adopted by states may determine how many facilities will be willing to contract with Medicaid.

Important differences between nursing homes and assisted living settings open up a number of alternative reimbursement strategies. Specifically, Medicaid pays both the room and board and service costs in nursing homes and hospitals but pays only the service costs in assisted living. Expenses for room and board are paid by assisted living residents. Separating the room and board from the service components of assisted living creates a number of reimbursement and rate setting possibilities. In general, states will have to develop different strategies for SSI beneficiaries and for those who are "spending down" their assets.

States using Medicaid 1915 (c) waivers have more flexibility. The typical room and board cost includes the development and real-estate costs, raw food, and meal service costs. Under the waiver, the cost of meal preparation and serving can be covered as a service, reducing the room and board that must be paid through the tenant's income. Waivers allow states to pay a greater percentage of the total cost than state plan services.

States deal with room and board in two ways. First, states can set a combined rate that includes room and board and service costs. The rate caps what can be paid to the facility. The resident pays the room and board and applies any excess income to services. Medicaid can pay the difference between the resident's payment and the maximum rate. Second, states set a rate only for assisted living services. The room and board charge is determined between the resident and the facility (e.g., Wisconsin). The former approach works best in states with lower development and capital costs since the Medicaid rate is more likely to be comparable to the actual room and board charge. The latter approach works better in states with high development costs and with residents whose income is sufficient to cover these higher costs that cannot be covered by Medicaid.

Rates for SSI and Medically Needy Beneficiaries

In general, states will have to develop different strategies for SSI beneficiaries and beneficiaries who are "spending down" their income and assets. The simplest approach for providing access for SSI beneficiaries or others with very low incomes would be to set a maximum rate for room and board for Medicaid recipients at the state's SSI payment standard. This approach would guarantee that Medicaid recipients could afford the room and board, while limiting Medicaid's payments for the services. Beneficiaries with incomes in excess of the SSI level would contribute that excess income, minus a personal needs allowance, to pay for services, and Medicaid would pay the difference. A major problem with this reimbursement method is that limiting room and board charges to the SSI rate may understate legitimate costs. As a result, facilities may choose not to accept Medicaid beneficiaries since no state requires that facilities accept SSI recipients or Medicaid beneficiaries.

States may want to consider separate policies that address SSI and non-cash assistance Medicaid beneficiaries. To increase access for SSI beneficiaries in areas with higher development costs, states could create a special SSI state supplement⁷ for assisted living in order to give beneficiaries enough income to pay for the room and board costs that cannot be covered by Medicaid. For example, Massachusetts has created a separate payment standard of $900 a month for assisted living compared to the community standard of $610 a month. No other state has adopted a new living arrangement for assisted living while maintaining other living arrangements and payment standards for board-and-care.

A different approach is needed to address the needs of older people who have too much income to qualify for SSI (and, therefore, under regular Medicaid eligibility) but too little income to pay for the private assisted-living rate. This group is sometimes referred to as "non-cash beneficiary" because they are not eligible for SSI yet they have medical expenses that reduce their income to the Medicaid income standard. Unable to afford alternatives, these individuals too often enter a nursing home and spend down in order to qualify eventually for Medicaid. This group accounts for the majority of Medicaid's long-term care spending for nursing home services. In 1995, Medicaid spent, on average, $2626 a year on long-term care services for SSI beneficiaries and $11,612 for "non-cash" beneficiaries.⁸ Serving frail older people through the special income option (under 300% of the federal SSI payment) makes assisted living affordable and can avert some nursing home admissions. It is also less cumbersome than the Medically Needy option.

The simplest strategy for serving this "spend down" population would be for states to pay for the services component of assisted living without any restrictions on what residents could spend for room and board. Under the special income option, states would reimburse services much as they do in-home services and allow beneficiaries to pay for room, board, and other supplemental services and amenities with their incomes.

States may wish to consider establishing a maintenance allowance that is higher than the SSI level that may be retained for room and board. Tenants would be required to apply excess income, after room and board payments and a personal needs allowance, to Medicaid service costs.

Reimbursement strategies for the "spend down" population may be especially relevant in states with higher land and construction costs which necessitate room and board charges significantly higher than SSI rates. As rate methodologies are developed, an assessment of the room and board and service components of market rate facilities would be helpful in setting appropriate rates. However, to do so requires judgements about the type of construction--"affordable" models or very high-income models--that would be examined. States will have to balance encouraging the use of assisted living with controlling Medicaid spending. This approach would create incentives for more facilities to contract with Medicaid, but the higher the allowance for room and board charges the less money there is available for the service component. Medicaid then must pay an increased amount of the monthly services fee. Since facilities themselves are unlikely to reveal financial data detailing actual room and board costs, discussions with state housing finance agencies and lenders may help formulate costs for prototype facilities from which fee structures may be devised.

State policy needs to address the differences in Medicaid's ability to pay for care in a nursing home and in a residential setting. In particular, the separation of services from room and board costs under assisted living creates an opportunity for state experimentation with a variety of reimbursement strategies. New rate-setting methodologies for assisted living can be expected to evolve in the coming years as more states cover services through Medicaid. Case mix systems for covering services and new approaches to separating service and room and board components are likely to be explored by states. Developments in this area warrant further discussion and research.

An important factor in state decision making will be the comparison between the net state cost for an individual in a nursing home and in assisted living. Using the special income option for people just over the income eligibility level and creating a special SSI state supplement, states can tailor a payment level that saves money compared to the nursing home rate and offers many consumers alternatives that they often prefer. Providing these options requires a higher state SSI supplement, in one instance, and less "excess income" applied to services in the second instance, but Medicaid still saves money when a consumer is able to receive services through assisted living rather than through a nursing home.

Some critics contend that expanding alternative services, even those costing less than a nursing home, add marginal costs by serving people in addition to those who enter a nursing home. There is some anecdotal evidence that the increased supply has resulted in lower nursing home occupancy rates, encouraging some nursing homes to close beds or convert to assisted living. Nebraska recently created a $40 million fund to facilitate conversions. Washington and Wisconsin have adopted occupancy penalties that reduce the nursing home per diem when occupancy drops. Facilities may de-license enough beds to raise their occupancy rate above the required threshold and receive the higher rate for occupied beds. As assisted living and in-home services expand, fewer nursing home beds assures that Medicaid can control institutional spending while expanding options that consumers and family members prefer.

Many states have a state supplement for board-and-care facilities that may be too low to cover more intense services needs and higher capitol costs in assisted living settings.
David Liska, Brian Broen, Alina Salganicoff, Peter Lory and Bethany Kessler. "Medicaid Expenditures and Beneficiaries: National and State Profiles and Trends--1990-1995." Kaiser Commission for the Future of Medicaid. Washington, DC. November 1997.

Conclusion

The review of state policy and activity shows that before long nearly every state will have reviewed their regulations governing residential care settings. State assisted living policy continues to follow multiple paths. While some states have developed a new category in addition to older board-and-care categories and view assisted living as a distinct model, others are consolidating multiple categories under a single term. Assisted living is increasingly used as a term to define the model of care, although the term has varied meaning across states. Regulations in twenty-two states now contain a statement of the philosophy of assisted living which distinguishes it from other residential care models. States that do not create new categories or use the term assisted living are updating their regulations and allowing a higher level of care to be provided.

This survey found that several states have moved or are seeking to combine multiple licensing categories under a single assisted living category that may include assisted living, board-and-care, multi-unit conventional elderly housing, and adult foster care. Arizona, Maine, Maryland, and New York are joining New Jersey and North Carolina in this approach.

Since the last study, broad, more flexible admission/retention criteria have been developed in Hawaii, Kansas, Maine, Vermont, and Wisconsin. These criteria treat assisted living much like a person's single-family home or apartment. In their own home, people can receive high levels of home health service. Recent state regulations allow a similar level of care as long as the facility has the capacity to deliver care or acceptable arrangements are made with outside agencies.

States are also focusing on the needs of people with Alzheimer's disease and dementia and on state regulations concerning this population. Fourteen states now have requirements that staff be trained in the needs of this population. Regulations also address the environment, activities, and disclosure statements for special care units.

Medicaid coverage of assisted living is likely to expand to more states, and the number of tenants who are Medicaid beneficiaries will also grow in the coming years. In the past, facilities targeted a wealthier, less-impaired population. Over time, supply has expanded, competition for tenants increased, tenants have aged-in-place, and Medicaid coverage has expanded. Today, in order to maintain occupancy levels, facilities are more interested in serving tenants with higher impairment levels. Several assisted living companies are now developing products to serve older people with low- and moderate-incomes. However, participation is still quite low and more work needs to be done.

To facilitate use of this housing and services model for people who can no longer live in their own home or apartment, states need to address both their payment rates and the training of case managers and other staff who serve older people through home- and community-based service programs. The experience in Washington and other states suggests that rates can be set that are compatible with the rates charged to private-pay residents which are lower than Medicaid nursing home rates. State policy makers may need to work with housing finance agencies and providers to understand the room-and-board costs that cannot be covered under Medicaid as well as the service costs that can be covered. To be able to move into assisted living residences, frail older people with low incomes will need to retain sufficient income to pay for the room and board costs.

As the supply of facilities and Medicaid coverage grows, hospital staff, home health agencies, home-care case managers, and other professional staff will need to become more familiar with assisted living and the opportunity it offers frail older people. States that have not developed or updated their regulations might consider revisions that address the institutional character of older "board-and-care" rules and develop assisted living as an affordable and home-like setting that provides a level of care that enables people to age-in-place.

Section II

COMPARISON OF STATE ASSISTED LIVING AND BOARD AND CARE REGULATIONS

State	Category	Facilities	Units/ Beds	NF Conversions	Units/ Beds Converted	CoN	Apts Required	Choice¹	Max # Occupants	Size - Single	Size² 2+
AL	Assisted living facilities	261	6,222	Unknown	---	N	N	N	2	80	130*
AK	Assisted living homes	77	1,075	0	0	N	N	Y	NA*	NA	NA
AR	Residential long term care facilities	130	4,800	---	---	M	N*	N	2	100	80
AZ	Assisted living facilities	880*	---	5	---	N	N	Y	2	80/220	60/320
CA	Residential care facilities for elderly	5,879	123,238	Unknown	---	N	N	Y	2	**	**
CO	Personal care boarding homes	469	10,071	Unknown	---	N	N	N	2	100	60
CT	Assisted living service agencies	22	NA	Unknown	---	Y	Y	Y	---	---	---
DE	Rest residential facilities	7	277	Unknown	---	N	N	N	4	100	80
DE	Assisted living	---	---	---	---	N	N	Y	2	**	**
FL	Assisted living facilities standard	2,056	66,293	Unknown	---	N	N	N	4	100	80
	Limited nursing services							N	4
	Assisted living extended congregate							Y	2
GA	Personal care homes	1,881	19,939	Unknown	---	N	N	N	4	80	60
HA	Assisted living facilities	---	---	---	---	N	Y	Y	Not stated	220	---
HA	Adult residential care home	532	2,766	---	---	N	N	N	4	90	70
ID	Residential care	227	4,902	0	0	N	N	N	2	100	80
IL	Shelter care facilities	137	7,606	Unknown	---	Y	N	N	4	70	60
	Supported residential living (demo)	16	1,486	2 planned	46	N	Y	Y	2	350	500
	Community based residential fac. (pilot)	2	220	---	---	N	N	Y	2	---	---
IN	Residential facilities	104	8,979	Unknown	---	N	N	N	5	100	80
IA	Assisted living facilities	32	1,455	24	1,114	N	N	Y	2	190/705	290/70
KS	Assisted living	66	3,510	38	952	N	Y	Y	2	200	200
KY	Assisted living (voluntary)	---	---	---	---	N	N	Y	Not specified
KY	Personal care homes	199	6,926	0	0	Y	N	N	4	Not specified
LA	Adult residential care (draft)	96	1,234	0	0	N	N	N	2	100	80
LA	Assisted living (draft)	---	---	---	---	N	Y	Y	2	310*	390*
ME	Assisted living: congregate housing	1	12	---	---	N	Y	Y	NA	NA	NA
ME	Assisted living: residential care I & II	747	6,257	31	Unknown	N	N	N	2	100	80
MD	Assisted living programs (draft)	4,000	13,554	---	---	N	N	N	2	80	60
MA	Assisted living residences	93	5,116	2	---	N	**	-	2/br	**	**
MI	Homes for the aged	155	10,000	Unknown	---	N	N	N	4	100	80
MI	Adult foster care: Large group homes	443	8,149	Unknown	---	N	N	N	2	80	65
MN	Board and lodging	NR	NR	None	---	N	N	N	-	70	60
MN	Registered housing with services	400	NR	Unknown	---	N	**	**	**	**	**
MO	Residential care facilities (I & II)	711	22,796	Unknown	---	Y	N	N	4	70	70
MS	Personal care homes	180	3,519	0	0	N	N	N	4	80	80
MT	Personal care facilities	52	NR	0	0	N	N	N	4	100	80
NE	Assisted living	---	---	---	---	N	N	N	2	100	90
NE	Residential care facilities	117	4,703	Est 40	---	N	N	N	3	80	60
NV	Residential care facilities	305	2,914	0	0	N	N	N	3	80	60
NH	Supported residential care facilities	60	1,816	0	0	N	N	N	2	80	70
NH	Residential care home facilities	80	960	0	0	N	N	N	2	80	70
NJ	Assisted living residences	33	2,772	0	0	Y	Y	Y	2	150	230
	Assisted living programs	4	---	---	---	Y	NA	Y	NA	NA	NA
	Comprehensive personal care homes	20	1,147	1	51	Y	N	Y	2	80	130
NM	Residential shelter care	260	---	Unknown	---	N	N	N	2	100	80
NY	Adult care homes	439	30,221	Unknown	---	N	N	N	2	100	160
	Enriched housing programs	52	1,622	Unknown	---	N	Y	N	2	85	140
	Residences for adults	9	811	Unknown	---	N	N	N	2	100	160
	Assisted living programs	36	1,932	Unknown	---	Y	Y/N	N	2	Note	Note
NC	Adult care homes 7+ beds	514	25,784	1	59	M	N	N	4	100	80
	Family care homes	757	4,194	0	0	N	N	N	3	100	80
	DDA group homes	213	1,225	0	0	N	N	N	---	100	80
ND	Basic care facility	41	1,488	Unknown	---	M	N	N	None	100	80*
OH	Adult care facilities	838	5,544	0	0	N	N	N	4	80	60
OH	Residential care facilities	355	20,000	0	0	N	N	N	3	100	80
OK	Residential care homes	189	6,710	0	0	N	N	N	2	80	60
OK	Assisted living centers	---	---	---	---	N	N	N	2	**	**
OR	Assisted living facilities	95	4,583	1	---	N	Y	Y	1	220	NA
OR	Residential care facilities	132	4,779	Est 15-20	---	N	N	N	2	70	120
PA	Personal care homes	1,696	62,241	Unknown	---	N	N	N	4	80	60
RI	Assisted living facilities	54	---	9	---	N	N	N	2	100	80
SC	Community residential care facilities	490	11,688	Unknown	---	N	N	N	4	80	60
SD	Assisted living centers	100	2,000	Unknown	Unknown	N	N	N	2	120	100
TN	Assisted living facilities	---	---	---	---	N	N	N	2	80	80
TN	Homes for the aged	274	7,183	Unknown	---	N	N	N	2	80	80
TX	Personal care homes	900	25,203	Unknown	---	N	N	Y	4	100	160
UT	Assisted living facilities	8	260	1	33	N	N	Y	2	100*	80*
UT	Residential health care	109	1,956	5	173	N	N	N	2	100	80
VA	Adult care residences	589	28,416	Unknown	---	N	N	N	4	100	80
VT	Adult care residences (draft)	---	---	---	---	N	Y	Y	---	225	NA
VT	Residential care facilities	129	2,279	0	0	N	N	N	2	100	80
WA	Boarding homes	439	18,515	Unknown	---	N	N	N	2	80	140
WA	Assisted living facilities (Medicaid)	104	1,500	Unknown	---	N	Y	Y	1	220	---
WV	Personal care homes	65	2,414	Unknown	---	N	N	N	2	80*	80
	Residential care homes	76	641	Unknown	---	N	N	N	3	80	60
	Residential care community (pending)	---	---	---	---	---	---	---	---	---	---
WI	Residential care apartment complexes	43	1,339	Unknown	---	N	Y	Y	2	250	---
WY	Assisted living facilities	5	406	0	0	N	N	N	2	120	80
Total		28,131	612,063	Total include family care homes, DDA group homes in North Carolina; exclude ALP in New York and Medicaid AL in Washington which are counted in other categories.

Notes:

M: moratorium
NR: not reported
NA: not applicable

Indicates whether residents share units by choice.
Square footage per resident in multi-occupancy units/rooms.

State notes:

AL: Private room with sitting areas, 160 square feet. Double room with sitting area, 200 square feet.
AK: rules do not specify unit space requirements and the maximum number that may share a room.
AZ: Figures represent combined supply under categories that will be replaced by proposed new rules. Unit size figures are for rooms/apartment units. Apartments are required for contracts with the ALTCS (Medicaid) Program.
CA: Choice whenever possible. No requirements for size of bedrooms.
CT: Rules only address requirements for assisted living service agencies. Unit requirements specified by the housing funding source.
DE: Space requirements are not specified.
LA: Draft rules require 190 square feet of living space and 120 square feet for bedrooms. Bedrooms shared by two people in an apartment unit must have 200 square feet. Efficiency units must have 120 square feet.
MA: New construction requires private bathroom and kitchenette or access to cooking capacity. Existing construction requires private half bathroom. Full bathrooms may be shared by up to 3 residents. Bedrooms may be shared.
MN: Licensing rules apply to service providers. Local codes apply to the building based on their use.
NJ: ALPs operate in conventional publicly subsidized senior housing complexes.
NY: Assisted living program numbers are included in adult home and enriched housing program figures. Since ALPs are found in both licensed settings, they comply with the rules of those settings.
ND: Rooms for three or more must have 70 square feet per resident.
OK: Regulations do not specify requirements for the size of bedrooms.
PA: Conversions: most nursing homes have converted beds or partial areas to personal care beds.
TX: Type A facilities require 80 square feet for single occupancy and 60 square feet per resident in multiple occupancy rooms.
UT: 160 and 200 square feet required for single and double occupancy units with a bedroom and additional living space. (Check)
WV: Apartments must have a minimum of 300 square feet.
WI: Allows sharing with a spouse or a roommate chosen by the tenant.

COMPARISON OF STATE ASSISTED LIVING AND BOARD AND CARE REGULATIONS (continued)

State	Category	#/Toilet	#/Bath or Shower	Awake Staff*	Assessment	Minimum Update	Negotiated Risk	Dementia Rules
AL	Assisted living facilities	8	8	1:6	30 days prior to move	Annually	N	Study
AK	Assisted living homes	---	---	N	Within 30 days	3 months	Y	N
AR	Residential long term care facilities	6	10	1	Prior to admission	---	N	N
AZ	Assisted living facilities	8	8	Needs	Within 14 days	Varies by license	N	Y
CA	Residential care facilities for elderly	6	10	Varies	Prior to admission	As necessary	N	Y
CO	Personal care boarding homes	6	6	Needs	None	None	N	Y
CT	Assisted living service agencies	---	---	---	On admission	120 days	Y	---
DE	Rest residential facilities	4	4	N	Within 14 days	Not specified	Y	N
DE	Assisted living	NA	NA	Needs	Within 14 days	As needed	Y	**
FL	Assisted living facilities standard	6	8	1 (17+)	60 days prior/30 post	Six months	Y	Y
	Limited nursing services	4	4	1 (17+)	60 days prior/30 post	Six months	Y	Y
	Assisted living extended congregate	4	4	1 (17+)	60 days prior/30 post	Annual	Y	Y
GA	Personal care homes	4	8	1:15	30 days prior	Annual	N	N
HA	Assisted living facilities	1	1	Y*	Prior to and in 30 days	Annual	Y	N
HA	Adult residential care home	8	14	Y*	Yes, not specified	Not specified	N	N
ID	Residential care	6	8	Y	14 days	Annually	N	Y
IL	Shelter care facilities	10	15	1	5 days prior/3 post	---	N	N
	Supported living facility	---	---	1 (10-75), 2 (76-150)	W/in 24 hours of adm.	Q health status & annual assessment	Y	N
	Community based residential facility	Ea. unit	Ea. unit	Y	Prior to admission	Annually	Y	N
IN	Residential facilities	Scale	Scale	Y	Prior to admission	6 months	N	N
IA	Assisted living facilities	1	---	N	Prior to admission	90 days*	Y	N
KS	Assisted living	NA	NA	Y	Prior to admission	Annual	Y	Y
KY	Assisted living	Not specified		N	Upon admission	Not specified	N	N
KY	Personal care homes	8	12	N	N	N	N	N
LA	Adult residential living	**	**	Y	Y	Quarterly	N	N
LA	Assisted living	1	1	Y	Y	Quarterly	N	N
ME	Assisted living: congregate housing	NA	NA	N	Y	6 months	N	Y
ME	Assisted living: residential care	6	15	2	Within 30 days	Annual	N	Y
MD	Assisted living programs	4	8	N	Prior to admission	6 months	N	N
MA	Assisted living residences	**	**	Needs	Prior to move in	6 months	Y	N
MI	Homes for the aged	8	15	Y	Not stated	Not stated	N	N
MI	Adult foster care: Large group homes	8	8	N	Prior to move in	Annual	N	N
MN	Board and lodging	10	20	N	14 days	Annual	N	N*
MN	Registered housing with services	---	---	NA	Within 2 weeks	Annual	N	N
MO	Residential care facilities	6	20	N	Within 10 days	Monthly	N	N
MS	Personal care homes	6	12	1:10	Within 5 days	Annually	N	N
MT	Personal care facilities	4	12	N	Within 3 days	Quarterly	N	N
NE	Assisted living (new facilities)	1*	8	Needs	Required	N	Y	Y
NE	Assisted living (existing facilities)	6	16	Needs	Required	N	N	N
NV	Residential care facilities	4	6	1:20	Required	Annual	Y	Y
NH	Supported residential facilities	6	6	Y	30 days prior	6 months	N	N
NH	Residential care facilities	6	6	Y	30 days prior	6 months	N	N
NJ	Assisted living residences	1	1	1	14 days	Quart. & bi-annual	Y	N
	Personal care homes	NA	NA	1	14 days	Quart. & bi-annual	Y	N
	Assisted living programs	NA	NA	1	14 days	Quart. & bi-annual	Y	N
NM	Adult residential care	8	8	1	5 days	Quarterly	N	Y
NY	Adult homes	6	10	Scale	30 days prior	Annual	N	N
	Enriched housing	3	3	N	30 days prior	Annual	N	N
	Residential	6	10	Scale	30 days prior	Annual	N	N
	Assisted living programs	**	**	N	30 days prior	45 days & 6 mos	N	N
NC	Adult care residences	5	10	Y	30 days	Annual	N	N
ND	Basic care facility	4	15	Y	Within 14 days	Quarterly	N	N
OH	Adult care facilities	8	8	N	Within 14 days	Annual	N	N
OH	Residential care homes	8	8	Y	Within 14 days	Annual	Y	Y*
OK	Residential care homes	6	10	N	None	None	N	N
OK	Assisted living centers	4	4	Needs	30 days prior & adm	14 days & annual	Y	Y
OR	Assisted living facilities	1	1	Y	Yes	Quarterly	Y	Y
OR	Residential care facilities	6	10	1:30	Yes	6 months	Y	Y
PA	Personal care homes	6	15	1 (16+)	30 days	Annual	N	N
RI	Assisted living facilities	8	10	1	Not stated	Not stated	N	Y
SC	Community residential care facilities	8	10	1:44	Admission	Annual	N	Y
SD	Assisted living centers	4	15	2	Admission & 30 days	Annual	N	Y
TN	Assisted living facilities	6	6	Y	Upon admission	Annual	N	Y
TN	Homes for the aged	6	6	Y*	Upon admission	Annual	N	Y
TX	Personal care homes	6	10	1:40	Within 14 days	Annual	N	Y
UT	Assisted living facilities	4	10	Needs	Within 7 days	6 months	N	N
UT	Residential health care	6	10	Needs	Prior to admission	Annual	N	N
VA	Adult care residences	7	10	1	Within 90 days prior	Annual	N	Y
VT	Adult living residences	NA	NA	**	Within 14 days	6 months	Y	Y
VT	Residential care facilities	8	8	0	On admission	Annual	N	N
WA	Boarding homes	8	12	Y	On admission	6 months	N	Y
WA	Assisted living (Medicaid)	1	1	Y	On admit & 30 days	6 months	Y	Y
WV	Personal care homes	5	10	1*	30 days	As needed	N	N
	Residential care homes	6	10	1	30 days	Annual	N	N
	Residential board and care	TBD	TBD	---	TBD	TBD	N	N
WI	Residential care apartment complexes	NA	NA	**	Prior to admission	Annually	Y	N
WY	Assisted living facilities	2	10	1	7 days prior/30 post	Annually	N	N

General notes:

* Indicates whether the regulations specifically require that one or more staff must be awake at night. States with a notation of "needs" do not specifically require awake staff but do require that staffing be appropriate to the needs of residents and therefore may require awake staff.
Assessment updates: most rules specify that an assessment is needed when the resident's condition changes. The entry in this column specifies the requirement in the absence of change.

State notes:

AZ: Staffing must be consistent with the needs of residents.
CO: At least one staff is required when residents needs supervision, assistance with ADLs or assistance with medications.
DE: If required based on resident needs. Dementia is not specifically mentioned however, staff must be trained to meet the needs of consumers.
HA: No specific requirements for awake staff but the facility must meet the needs of residents which may require awake staff.
IA: Residents receiving personal care or skilled nursing must be reviewed every 90 days.
MA: New construction requires private bathroom and kitchenette or access to cooking capacity. Existing construction requires private half bathroom. Full bathrooms may be shared by up to 3 residents. Bedrooms may be shared.
ME: Awake staff for facilities with more than 10 beds.
MN: Regulations apply to the service provider.
NE: For new facilities, a toilet and sink is required adjoining each bedroom.
NH: Must have awake staff in facilities with 17+ residents.
NY: Assisted living programs may exist in adult homes and enriched housing programs and they meet the requirements of the settings in which they are located.
TN: Awake staff are required if the facility has five or more residents whose level of evacuation capability is "slow."
UT: Awake staff are required based on the needs of the residents.
VT: Awake staff are required based on the needs of the residents.
WV: Requires one awake staff per floor in facilities larger than 10 beds.

ASSISTED LIVING PHILOSOPHY AND INDICATORS

	AL	AK	AZ	AR	CA	CO	CT	DE	FL	GA	HI	ID	IL³	IN	IA	KS	KY⁴
Philosophy described			X					X	X		X		X		X	X	X
Apartments required			X²								X		X			X
Units/bedrooms shared only by choice			X²				X	X	X		X		X		X	X
Training							X		X		X					X
Shared risk process							X	X	X		X				X	X
	LA	ME	MD	MA	MI	MN	MS	MO	MT	NE	NV	NH	NJ	NM¹	NY	NC	ND
Philosophy described	X	X	X	X						X			X	X
Apartments required	X	M		M									M
Units/bedrooms shared only by choice	X									X				X
Training				X									X			X
Shared risk process													X
	OH	OK	OR	PA	RI¹	SC	SD	TN	TX	UT	VT	VA ¹	WA⁵	WV	WI	WY
Philosophy described			X		X					X	X	X	X			X
Apartments required			X							M	X		X
Units/bedrooms shared only by choice			X		X					X	X		X
Training			X								X		X		X
Shared risk process	X	X	X							X	X		X

Notes:

M = states may require apartments for new construction, certain settings or categories and bedrooms in other settings.

The policy is contained in Medicaid rules or contract requirements rather than the licensing rules.
AZ: Contained in regulations implementing a supportive living residential centers program.
IL: These provisions are included in a demonstration program.
KY: Applies to the voluntary certification program.
WA: The policy is contained in the Medicaid contract regulations (WAC 388-110).

REQUIREMENTS FOR FACILITIES SERVING RESIDENTS WITH ALZHEIMER'S DISEASE

	AL	AK	AZ	AR	CA	CO	CT	DE	FL	GA	HI	ID	IL	IN	IA	KS	KY
Training			X		X				X	X		X				X
Activities					X				X	X		X
Environment			X		X				X	X		X			**
Disclosure					X				X	X					**
Other								X					**		**
	LA	ME	MD	MA	MI	MN	MS	MO	MT	NE	NV	NH	NJ	NM	NY	NC	ND
Training		X	X	X						X	X			X		X
Activities		X									X			X
Environment											X			X
Disclosure			X
Other
	OH	OK	OR	PA	RI	SC	SD	TN	TX	UT	VT	VA	WA	WV	WI	WY
Training	X	X	X				X		X		X	X	X
Activities			X				X		X			X	X
Environment			X						X			X	X
Disclosure			X		X	X			X				X
Other				X			X									X

Delaware: Facilities must develop policies to prevent wandering away and safe storage of medications.
Illinois: An Alzheimer's facility has been selected for one pilot program and it must meet all applicable state, federal and local requirements.
Iowa: These policies are covered by language stating that facilities must be appropriate for the needs of the residents. Requirements are not specified in regulation but are negotiated.
Pennsylvania: Internal policy, not in regulations.
South Dakota: Also has fire safety/evacuation provisions.
Tennessee: An interdisciplinary team must review residents with early stage Alzheimer's disease to quarterly to examine appropriateness of placement.
Wyoming: Facilities must provide cuing with guidance for ADLs for people who are intermittently confused and/or agitated and require occasional reminders to time, place and person.

ADMISSION/RETENTION CRITERIA (General Descriptions Only--See State Summaries for Details)
	AL	AK	AZ	AR	CA	CO	CT	DE	FL	GA	HI	ID	IL	IN	IA	KS	KY
General Criteria
Needs can be met by facility/agency					X		X	X*	X	X	X					X
Health Related Conditions
Do not need hospital/nursing home care	X			X					X			X	X
Must have stable medical conditions							X	X*	X			X
Do not need 24 hour nursing care	X	X	X*	X*	X	X			X	X		X			<8	**
Nursing care limited to # days		451							X						21
Don't need daily medication supervision
May provide p/t, intermittent nursing		X													X*
Must self-administer medications				X	X							X
Must be continent unless controlled						X
May not have:
Gastronomy tubes				X	X					**		X
Intravenous tubes/feeding				X						**		X			**
Naso-gastric tubes					X					**		X			**
Tracheotomies				X	X							X
Catheters (unless self-maintained)										**		X
Suctioning										**		X
Sterile wound care												X			**
Stage III, IV ulcers	X		X*		X				X			X			**
Communicable disease	X			X	X	X			X	X		X	X
Ventilator dependent												X			**
Cannot require tx for alcohol, drug abuse	X			X				X
Functional Criteria
Able to evacuate without assistance
Must be able to feed self										X		X
Cannot be bedridden more than ... days					143			**	14						21
Cannot need more than 1 person assist	X							X								X*
Cannot be totally bedfast/bedbound			X*			X			X			X
Must be ambulatory				X					X	X							X*
Must be able to direct care			X*									X
Cannot have 4 or more ADLs									X
Alzheimer's/Dementia Related
Can't serve severe symptoms of senility	X				**							**
May admit persons with mild dementia					X				X	X					X
Late stage of Alzheimer's disease					X
Must be able to make simple decisions										X
Behaviors
Cannot be danger to/violence self/others	X		X	X				X	X			X	X		X
Cannot need restraints	X			X		X			X
Must be able to communicate needs				X
Other (see summaries)	X			X	X				X			X	X

ADMISSION/RETENTION CRITERIA (continued)
(General Descriptions Only--See State Summaries for Details)

	LA	ME	MD	MA	MI	MN	MS	MO	MT	NE	NV	NH*	NJ	NM	NY	NC	ND
General Criteria
Needs can be met by facility/agency	X					X										X
Health Related Conditions
Do not need hospital/nursing home care																X	X
Must have stable medical conditions										**			**
Do not need 24 hour nursing care	X*		X	X	X						X	X	**	X		X	X
Nursing care limited to # days									20*
Don't need daily medication supervision
May provide p/t, intermittent nursing												X
Must self-administer medications									**
Must be continent unless controlled									**
May not have:
Gastronomy tubes											X
Intravenous tubes/feeding											X		**
Naso-gastric tubes			X											X
Tracheotomies														X
Catheters (unless self-maintained)							**
Suctioning
Sterile wound care
Stage III, IV ulcers			X										**	X
Communicable disease			X		X		X				X			X
Ventilator dependent			X										X	X		X
Cannot require tx for alcohol, drug abuse
Functional Criteria
Able to evacuate without assistance								X				X
Must be able to feed self
Cannot be bedridden more than ... days													**
Cannot need more than 1 person assist
Cannot be totally bedfast/bedbound									**		X
Must be ambulatory							X
Must be able to direct care
Cannot have 4 or more ADLs													**
Alzheimer's/Dementia Related
Can't serve severe symptoms of senility
May admit persons with mild dementia
Late stage of Alzheimer's disease
Must be able to make simple decisions													**
Behaviors
Cannot be danger to/violence self/others	X		X				X						**	X	X	X
Cannot need restraints									**		X
Must be able to communicate needs
Other (see summaries)		X	X		X			X	**			X		X		X

ADMISSION/RETENTION CRITERIA (continued)
(General Descriptions Only--See State Summaries for Details)

	OH	OK	OR	PA	RI	SC	SD	TN	UT	VT	VA	WA	WI	WV	WY
General Criteria
Needs can be met by facility/agency	X	X		X		X				X	X	X	X*
Health Related Conditions
Do not need hospital/nursing home care				X	X	X
Must have stable medical conditions				X						P
Do not need 24 hour nursing care		X		X		X	X		X	P	X	X		X
Nursing care limited to # days														**
Don't need daily medication supervision
May provide p/t, intermittent nursing	X	X		X								X		X
Must self-administer medications
Must be continent unless controlled															X
May not have:
Gastronomy tubes											X*
Intravenous tubes/feeding				X				**			X
Naso-gastric tubes				X				**			X*	X
Tracheotomies
Catheters (unless self-maintained)								**							X
Suctioning								X				X
Sterile wound care															X
Stage III, IV ulcers				X				**		P	X*				X
Communicable disease											X
Ventilator dependent				X							X	X
Cannot require tx for alcohol, drug abuse															X
Functional Criteria
Able to evacuate without assistance					**									X
Must be able to feed self															X
Cannot be bedridden more than ... days										P
Cannot need more than 1 person assist
Cannot be totally bedfast/bedbound
Must be ambulatory														X
Must be able to direct care
Cannot have 4 or more ADLs										P
Alzheimer's/Dementia Related
Can't serve severe symptoms of senility
May admit persons with mild dementia
Late stage of Alzheimer's disease								**
Must be able to make simple decisions										P
Behaviors
Cannot be danger to/violence self/others		**	X	X				X	X	X	X
Cannot need restraints		X						X						X
Must be able to communicate needs
Other (see summaries)	X			X			X	X	X	X					X

State notes:

AS: Limitation of bedridden may be extended with physician and RN approval.
AR: Cannot require nursing care.
AZ: Residents with the indicated conditions may be served if services are provided by a licensed home health or hospice agency and other are met. See state summary.
CA: May serve people needing incidental medical services. May admit people with Alzheimer's disease who are not able to respond to verbal instructions under special conditions. May retain longer than 14 days with a physician's statement that the condition is temporary.
DE: Agencies may serve people with these conditions based on their capacity.
FL: Has separate requirements for admission and retention. Those listed cover retention in Extended Congregate Care Facilities. See state summary for complete discussion.
GA: Absence of a need for continuous skilled care implies that residents may not have conditions noted by an asterisk.
ID: See summary for Alzheimer's disease provisions.
IA: Temporary exceptions are available to allow facilities to serve tenants needing more than part time or intermittent health care. Residents may only receive skilled services on a daily basis for up to 21 days.
KS: May serve residents with specified conditions if a negotiated services plan involving hospice, family or other agencies is negotiated.
LA: Residents may receive continuous nursing care for 90 days. All health related services must be arranged by the resident/family with an outside agency.
ME: Residents in residential care facilities II who meet the nursing home criteria may be served if they receive skilled services from the licensed home health or hospice agency.
MS: No indwelling catheters.
MT: May be served if a physician agrees to the admission.
NJ: Facilities may admit persons with conditions noted by an asterisk if they note this type of care in their licensing application.
NM: Exceptions are allowed when agreed to by a team.
OR: May be asked to leave for behavior problems.
RI: Unless facility meets more stringent life safety code.
SD: Residents must be in reasonably good health with no chronic illness or disability requiring more than cuing, supervision and limited physical assistance.
TN: May retain residents for 21 days with these conditions or longer if approved by Department of Health. Residents with Alzheimer's disease must be reviewed by a team quarterly.
VA: Residents with conditions noted with an asterisk may be served under certain conditions.
VT: Residences may, but are not required to, move residents with unstable medical conditions and other conditions indicated by P.
WI: Cannot serve residents who need more than 28 hours of supportive, personal and nursing services a week.

CRITERIA FOR ADMINISTRATORS (see note)

	AL	AK	AZ	AR	CA	CO	CT	DE	FL	GA	HI	ID	IL	IN	IA	KS	KY
None stated							X	X
Age	19	21	21	21		18			18	21			18		21	21	21
High school diploma/GED				X					X							X	X
Advanced degree					**
Experience		X	X		X					X*	X
License/certification			X	X	X					X	X*	X		X		X
Specified abilities/knowledge	X				X							X
Criminal or background check		X	X	X	X	X			X	X		X			X
CEUs/hours of training	6		12		20				12	16
Other				X
	LA	ME	MD	MA	MI	MN	MS	MO	MT	NE	NV	NH	NJ	NM	NY	NC	ND
None stated										X							X
Age	25		21	21	21		21				18	21	21	21		18
High school diploma/GED			X						X			X1	X	X		X
Advanced degree	X*			X								X1
Experience	X*			X								X1				X
License/certification											X		X
Specified abilities/knowledge			X								X			X		X
Criminal or background check	X		X								X	X				X	X
CEUs					16				6		8	12	10			15	12
Other																X
	OH	OK	OR	PA	RI	SC	SD	TN	TX	UT	VT	VA	WA	WV	WI	WY
None stated															X
Age	21	21		21	21	21		18		21	21	21	21	21		21
High school diploma/GED				X		X	X	X	X			X	X
Advanced degree										X		X*	X*
Experience										X	X
License/certification		X*			X	X	X*	X		X			X*
Specified abilities/knowledge	X			X	X	X				X						X*
Criminal or background check	X	X*	X	X	X			X			X	X	X	X
CEUs/hours of training	9		20	40	16			24	12	X	20	20	10	10
Other			X	X		X

Notes:

In states with two or more licensure categories, the criteria apply to assisted living facilities, if licensed, or the category that offers the highest level of care.
CA: Requirements vary by the size of facility.
GA: This requirements applies to administrators in homes that participate in the Medicaid HCBS waiver.
HA: Must complete an assisted living administrators course or equivalent acceptable to the Department.
LA: Experience or a bachelor's degree.
NH: The experience requirements vary with the degree: HS + five years in a facility; AB + 3 years in health setting; BA + none. Also need 3 references.
OH: Must be licensed or have 2000 hours of operation experience in a related facility, 100 hours of post high school credit in gerontology, a licensed health professional or have a baccalaureate degree.
OK: the items noted with an asterisk apply to both licensure categories.
OR: Must demonstrate competency in the provision of services and the principles of assisted living.
PA: Must complete 40 hours of training/CPR/first aid or be a licensed nursing home administrator and complete 6 CEUs every year.
SC: Requires three references.
SD: Administrators must be licensed or have completed a training and certification program.
TN: 24 CEUs every two years.
UT: A degree is required depending on the size of the facility. Administrators must have appropriate experience, a degree or a license.
VA: High school diploma and at least 2 years post secondary education or 1 year of human service study in an accredited college opr department approved curriculum is required for administrators providing an assisted living level of care.
WA: May have high school diploma, and 2 years experience, or advanced degree or certification.
WY: Must have knowledge of and pass a test on regulations and be a CNA or equivalent.

STATE ASSISTED LIVING TRAINING REQUIREMENTS

	AL	AK	AZ	AR	CA	CO	CT	DE	FL	GA	HI	ID	IL	IN	IA	KS	KY
Direct Care Issues
Approved course								X	X
General requirements							X		X		X		X		X
Principles of assisted living			X				X		X		X					X
Personal/direct care skills	X		X			X			X	X¹		X		X			X
Meetings needs of consumers/residents			X						X	X					X
Appropriate, related to tasks/duties					X			X		X					X
Hygiene			X						X	X¹
Housekeeping/sanitation			X		X					X		X					X
Nutrition/food preparation/diets			X		X	X			X								X
Social/recreation activities						X				X
Dementia/Alzheimer's care			X						X	X						X
Mental health/emotional/behavior needs			X			X			X	X							X
Related to restraints									X								X
Health Related Issues
Basic nursing skills														X	X²
Prevention/restorative services															X²
Observation/reporting skills					X					X¹		X			X²
Medication administration/assistance			X	X	X				X	X		X		X	X²		X
Knowledge Areas
Residents rights	X		X	X		X			X	X		X		X		X	X
Aging process/gerontology			X							X		X					X
Working with/needs of elderly										X							X
Death and dying												X
Psycho-social needs										X				X
Assessment skills						X				X¹			X
Care plan development			X							X¹			X
Communication skills					X
Knowledge of community services					X								X
Safety/Emergency Issues
CPR	X		X					X	X	X	X
First aid	X		X			X		X	X	X	X	X
Fire, safety, emergency procedures			X	X		X		X		X		X	X	X	X	X
Infection prevention/control	X		X					X	X	X		X		X		X
Process Issues
Agency/facility policies			X				X					X		X
Regulations/law							X		X
Reporting abuse/neglect			X	X					X	X					X	X
Complaint procedures									X			X
Record keeping			X						X	X							X
Confidentiality			X						X					X
Legal/ethical issues									X	X				X
Survey process	X								X			X
No requirements described		X

STATE ASSISTED LIVING TRAINING REQUIREMENTS (continued)

	LA	ME	MD	MA	MI	MN	MS	MO	MT	NE	NV	NH	NJ	NM	NY	NC	ND
Direct Care Issues
Approved course		X				X							X		X	X
General requirements							X						X	X		X
Principles of assisted living				X									X			X
Personal/direct care skills			X	X	X	X			X			X	X		X	X
Meetings needs of consumers/residents					X						X		X	X	X	X
Appropriate, related to tasks/duties			X	X				X					X		X	X
Hygiene	X			X		X			X				X			X
Housekeeping/sanitation	X		X	X		X
Nutrition/food preparation/diets	X		X	X	X	X			X				X				X
Social/recreation activities	X											X				X	X
Dementia/Alzheimer's care		X		X							X					X
Mental health/emotional/behavior needs	X											X				X	X
Related to restraints																X
Health Related Issues
Basic nursing skills													X			X
Prevention/restorative services													X			X
Observation/reporting skills			X	X		X			X				X			X
Medication administration/assistance			X	X		X			X		X	X	X	X
Knowledge Areas
Residents rights	X	X	X	X	X	X		X		X		X	X		X	X	X
Aging process/gerontology	X			X									X			X
Working with/needs of elderly													X			X
Death and dying				X									X			X
Psycho-social needs			X										X			X
Assessment skills			X													X
Care plan development	X		X
Communication skills		X		X									X			X
Knowledge of community services	X
Safety/Emergency Issues
CPR			X		X					X
First aid	X		X		X					X		X		X		X
Fire, safety, emergency procedures	X	X	X		X	X		X				X	X		X		X
Infection prevention/control		X	X	X	X	X		X					X			X	X
Process Issues
Agency/facility policies		X											X		X	X
Regulations/law						X					X		X
Reporting abuse/neglect				X	X	X		X					X
Complaint procedures						X							X
Record keeping	X								X
Confidentiality		X						X					X
Legal/ethical issues													X
Survey process
No requirements described

STATE ASSISTED LIVING TRAINING REQUIREMENTS continued...

	OH	OK	OR³	PA	RI	SC	SD	TN	TX	UT	VT	VA	WA	WV	WI	WY
Direct Care Issues
Approved course		X										X	X
General requirements	X		X	X												X
Principles of assisted living			X								X		X		X
Personal/direct care skills	X	X	X		X					X	X		X	X	X
Meetings needs of consumers/residents									X				X	X
Appropriate, related to tasks/duties	X	X				X						X	X	X	X
Hygiene				X										X
Housekeeping/sanitation				X	X	X				X			X
Nutrition/food preparation/diets				X	X	X				X			X
Social/recreation activities		X		X		X							X
Dementia/Alzheimer's care	X	X		X			X				X	X	X
Mental health/emotional/behavior needs	X			X					X		X	X	X		X
Related to restraints				X			X					X	X
Health Related Issues
Basic nursing skills
Prevention/restorative services												X
Observation/reporting skills	X	X							X	X		X
Medication administration/assistance		X		X	X	X				X		X	X
Knowledge Areas
Residents rights	X	X		X	X	X	X				X	X	X	X	X	X
Aging process/gerontology				X					X				X		X
Working with/needs of elderly				X								X		X	X
Death and dying
Psycho-social needs															X
Assessment skills		X							X						X
Care plan development
Communication skills	X								X	X	X		X
Knowledge of community services
Safety/Emergency Issues
CPR		X		X								X	X	X	X
First aid	X	X		X	X	X						X	X	X	X
Fire, safety, emergency procedures	X	X		X	X	X	X			X	X	X	X	X	X	X
Infection prevention/control				X	X	X	X				X		X	X
Process Issues
Agency/facility policies	X				X								X	X	X
Regulations/law					X	X	X						X
Reporting abuse/neglect	X	X					X		X		X	X	X	X
Complaint procedures													X	X	X
Record keeping	X	X		X	X						X		X
Confidentiality		X					X		X			X	X	X
Legal/ethical issues									X				X
Survey process
No requirements described								X

State notes:

GA: Items with an asterisk are required for facilities serving Medicaid waiver beneficiaries.
IA: Health related task requirements are included in the state's nurse practice act.
OR: These requirements apply to the administrator of the facility.
ND: Requirements apply to Medicaid HCBS waiver providers.

COMPARISON OF STATE MEDICAID POLICY AND REIMBURSEMENT

State	Reimburse	Type Coverage	Payment Methodology	300% Eligibility	"Bed Hold" Policy	# Facilities Contracting	Number Participants	Occupancy Limits
AK	X	Waiver	Setting	X	N	76	@175	N
AZ	X	Waiver	Tiered	X	N	NR	92	Recommend 20/30
AR	X	State plan	FFS	NA	N	NR	@1,000	N
CO	X	Waiver	Flat	N	N	179	1,400	N
CT	Pilot	Waiver	TBD	---	---	---	---	---
DE	Planned	Waiver	Tiered	250%	18 days¹	---	---	N
FL	X	Waiver	Flat²	X	N	91	520
GA	X	Waiver	Flat	X	7 days	117	1,154	N
HA	Planned	Waiver
IL	Pilot	Waiver	Flat	X	N	16	1,300³	N
IA	X	Waiver	Care plan	X	N	NA	---	N
KS	X	Waiver	Care plan		N			N
LA	Planned	Waiver	TBD
ME	X	Waiver/plan	Flat⁴		N	182	3,759	N
MD	X	Waiver	Flat	200%	N	---	44	N
MA	X	State plan	Flat	NA	N	30	312	N
MI	Pilot	Waiver	Flat	Y	N	1	5	N
MN	X	Waiver	Case mix	Pending	N	NA	260	N
MO	X	State plan	Care plan	NA	N	600	6,390	N
MT	X	Waiver	Care plan	N	N	NA	130⁵	N
NE	Planned	Waiver	Flat	N	N	NA	NA	NA
NV	X	Waiver	Flat	N	N	54	52	N
NH	Planned	Waiver
NJ	X	Waiver	Setting²	Y	N	21	120	N
NM	X	Waiver	Flat	200%	N	6	0	N
NY	X	State plan	Case mix	NA	30 days⁶	35	2,100	(6)
NC	X	State plan	Flat⁴	NA	60 days/year	1,800⁷	20,000⁸	N
ND⁹	X	State funds	Care plan	NA	NR	NR	NR	N
OR	X	Waiver	Tiered	Y	N	35	1,500	N
RI	X	Waiver	Flat	Y	1 month¹⁰	19	20	N
SC	Planned	Waiver
SD	X¹¹	Waiver	Flat		15 days	38	65	N
TX	X	Waiver	Setting	300%	N	179	565	N
UT	Planned	Waiver
VA	X	Waiver	Flat	N	N	165	1,400	N
VT¹²	X	Waiver	Flat	X	N	26	88	N
WA	X	Waiver	Tiered	X	30 days	104	1,500	N
WI	X	Waiver	Tiered	X	N	15	25	N

State notes:

DE: 18 days for social absence.
FL and NJ: Considering a tiered methodology.
IL: Sixteen sites have been selected with a capacity of 1,300 residents. The authorizing legislation limited the pilot to 2,000 participants.
ME and NC: Developing a case mix methodology.
MT: Figures include participants in adult foster care and personal care homes.
NY: The bed hold policy is stated in the resident agreement which requires 30 days notice. The number of units is limited through the Medicaid bidding and contracting process.
NC: Figures include mental health group homes licensed by the state. A break out for elderly residents was not available.
NC: This is the total number of residents eligible for state/county special assistance and, therefore, automatically eligible for Medicaid.
ND: Uses state general revenues rather than Medicaid but is considering covering services under the Medicaid waiver.
RI: Facilities receive one month prospective payment and would hold the unit for the remained of the month.
SD: Presently provides Medicaid payment for medication administration under its waiver and is considering covering personal care as a state plan service.
VT: Residential care facilities are presently covered and assisted living facilities will be added when the assisted living regulations are adopted. A tiered payment system will be implemented in 1998. A flat rate is presently used for enhanced residential care.

Section III

Notes on State Summaries

Each state summary includes the regulatory or statutory citation and category name and includes a description of the state's approach to assisted living or board and care, the definition, unit requirements, tenant admission and retention policy, services that may be provided, the availability of Medicaid reimbursement for low income residents, medication assistance, staffing requirements, training requirements, background checks and monitoring.

This information was abstracted from state statutes, regulations or draft regulations. Copies of each state's summary were sent to appropriate state officials in April 1998 for their review and comment.

The information for each state is based on statutes, regulations, draft legislation, draft regulations and task force reports. Information from states based on draft material is presented to indicate the potential direction of state policy. Final legislation and rules may vary from the source material.

Alabama

Citation

Assisted living Chapter 420-5-4

General Approach

Regulations for assisted living were effective in 1991. A task force chaired by the state Department of Public Health was appointed in 1996 and held two meetings. A transcript and comments from task force members were submitted for further action. The Department is now developing significant revisions to the regulations. The primary issues being addressed include aging-in-place, admission/retention criteria and serving people with Alzheimer's disease. Draft revisions will be issued for comment in the Spring and final rules by the Spring of 1999. The State Health Coordinating Committee is also reviewing assisted living. The Committee is interested in covering assisted living under Medicaid and determining the number of nursing facility residents that could be served in an assisted living setting.

The current regulations license three categories of facilities. Congregate assisted living facilities serve 17 or more adults, group assisted living facilities serve 4-16 adults and family assisted living facilities serve 2-3 adults. Since 1992 the number of licensed assisted living facilities has grown from 171 to 207 in 1995 and 261 by March 1998. The number of beds has increased from 3,710 in 1992 to 4,840 in 1995 and 6,222 in 1998.

Definition

Assisted living facility "means a permanent building, portion of a building, or group of buildings (not to include mobile homes and trailers) in which room, board, meals, laundry, and assistance with personal care and other services provided are for not less than twenty-four hours in any week to a minimum of two ambulatory adults not related by blood or marriage to the owner and/or administrator."

Unit Requirements

The regulations do not require separate living and sleeping quarters. Private bedrooms without sitting areas must provide 80 square feet and double rooms 130 square feet. If sitting areas are included, private rooms must be 160 square feet and double rooms 200 square feet. Bath tubs or showers must be available for every eight beds, and lavatories and toilets for every six beds. Lockable doors are permitted.

Tenant Policy

The regulations provide that assisted living facilities may serve "ambulatory adults who do not require acute, continuous or extensive medical or nursing care and are not in need of hospital or nursing home care." Facilities may not serve anyone with communicable or infectious disease, chronic health conditions requiring extensive nursing care and/or daily medication supervision, persons requiring daily professional observation or the exercise of professional judgement by staff. People who need assistance from more than one person to evacuate a building, show severe symptoms of senility, or require restraint or treatment for addiction to alcohol or drugs may not be admitted or retained. Evacuation. Residents must be ambulatory on admission either aided or unaided by prosthesis.

Services

Assisted living facilities must provide personal care for bathing, oral hygiene, hair care and nail care. Facilities may provide for general observation and may arrange or assist residents to obtain medical attention or nursing services when needed. Home health may be provided by a certified agency as long as residents do not require hospital or nursing home care.

Financing

Other than SSI, no public financing is available for assisted living.

Medication

Assistance is limited to reminders, reading container labels to the resident, checking the dosage and opening containers. Licensed nurses are allowed to administer medications for residents who do not require acute, continuous or extensive medical or nursing care.

Staffing

The regulations require at least one staff member per six residents 24-hours a day and personal care staff to meet the needs of residents.

Training

Administrators must have 6 hours of continuing education annually on state law and rules, identifying and reporting abuse, neglect and exploitation, special needs of the elderly, mentally ill and mentally retarded, basic first aide/CPR training; business management; human resource management and plant management and safety.

Staff must receive core training that includes but is not limited to: basic first aid; CPR; bathing, grooming, handling of the elderly - 16 hours; infection control; resident's rights; and the survey process. CNAs in good standing are exempt.

Background Check

Not specified.

Monitoring

Facilities are monitored through licensing review and periodic inspections by the Board of Health depending on funding for inspectors.

Fee

Licensure fees are $200 plus $5 per bed over 10 beds.

Alaska

Citation

Assisted living homes, Alaska Statute § 47.33.005 et seq.; 7 Alaska Administrative Code § 75.010 et seq.

General Approach

The state's assisted living regulations are being reviewed by the state aging office to strengthen license revocation and appeal procedures and other aspects of the program. Proposed revisions are being developed for public comment. No timetable has been set for issuing revised regulations.

In 1997 legislation was passed requiring a criminal background check on all staff. Prior to 1997, criminal background checks were in regulation but not in statute. Rules to implement the amended law are being drafted. A new methodology for reimbursing Medicaid beneficiaries is also being developed.

The states assisted living law was passed in 1994 to encourage the development of assisted living homes to provide a homelike environment for older persons and persons with a mental or physical disability needing assistance with activities of daily living. The law promotes resident participation in the community, recognizes the resident's right and responsibility to evaluate and make choices concerning the services to be provided. The law provides for licensing assisted living homes for elders, people with dementia, and people with physical, mental or developmental disabilities. The Department of Health and Social Services licenses homes for people with mental or developmental disabilities and the Department of Administration licenses homes for older people, people with dementia and people with physical disabilities. The agencies issued joint regulations in 1995 setting additional requirements and standards.

In March 1998, 78 homes with a total of 478 beds had been licensed by the Division of Senior Services. This total does not include the state's Pioneer Homes which are six state operated homes that also provide supportive services. Of the licensed homes, 85% have five or fewer beds. One home has 60 units which are individual apartments. An estimated 50% of the units are private rooms.

The regulations set minimal requirements which are defined in more detail in policies and procedures. Based on their initial experience, state officials are reviewing the regulations governing the overall enforcement and sanctions procedures to expedite action when warranted; to make the criminal check procedures consistent with those used by other agencies; and to clarify liability insurance requirements. To expedite reviews and maximize staff capacity, the licensure staff conduct regular orientation sessions to explain the program and its requirements to interested providers. The sessions are held about every six weeks and have reduced the amount of staff time spent explaining the application process to individual providers or others interested in obtaining a license.

Definition

The law creates "Chapter 33. Assisted Living Homes" to emphasize that assisted living serves as the resident's home. The statute applies to residential facilities serving three or more adults who are not related to the owner of the residence by blood or marriage that provide housing, food service, and provide, obtain or offer to provide assistance with activities of daily living, personal assistance (help with IADLs, obtaining supportive services [recreational, leisure, transportation, social, legal, et. al.], being aware of the resident's whereabouts when traveling in the community, and monitoring activities) or a combination of ADL assistance and personal assistance.

Unit Requirements

No requirements are specified for the type of unit. Shared rooms are allowed. Facilities must meet life safety code requirements applicable for buildings of its size. Homes for six or more people must meet applicable state and municipal standards for sanitation and environmental protection. In view of the vast expanse and geographic variation within the state, the licensing standards are based on community and neighborhood standards rather than a statewide standard. This allows homes to be licensed that are consistent with prevailing local housing standards.

Tenant Policy

The home and each resident must sign a residential service contract that describes the services and accommodations to be provided, rates, the rights, duties and obligations of the resident, and the policies and procedures for terminating the contract. Residents who have exceeded the 45 consecutive day limit for receiving 24-hour skilled nursing (see below) may continue to live at the home if the home and the resident or resident's representative have consulted with the resident's physician, discussed the consequences and risks and a revised plan without 24-hour nursing has been reviewed by a registered nurse. Terminally ill residents may continue to reside in the residence if a physician certifies that the person's needs are being met.

Evacuation. These requirements are included in life safety code standards and facility procedures for emergency evacuation drills.

Services

Each resident must have a service plan of care developed within 30 days of move-in that identifies strengths and weaknesses performing ADLs, physical disabilities and impairments, preferences for roommates, living environment, food, recreation, religious affiliation and other factors. The plan also identifies the ADLs with which the resident needs help, how help will be provided by the home or other agencies, and health related services and how they will be addressed. The plan must also identify the resident's reasonable wants and how those will be addressed. If health related services are provided or arranged, the evaluation must be done quarterly. If no health related services are provided, an annual evaluation is required. Assisted living homes may provide intermittent nursing services to residents who do not require 24-hour care and supervision. Intermittent nursing tasks may be delegated to unlicensed staff for tasks designated by the board of nursing. Twenty four hour skilled care may be provided for not more than 45 consecutive days.

Financing

In a limited number of cases, room and board and some services are covered by the state's "general relief" program. The payment amounts in the Anchorage area are $30.00 a day for Level I homes, $33.95 for Level II homes and $40.90 for Level III homes.

Services for Medicaid waiver certified individuals in assisted living homes are funded under the state's Choice Program, a Medicaid HCBS waiver. The Senior Services Division is in process of revising the reimbursement methodology which is currently based on levels of care related to the previous licensure categories. Rates vary by area of the state. In the Anchorage area, Level I homes, formerly adult foster care, provide 24-hour awake staff but do not meet unscheduled needs directly and receive $40.38 a day. Level II homes receive $50.89 a day and have staff capacity to meet unscheduled needs, particularly at night. Level III homes receive $61.39 a day. Homes caring for residents needing extra staff (incontinent, skin care, added supervision, help with medication) can receive a $15.76 per day add-on to the rate. If a resident is also attending adult day care three or more days a week, the rate is reduced to between $29 and $51 a day depending upon the level of the facility. A multiplier is applied to the rates which results in higher payments in rural and frontier areas.

The levels of reimbursement were originally based on the size and staffing level of the three licensing levels of facilities. The rate structure will be revised to reflect residents needs and acuity rather than the size of the facility.

A preliminary methodology would develop a payments for low, intermediate and high needs for medical and acute care needs, physical care needs and cognitive needs. See table.

About 30% of the elderly Choice participants, 175 people, reside in assisted living homes. Case managers from local organizations contract with the Division of Senior Services to conduct assessments, determine eligibility and develop a plan of care for Choice participants who reside in assisted living homes.

Medications

"Home staff persons" may provide medication reminders, reading labels, opening containers, observing a resident while taking medication, checking self-administered dosage against the label, reassuring the resident that the dosage is correct, and directing/guiding the hand of a resident at the resident's request.

Staffing

Homes must have the type and number of staff needed to operate the home and must develop a staffing plan that is appropriate to provide services required by resident care plans. Staff must pass a criminal background check. Administrators must be 21 years of age or older and have sufficient experience, training or education to fulfill the responsibilities of an administrator.

Training

No additional training requirements are specified for administrators or staff.

Background Check

An administrator must provide a sworn statement as to whether the person has been convicted of a felony, a misdemeanor involving drugs or physical or sexual abuse or a misdemeanor involving alcohol. Individuals must also provide the results of a name check, criminal background check and fingerprint investigation conducted by the Alaska Department of Public Safety. Further regulations implementing criminal background checks are being developed.

Monitoring

Both the Department of Health and Social Services and the Division of Senior Services are responsible for screening applicants, issuing licenses and investigating complaints. The departments may delegate responsibility for investigating and making recommendations for licensing to a state, municipal or private agency. Homes must submit an annual self-monitoring report on forms provided by the department. Case managers monitor Choice waiver participants monthly.

Fees

Facilities receiving a voluntary license pay a fee of $25, homes serving 3-5 people pay $75 and homes serving six or more residents pay $150.

ALASKA PAYMENT RATES--ANCHORAGE AREA
	Level I	Level II	Level III
Room and board	$900.00	$1018.50	$1299.77
Waiver services	$1211.40	$1526.70	$1841.70
Total	$2111.40	$2545.20	$3141.47
Add on	$472.80	$472.80	$472.80
Total	$2584.20	$3018.00	$3614.27

DRAFT PAYMENT METHODOLOGY
Category	Low Impairment Care Service Rate	Intermediate Care Service Rate	High Impairment Care Service Rate	Augmented Service Factor
Medicaid and acute care needs	Chronic health problem may be present and treatment may be ongoing. No need for ongoing specialized equipment or procedures.	Chronic health problems are typically present and treatment ongoing. Minimal need for ongoing specialized equipment and/or procedures to intervene.	Acute medical/health care needs typically present and needs ongoing treatment. Need for ongoing specialized medical equipment and procedures to intervene.	Examples of factors which may justify granting an augmented rate: Unstable medical conditions; Immobility; Frequent turning in bed; Requires frequent skin care; Decubitus ulcers; Sterile dressing changes; IV, NG or GT tubes; Requires rehab 5 or more days/week; Chronic incontinence; Requires 24-hour observation.
Physical care needs	Level of physical impairment minimally impact ability to perform self care. 0-1 ADL dependent. Needs assistance with 1-2 ADLs.	Level of physical impairment adversely affects ability to do self care. 2-3 ADLs. Needs assistance with 3-4 ADLs.	Level of impairment significantly and adversely affects ability to perform self care. 4 or more ADLs. Needs assistance with 5 or more ADLs.
Cognitive needs	Level of cognitive functioning adequate to survive independent of 24-hour supervision.	Level of cognitive dysfunction impacts ability to survive independent of ongoing oversight. (mild dementia)	Level of cognitive functioning significantly and adversely impact ability to survive independent of oversight. Mild to late stage dementia.

Arizona

Citation

Assisted living facilities. Comprehensive administrative rules and regulations §R9-10-701 et seq.

General Approach

Rapid growth in the number and types of home and community based settings serving elderly and adults with physical disabilities, ranging from private homes to facilities providing specialized care to large retirement complexes, has outpaced the regulations developed to guide this development. In the Spring of 1997, the Arizona Department of Health Services' Office of Home and Community Based Licensure established a 28 member task force to help consolidate five of the existing six licensing classifications (adult care homes, supported residential living centers, supervisory care homes, unclassified homes and adult family care) into a single assisted living category. Rules have been issued which are expected to be effective in November, 1998.

The new assisted living facility category has requirements based on the size of the facility and supplemental requirements depending on the level of service provided. The core requirements address facilities serving 10 or fewer residents, eleven or more residents and adult foster homes which serve 1-6 residents. Facilities will be licensed to provide one of three levels of care supervisory care services, personal care services, and directed care services and must meet supplemental requirements.

The directed care level will serve people with Alzheimer's disease or dementia who cannot self-direct their care, eg., cannot recognize danger, summon assistance, express need or make basic decisions. Requirements for specialized training, activities, physical plant and services will be established.

The goal of the task force was to develop regulations that are consistent and ensure minimum standards for health, safety and welfare. Regulations will be based on the resident's level of need and promote dignity, independence, self-determination, privacy and choice. Legislation was approved in 1998 authorizing the new category.

AHCCCS, which administers the state's Medicaid managed care program, will retain higher standards (eg., private living units), for providers interested in serving Medicaid beneficiaries.

Pilot program expanded statewide Chapter 163 (1993) authorized a three year supportive residential living centers (SRLC) pilot project, which is the same as assisted living, to test the feasibility of developing additional cost effective alternatives to nursing homes for participants in the Arizona Long Term Care Systems (ALTCS). The pilot was implemented in Maricopa County by the Maricopa Managed Care Systems, a county based HMO which contracts with the state Medicaid agency, AHCCCS, to operate the ALTCS system. In 1996, the legislature approved the statewide expansion of the program and provided funding for 700 ALTCS members and no restrictions on the number of private pay residents. After 1997, there is no limit on the number of members who can be served through Supportive Residential Living Centers (to be renamed assisted living facilities).

As required by legislation, Maricopa Managed Care Systems issued a report in December 1995. The report recommended a statewide expansion of the program based on three primary findings: cost effectiveness, high satisfaction level among participants and the ability to meet resident needs in a less restricting environment.¹ The study found annual savings of $2 million based on the continuous enrollment of 100 participants.

The evaluation collected data on resident satisfaction, number of residents, length of stay, level of care, emergency room utilization, urgent care visits, number of days of hospitalization and cost, average daily cost of supportive residential living, service levels, demographic information, functional information, and medical information. The study identified three areas for further study: building codes, public versus private pay criteria and level of care.

The following information is based on the new proposed regulations.

Definition

Assisted living facility means a residential care institution, including adult foster care, that provides or contracts to provide supervisory care services, personal care services or directed care services on a continuing basis.

Supervisory care services mean general supervision, including daily awareness or resident functioning and continuing needs, the ability to intervene in a crisis and assistance in the self-administration of prescribed medications.

Personal care services mean assistance with activities of daily living that can be performed by persons without professional skills or professional training and include the coordination or provision of intermittent nursing services and the administration of medication and treatments by a nurse who is licensed pursuant to Title 32, Chapter 15 or as otherwise provided by law.

Directed care services means programs and services, including personal care services, provided to persons who are incapable of recognizing danger, summoning assistance, expressing need or making basic care decisions.

The ALTCS program will contract with assisted living homes (10 or less) and assisted living centers but only centers that offer residential units (apartments).

Unit Requirements

Assisted living centers (11+ residents) may provide residential units or bedrooms. Residential units must have at least 220 square feet of floor space, excluding bathroom and closet for one person with an additional 100 square feet for a second person. Units must have a keyed entry, bathroom, resident controlled thermostat and a kitchen area with sink, refrigerator, cooking appliance that may be removed or disconnected and space for food preparation.

Assisted living centers and homes providing bedrooms must have 80 square feet in single rooms and 60 square feet per resident in double rooms. No more than two residents may share a room. Rooms occupied by residents receiving personal care services or directed care services must have a bell, intercom or other mechanical means to contact staff. At least one toilet, sink and shower is required for every eight residents

Tenant Policy

ALFs providing supervisory care services may serve residents who need health or health related services if these services are provided by a licensed home health or hospice agency.

ALFs with a personal care service license may not accept or retain any resident who is unable to direct self-care; requires continuous nursing services unless the nursing services are provided by a licensed hospice agency or a private duty nurse; residents with a stage III or IV pressure sore or someone who is bed bound due to a short illness unless the primary care physician approves, the resident signs a statement and the resident is under the care of a nurse, a licensed home health agency, or a licensed hospice agency.

ALFs licensed to provide direct care services may admit residents who are bedbound, need continuous nursing services or have a stage III or IV pressure sore if the requirements for facilities providing personal care services are met.

Services

Residents must receive an assessment and a service plan within 14 days of acceptance. Plans must be reviewed every 12 months for residents receiving supervisory care services, every six months for residents receiving personal care services and every three months for residents receiving directed care services. Services must meet scheduled and unscheduled needs. Facilities must provide general supervision; promote resident independence, autonomy, dignity, choice, self-determination and the resident's highest physical, cognitive and functional capacity; help utilizing community resources; encouragement to preserve outside supports; individual attention and social interaction and activities.

Facilities providing personal care services also provide skin maintenance, sufficient fluids to maintain hydration, incontinence care, an assessment by a primary care provider for residents needing medication administration or nursing services.

Facilities providing directed care must provide cognitive stimulation and activities to maximize functioning; encouragement to eat meals and snacks; and an assessment by a primary care provider.

ALTCS Services are grouped into three types: hotel services, personal care services and nursing care services. Hotel services include meals, linen and personal laundry, housekeeping and social and recreational services. Personal care includes assistance with ADLs, managing functional and behavior problems, assisting with medication and oversight. Nursing services cover observation and assessment, routine nursing tasks, intermittent nursing care and terminal care delivered by hospice providers.

Prior to move in, an interdisciplinary team (manager, staff, RN if nursing services are provided, resident and/or representative and case manager if applicable) conducts an assessment. A plan of care is developed with the resident or their representative that identifies the services needed, the person responsible for providing the service, method and frequency of services, measurable resident goals and the person responsible for assisting the resident in an emergency.

Financing

Assisted living facilities can contract with ALTCS program contractors to serve beneficiaries meeting the nursing home criteria. Program administrators used rates set for adult foster care, nursing facilities, the Oregon assisted living program and the Arizona HCBS program as guidelines in setting the rates paid to what were formerly called Supportive Residential Living Centers. (ALTCS will use the new terms contained in the assisted living regulations.) Administrators also consider the package of services provided and ask each Center to submit a budget. Three classes of rates are negotiated based on the level of care: low, intermediate and high skilled. The rates include room and board which is paid by the resident. The monthly room and board amount is the resident's "alternative share of cost" (spend down) or 85% of the current SSI payment, whichever is greater. For residents who receive SSI, the payment rate is $470 a month of which $403.10 is paid to the residence to cover room and board charges and $66.90 is retained by the resident.

ARIZONA RATES BY PROGRAM CONTRACTOR
	Class I	Class II	Class III
APIPA	$46.67	$56.67	$66.67
Ventana	$50.00	$56.67
MMCS	$47.33	$60.42	$73.88
Pima	$46.45	$59.30	$72.51

An evaluation of the SLRC program found that the average cost of SRL was 58.7% of the cost of a nursing facility in FY 95 - $1567 a month compared to $2669 for nursing facility residents, for a savings of $1102 a month. Ancillary health costs (inpatient, physician, transportation, emergency rooms etc.) were 30% lower for SRL participants than nursing home residents.

Medications

Facilities must have policies and procedures governing the procurement, administration, storing and disposal of medications. Staff may supervise self-administration by opening bottle caps, reading labels, checking the dosage and observing the resident taking the medication. Medications which cannot be self-administered must be administered by an RN or "as otherwise permitted." The phrase as otherwise permitted was included to accommodate any future statutory changes in the state's nurse practice act. Medication organizers can be prepared a month in advance by an RN or family member.

Staffing

Facilities are required to ensure that sufficient staff are available to provide services consistent with the level of care for which the facility is licensed, services established in a care plan, service to meet resident needs for scheduled and unscheduled needs, general supervision and intervention in a crisis 24-hours a day, food services, environmental services, safe evacuations and ongoing social and recreational services.

Training

Managers must be 21, certified and have a minimum of 12 months of health related experience.

Staff must complete an orientation that includes the characteristics and needs of residents; the facility's philosophy and goals; promotion of resident dignity, independence, self-determination, privacy, choice and resident rights; the significance and location of service plans and how to read and implement a service plan; facility rules, policies and procedures; confidentiality of resident records; infection control; food preparation, service and storage if applicable; abuse, neglect and exploitation; accident, incident and injury reporting; and fire, safety and emergency procedures.

Managers and staff must complete 12 hours of ongoing training annually covering promoting resident dignity, independence, self-determination, privacy, choice, and resident rights/fire, safety and emergency procedures; infection control; abuse, neglect and exploitation. Staff in facilities licensed to provide directed care services must receive a minimum of four hours of training in providing services to residents.

In addition to the above topics, training may include providing services to residents; nutrition, hydration and sanitation; behavioral health or gerontology; social, recreational or rehabilitative services; personnel management, if applicable; common medical conditions, medication procedures, medical terminology and personal hygiene; service plan development, implementation or review and other needs identified by the facility.

Staff must also maintain current CPR certification and complete six hours of continuing education annually pursuant to §36-448.11(D). Nurses aides in good standing are deemed to meet the initial training requirements.

Certificate of training Staff must obtain a certificate of training. Facilities may develop their own training and certificate program with approval from the department. Department approved training programs have requirements for instructors and the method of instruction. The competency based approach sets standards for supervisory care services, personal care services, directed care services, and manager training.

Supervisory care services: 20 hours or the amount of time needed to verify a person demonstrates skills and knowledge in assisted living principles; communication; managing personal stress; preventing abuse, neglect and exploitation; controlling the spread of disease and infection; documentation and record keeping; implementing service plans; nutrition, hydration and food services; assisting with self-administration of medications; providing social, recreational and rehabilitative activities; and fire, safety and emergency procedures.

Personal care services: 30 hours (50 total) or the amount of time needed to verify a person demonstrates skills and knowledge in additional skills areas such as the aging process, common medical conditions associated with aging or physical disabilities and medications; assisting with ADLs and taking vital signs.

Directed care services: 12 hours (75 total) or the amount of time needed to verify a person demonstrates skills and knowledge of Alzheimer's disease and related dementia; communicating with residents with residents w ho are unable to direct care; providing services including problem solving, maximizing functioning and life skills training for those unable to direct care; managing difficult behaviors; and developing and providing social, recreational and rehabilitative activities for such persons.

Background Check

Staff must comply with fingerprint requirements under A.R.S. 36-411. Legislation requiring federal criminal background checks is likely to be passed and implemented in 1998.

Monitoring

The licensing agency conducts annual renewal inspections. Licenses may be renewed for two years for facilities that are free of deficiencies.

Facilities are monitored by ALTCS program contractors and the Arizona Department of Health Services. Sites are recertified annually by the Department of Health Services. During the pilot phase, MMCS monitored resident care on a quarterly basis, provided technical assistance and conducted meetings of providers to obtain feedback on the program. With statewide expansion, participants are visited at least quarterly by their ALTCS case manager. Annual operating and financial reviews of ALTCS contractors (HMOs) are conducted annually by AHCCCS. The reviews also include case management and provider records and claims data. AHCCCS also reviews a random sample of residents, including assisted living residents, to evaluate the appropriateness and quality of care. The review found no unmet needs or quality of care problems.

---------------------

Supportive Residential Living Pilot Project. A Report on the SRL Pilot Status of ALTCS members. Maricopa Managed Care Systems. Phoenix, Arizona. December 1995.

Arkansas

Citation

Residential long term care facilities Arkansas Annotated Code §§20-76-201 (b)(3), 2010-203 and 20-10-224.

General Approach

Rules were revised and updated in 1996. State agencies are exploring reimbursement for an assisted living model.

Definition

Residential long term care facility means a building or structure which is used or maintained to provide, for pay on a 24-hour basis, a place of residence and board for three or more individuals whose functional capabilities may have been impaired, but who do not require hospital or nursing home care on a daily basis, but could require other assistance with activities of daily living.

Unit Requirements

A minimum of 100 square feet is required for single rooms and 80 square feet per resident in shared rooms. Rooms may be shared by two residents. A minimum of one toilet/lavatory is required for every six residents and one tub/shower for every 10 residents.

Tenant Policy

Tenants must be 18 or older; independently mobile (physically and mentally capable of vacating the facility within 3 minutes); able to self-administer medications; be capable of understanding and responding to reminders and guidance from staff; do not have a feeding or intravenous tube; are not totally incontinent of bowel and bladder; do not have a communicable disease that poses a threat to the health or safety of others; do not need nursing services which exceed those that can be provided by a certified home health agency on a temporary or infrequent basis; do not have a level of mental illness, retardation or dementia or addiction to drugs or alcohol that requires a higher level of medical, nursing or psychiatric care or active treatment than can safely be provided in the facility; does not require religious, cultural or dietary regimens that cannot be met without undue burden; and do not require physical restraints, or have current violent behavior.

Services

Facilities may provide personal care; supportive services (occasional or intermittent guidance, direction or monitoring for ADLs); activities and socialization; assistance securing professional services; meals; housekeeping; and laundry. Residents have a choice of providers for receiving personal care services and they may use an agency that is not the facility. RCFs may not provide medical or nursing services. Home health services may be provided by a certified home health agency when ordered by a physician.

Financing

Personal care services are reimbursed as a state plan service under Medicaid based on a plan of care. Facilities are reimbursed fee for service. A maximum of 64 hours of care per month may be covered without prior authorization. About 1,000 residents are covered each month.

Medication

RCFs may remind residents to take medications, read label instructions and remove the cap or packaging.

Staffing

The number of direct care staff needed is scaled for daytime, evening and night shifts based on the number of residents. Staffing must be sufficient to meet the needs of residents.

Training

Administrators must have a current certification as a residential care facility administrator, or complete a course of instruction and training prescribed by the Department.

Staff An orientation covering, at a minimum, job duties, resident rights, abuse/neglect reporting requirements and fire and tornado drills is required. Four hours of in-service training or continuing education a year covering resident rights, evacuation of a building, safe operation of fire extinguishers, incident reporting and medication supervision are required for direct care staff.

Background check Administrators may not have any prior conviction pursuant to Arkansas Code Annotated §20-10-401 or relating to the operation of a long term care facility nor any conviction for abusing, neglecting or mistreating individuals.

Fees

$5 per bed.

California

Citation

Residential care facilities for the elderly Title 22, Division 6, Chapter 8.

General Approach

California licenses 5,900 residential care facilities for the elderly with 123,238 residents. About 70% of the facilities serve fewer than six residents. These facilities account for between 25-30% of all residents. As in other states, nursing facilities are concentrating on providing specialty, subacute and rehabilitative care, many through contracts with HMOs. Nursing homes have not expressed interest in converting to assisted living facilities, however, many nursing homes are adding assisted living to free beds for higher need residents and to provide referrals as assisted living residents age.

At the direction of the state legislature, a study of state approaches to assisted living was conducted by the Department of Health and filed in 1997. Informal discussions among state agencies, assisted living providers and legislative staff were to discuss the definition of assisted living and where it fits or how it compares to the current residential care facilities for elderly model. The discussion has focused on if assisted living is different, what services should be allowed and whether assisted living should be considered a bundle of services that is provided without regard to the building. Other issues addressed included the definition, information needed by consumers, the scope of services to be covered and the needs of clients that can be met, the place of assisted living in the continuum of care and whether a new licensure category was needed or appropriate.

The 18 member group has discussed financing for low income elders but believes Medicaid waiver financing would lead to a medical model. The Department of Health has concerns about residents meeting the nursing home level of care criteria being served in settings that are not licensed. The aging community believes there are too many licensure categories already and new ones only serve providers seeking higher levels of reimbursement without really increasing the services provided.

During 1995, legislation (Chapter 550 of the Acts of 1995) was passed that allows RCFEs that serve people with Alzheimer's Disease to develop secure perimeters. Based on the results of a pilot project, the law allows facilities that meet specific additional requirements to secure exterior doors or perimeter fences, or to install delayed egress devices on exterior doors and perimeter fence gates. Resident supervision devices, wrist bracelets which activate a visual or auditory alarm when a resident leaves the facility may also be used. Facilities must provide interior and exterior space for residents to wander freely, receive approval from the local fire marshal and conduct quarterly fire drills. Facilities with delayed egress devices must be sprinklered and contain smoke detectors and the devices must deactivate when the sprinkler system or smoke detectors activate. The devices must also be able to be deactivated from a central location and deactivate when a force of 15 pounds is applied for more than two seconds to the panic bar. In addition facilities shall permit residents to leave who continue to indicate such a desire and staff must ensure continued safety. Reports must be submitted when residents wander away from the facility without staff. Delayed egress devices may not substitute for staff.

A voluntary disclosure process has been adopted under which facilities offering special services for people with Alzheimer's Disease disclose information concerning their program. A consumer's guide has been developed which alerts family members to several key questions that should be asked. The areas include the philosophy of the program and how it meets the needs of people with Alzheimer's, the pre-admission assessment process used by the facility, the transition to admission, the care and activities that will be provided, staffing patterns and the special training received by staff, the physical environment and indicators of success used by the facility.

Definition

Residential care facility for the elderly means a housing arrangement chosen voluntarily by the resident, or the resident's guardian, conservator or other responsible person, where 75% of the residents are 60 years of age or older, or, if younger, have needs compatible with other residents and where varying levels of care and supervision are provided, as agreed to at time of admission or as determined necessary at subsequent times of reappraisal.

Unit Requirements

Occupancy is limited to two residents per bedroom which must be large enough to accommodate easy passage between beds, required furniture and assistant devices such as wheelchairs or walkers. One toilet and sink is required for every six residents and a bath tub or shower for every 10 residents.

Tenant Policy

Facilities may admit or retain residents who are capable of administering their own medications; receive medical care and treatment outside the facility or from a visiting nurse; residents who need to be reminded to take medications; and people with mild dementia, or mild temporary emotional disturbance resulting from personal loss or change in living arrangement. Facilities may not admit or retain anyone with a communicable disease; anyone who requires 24-hour skilled nursing or intermediate care or is bedridden more than for more than 14 days including residents who are unable to transfer independently to and from bed and are unable to leave the building unassisted in an emergency. The regulations allows residents with health conditions requiring incidental medical services which are specified in the rules to be admitted and retained (eg., intermittent positive pressure breathing, indwelling catheter, management of incontinence, colostomy/ileostomoy, contractures, healing wounds). Residents who will be bedridden more than 14 days may be retained if the facility submits a physician's statement to the Department of Health stating that the condition is temporary and an estimated date upon which the resident will no longer be confined to bed is provided.

Alzheimer's projects Facilities may admit and retain people with Alzheimer's Disease who are not able to respond to verbal instructions to leave a building without assistance provided they have:

Submitted a waiver exception request that includes a plan of operation which specifically addresses the needs of Alzheimer's residents;
A training plan which ensures that facility staff can meet the needs of residents;
An activity program and resident assessment and re-assessment procedures;
Procedures to notify physicians when behavior changes;
A written plan to minimize the use of psycho-tropic medications; and
A disaster and mass casualty plan.

Services

Services are divided into basic services and care and supervision. Basic services include safe and healthful living accommodations; personal assistance and care; observation and supervision; planned activities; food service; and arrangements for obtaining incidental medical and dental care. Care and supervision covers assistance with ADLs and assumption of varying degrees of responsibility for the safety and well being of residents. The tasks include assistance with dressing, grooming, bathing and other personal hygiene; taking medications; and central storing and distribution of medications.

Medications

Facilities may assist with self-administration of medications and, if staff is authorized by law, administer injections.

Staffing

Sufficient staff must be employed to deliver services required by residents. On the job training or experience is required in the principles of nutrition, food storage and preparation, housekeeping and sanitation standards, skill and knowledge to provide necessary care and supervision, assistance with medications, knowledge to recognize early signs of illness and knowledge of community resources.

Requirements for awake staff vary by the size of the facility. For 16 or less, staff must be available in the facility; 16-100, at least one awake staff; 101-200, 1 on call and 1 awake with an additional awake staff for each additional 100 residents.

Training

Administrators Individuals shall complete an approved certification program prior to be being employed as an administrator. The program must include 40 hours of classroom training which covers laws, rights, regulations and policies (12); business operations (3); management and supervision (3); psycho-social needs of the elderly (5); physical needs of the elderly (5); community and support services (2); use, misuse and interaction of drugs (5); and admission, retention and assessment procedures (5). All administrators shall be required to complete at least 20 clock hours of continuing education per year in areas related to aging and/or administration.

Staff Personnel must be given on the job training or have related experience in: the principles of good nutrition, good food preparation and storage and menu planning; housekeeping and sanitation procedures; skill and knowledge required to provide necessary resident care and supervision including the ability to communicate with residents; knowledge required to safely assist with prescribed medications which are self-administered; knowledge necessary in order to recognize early signs of illness and the need for professional help; and knowledge of community services and resources.

Facilities licensed for 16 or more must have a planned on the job training program in the above areas including orientation, skill training and continuing education.

Background Check

The licensing agency conducts a criminal background check of officers of the organization, adults responsible for administration and direct supervision, persons providing direct care and employees having frequent contact with residents and others and may approve or deny a license or employment based on its findings. A fingerprint clearance shall be received by the licensing agency on all persons subject to criminal record review prior to issuing a license.

Monitoring

Facilities must be inspected annually. Three levels of penalties are allowed for violations with an (A) immediate, (B) potential and (C) technical impact. $50 per day civil penalties are allowed for A and B violations increasing to $100 per day if the same violation is repeated 3 times in a 12 month period. Consultation is provided for Type C violations.

Fees

Licensing fees required at initial licensure and annually thereafter, are adjusted by facility size: 16 - $300; 7-15 - $450; 16-49 - $600 and 50+ - $750.

Colorado

Citation

Personal Care Boarding Homes Chapter VII, §1.1 et seq.

General Approach

Colorado licenses assisted living under personal care boarding home rules. Rules were revised in 1993. The number of licensed facilities has risen from 238 in 1990 to 385 in 1995 and 469 in 1998. Nursing home beds occupied by Medicaid recipients have remained stable over the past 10 years at 10,400. State respondents attributed the stable census to the expansion of home and community based programs, including reimbursement of personal care boarding homes. In 1995, the legislature revised the Medicaid rate for alternative care facilities (personal care boarding homes) and participation rose from 70 facilities to 179 by March 1998. The number of HCBS waiver participants in ACFs rose from 600 to 960 by June 1996 and 1,400 by March 1998.

While the regulations allow double occupancy and shared bathrooms, the majority of new construction provide private rooms or apartments, including homes that contract with the state to serve Medicaid recipients. The supply of personal care boarding homes is expected to increase. The licensing agency notes that many nursing facility owners are developing their own personal care boarding homes and few nursing home operators have complained about the level of care offered.

Definition

Personal care boarding home is "a residential facility that makes available to three or more adults not related to the owner of such facility, either directly or indirectly through a provider agreement, room and board and personal services, protective oversight, and social care due to impaired capacity to live independently, but not to the extent that regular 24-hourmedical or nursing care is required."

Units

The rules allow no more than two people to share a room for facilities built after July 1, 1986. Single occupancy rooms must have at least 100 square feet and double occupancy rooms at least 60 square feet per person. Cooking is not allowed in bedrooms and facilities must provide access to a food preparation area for heating or reheating food or making hot beverages subject to "house rules." Cooking may be allowed in facilities which provide apartments rather than bedrooms. Facilities must provide at least one bathroom for every six residents.

Tenant Policy

Personal care boarding homes may not admit or retain residents who are:

Consistently, uncontrollably incontinent of bladder unless the resident or staff is able to prevent it from becoming a health hazard;
Incontinent of bowel unless they are capable of self-care;
Totally bedfast;
Require 24-hour nursing or medical service;
Need restraints; or
Have a communicable disease.

Each facility develops their own admission criteria based on the capacity of the facility. A review of Medicaid pre-admission screening assessment forms showed that Medicaid waiver participants in ACFs had fewer skilled needs than nursing home residents.

Services

Facilities must provide a physically safe and sanitary environment, room and board, personal services (transportation, assistance with activities of daily living and instrumental activities of daily living, individualized social supervision), protective oversight and social care. Written "board and care plans," which must be reviewed at least annually, are required for each resident and include a list of current prescribed medications (dosage, time and route of administration, whether self-administered or assisted), dietary restrictions, allergies and any physical or mental limitations or activity restrictions.

Nursing and therapies may be received if provided by a home health agency.

Reimbursement

Medicaid rules limit room and board charges for Medicaid recipients to $448 a month. Effective July 1998, the Medicaid rate for services is $29.88 a day. The rate covers oversight, personal care, homemaker, chore and laundry services. The state is interested in developing tiered rates.

MONTHLY RATES
Room and board	$488.00
Service	$864.40
Total	$1344.60

Medications

Most larger facilities have hired LPNs to administer or manage medications and ensure that physician's order have been received and recorded. Unlicensed staff may assist with self-administration but they cannot take physicians' orders over the phone.

Staffing

Facilities must employ sufficient staff to ensure provision of services necessary to meet resident needs.

Training

Administrators must meet the minimum education, training and experience requirements by successfully completing a program approved by the department. Acceptable programs may be conducted by an accredited college, university or vocational school, or a program, seminar or in-service training program sponsored by an organization, association, corporation, group or agency with specific expertise in that area. The curriculum includes at least 30 actual clock hours of which at least 15 are comprised of a discussion of each of the following topics: resident rights; environment and fire safety, including emergency procedures and first aid; assessment skills; identifying and dealing with difficult behaviors, and nutrition.

The remaining 15 hours shall provide emphasis on meeting the personal, social and emotional care needs of the resident population served.

Staff All staff, including volunteers, must be given on the job training or have related experience in the job assigned to them and shall be supervised until they have completed on the job training appropriate to their duties and responsibilities or had previous related experience evaluated. Training and orientation in emergency procedures shall be provided to each new staff member, including volunteers, within three days of employment.

Staff members not serving as an operator who have direct responsibility for the provision of personal care, i.e. hygiene, of residents or for the supervision or training of residents in the resident's own personal care, shall provide documentation of either successful completion of course work in the provision of personal care or previous and related job experience in providing personal care to residents.

The facility shall provide adequate training and supervision for staff comprised of a discussion of each of the following topics: resident rights, environment and fire safety, including emergency procedures and first aid; assessment skills; and identifying and dealing with difficult situations and behaviors.

Background Check

The owner or licensee may have access to and shall obtain any criminal history record information from a criminal agency for all persons responsible for the care and welfare of residents.

Monitoring

The regulations require that facilities provide access to the ombudsman program to the facility and residents at reasonable times.

Connecticut

Citation

Assisted living services agency. Connecticut General Statutes §19a-490; Connecticut Agency Regulations §19-13-D105.

General Approach

Assisted living regulations were issued by the Health Department and approved by the Legislative Review Committee in December, 1994. The regulations take a unique approach by allowing "managed residential communities" (MRCs) to offer assisted living services through assisted living services agencies (ALSAs). MRCs may obtain a license to also serve as an ALSA.

Twenty two assisted living service agencies have been licensed. About 115 homes for the aged have been licensed. The supply, which declined for several years, seems to be increasing as more multi-facility, for-profit companies enter the market and small owner operated homes decline.

The ALSA regulations focus on the licensing of agencies to provide services rather than the building and services as an entity. MRCs have to notify the health department of their intention to provide assisted living services. The ALSA, either the MRC or another agency, must be licensed by the Department of Public Health and Addiction Services to provide services. The MRC is not licensed by the Department of Public Health and Addiction Services. MRCs must show evidence of compliance with local zoning ordinances and building codes.

A bill authorizing a pilot project in three cities with up to 300 units was signed that provides Medicaid reimbursement for assisted living services in elderly housing complexes. The pilot will be developed by the Department of Social Services and the Connecticut Housing Finance Agency. Another bill passed that repeals the certificate of need requirement.

Definition

Assisted living services: nursing services and assistance with ADLs provided to clients living within a managed group living environment having supportive services that encourage clients primarily age 55 or older to maintain a maximum level of independence. Routine household services may be provided as assisted living services or by the managed residential community. These services provide an alternative for elderly persons who require some help or aid with ADLs and/or nursing services.

Unit Requirements

To qualify as a managed residential community and a setting in which assisted living services may be provided, units are defined as a living environment belonging to a tenant(s) that includes a full bathroom within the unit including water closet, lavatory, tub or shower bathing unit and access to facilities and equipment for the preparation and storage of food.

Tenant Policy

Each ALSA agency will develop its own admission criteria but the regulations do not allow the ALSAs to impose unreasonable restrictions and screen out people whose needs may be met by the ALSA. Assisted living services may be provided to residents with chronic and stable health, mental health and cognitive conditions as determined by a physician or health care practitioner.

Services

Services may only be provided by organizations licensed as an assisted living services agency. Nursing services delivered under the regulations and include client teaching, wellness counseling, health promotion and disease prevention, medication administration and delegation of supervision of self-administered medications and provision of care and services to clients whose conditions are chronic and stable.

Registered nurses may also perform quarterly assessments, coordination, orientation, training and supervision of aides.

Financing

The Health and Education Facilities Authority provides loans for the development of assisted living settings. As yet, no specific program has been developed to subsidize services for low income residents but a bill authorizing a Medicaid demonstration was passed and awaiting action by the Governor.

Medications

The regulations allow for administration of medications by licensed staff. Assisted living aides may supervise the self-administration of medications which includes reminding, verifying, and opening the package.

Staffing

ALSAs must have at least one RN and an on-site supervisor 20 hours a week for every 10 or fewer RNs and aides and a full time supervisor for every 20 RNs and aides. A sufficient number of aides must be available to meet residents' needs. All aides must be certified Nurses Aides or Home Health Aides and complete 10 hours of orientation and one hour of in-service training every two months.

Twenty-four hour awake staff are not required since the needs will vary among managed residential communities. However, 24-hour staffing could be required if indicated by resident plans of care. An RN must be available on-call 24-hours a day.

Training

Each agency must have an orientation policy and procedure for all employees which shall include but not necessarily be limited to the following:

Organizational structure of the agency and philosophy of assisted living services;
Agency client services policies and procedures;
Agency personnel policies; and
Applicable regulations governing the delivery of assisted living services.

Each agency shall have an in-service education policy that provides an annual average of at least one hour bimonthly for each assisted living aide.

The in-service training shall include but not be limited to current information regarding specific service procedures and techniques and information related to the population being served.

Monitoring

ALSAs are required to establish a quality assurance committee that consists of a physician, a registered nurse and social worker. The committee meets every four months and reviews the ALSA's policies on program evaluations, assessment and referral criteria, service records, evaluation of client satisfaction, standards of care and professional issues relating to the delivery of services. Program evaluations are also to be conducted by the quality assurance committee. The evaluation examines the extent to which the managed residential community's policies and resources are adequate to meet the needs of residents. The committee is also responsible for reviewing a sample of resident records to determine whether agency policies were followed, whether services are provided only to residents whose level of care needs can be meet by the ALSA, and whether care is coordinated and appropriate referrals are made when needed. The committee submits an annual report to the ALSA summarizing findings and recommendations. The report and actions taken to implement recommendations are made available to the state Department of Public Health.

Agencies are inspected biennially. Penalties include revocation, suspension or censure; letter of reprimand; probation; restrict acquisition of other entities; consent order compelling compliance; and civil monetary penalties.

Fees

Fees are not required for ALSAs.

Board and Care

Homes for the aged provide personal care and a maximum of two people to a room. One toilet is required for every six residents per floor and bathing facilities are required for every eight residents. Residents may receive temporary nursing services from a community agency.

Delaware

Citation

Assisted living agencies: Title 16 Health and Safety, Part II, Chapter II, § 63.0 et seq.

Rest residential homes Delaware code, Part II §59.0 et seq.

General Approach

Regulations governing assisted living were adopted in 1998. The philosophy of the regulations is stated in the opening "purpose" section and directs that the "services are provided based on the social philosophy of care and must include oversight, good, shelter and the provision or coordination of a range of services that promote quality of life of the individual. The social philosophy of care promotes the consumer's independence, privacy, dignity and is provided in a home-like environment."

Definition

Assisted living is a residential arrangement for fee for dependent elderly and adults with disabilities which provides assistance with activities of daily living and other services that promote the consumer's quality of life.

Rest residential home is an institution that provides resident beds and personal care services for persons who are normally able to manage activities of daily living. The home should provide friendly understanding to persons living there as well as appropriate care in order that the resident's self-esteem, self-image and role as a contributing member of the community may be reinforced.

Tenant Policy

Assisted living The rules do not allow agencies to provide services to people who have conditions that exceed the agency's capabilities or who present a danger to self or others or engage in illegal drug use. Two other groups of consumers cannot be served--unless the attending physician certifies that despite the presence of the following factors, the consumer's needs may be safely met by a service agreement developed by the agency, the attending physician, a registered nurse, the consumer or his/her representative if the consumer is incapable of making decisions and other appropriate health care professionals:

Consumers whose medical conditions are unstable to the point that they require frequent observation, assessment and intervention by a licensed professional nurse, including unscheduled nursing services, and
Consumers who are bedridden for 14 consecutive days.

Rest residential homes No specific requirements are stated other than in the definition of a resident.

Living Unit

Assisted living The rules require individual living units. Consumers must have access to a readily available central kitchen if one is not provided in the unit. Bathing facilities must be provided in the unit or in a readily accessible area. Sharing of a bedroom is limited to two consumers and only with their consent.

Rest residential homes provide 100 square feet for single occupancy and 80 square feet per resident for multiple occupancy. No more than four people may share a room. One bath tub or shower and one toilet and wash basin are required for every four residents.

Services

Assisted living Services are based on an assessment of the consumer completed 30 prior to admission and reviewed and revised within 14 days of admission, if appropriate, and a medical evaluation completed within 30 days prior to admission. A service agreement describes the scope, frequency and duration of services and monitoring. A managed risk process may be part of the service agreement. The agreement must address the need for personal services; nursing services; food services; environmental services including housekeeping, trash removal, laundry and safety; social/emotional services; financial management; transportation; individual living unit furnishings; assistive technology and durable medical equipment; rehabilitation services; qualified interpreters; and reasonable accommodations for persons with disabilities. The agreement includes shared responsibility and bounded choice except for people who are bedridden or have unstable medical conditions.

Provisions for Cognitively Impaired Residents

The regulation require that each agency shall develop policies to prevent cognitively impaired residents from wandering away from safe areas and the safe storage of medications.

Rest residential homes provide shelter, housekeeping, board, personal surveillance or direction in activities of daily living.

Reimbursement

Beneficiaries with income below 250% of the SSI level will be eligible for waiver services. The room and board payment from the beneficiary will be $548 and three levels of reimbursement for services are planned. The payment levels were devised based on an analysis of spending for HCBS waiver clients living in their own homes and participants in the adult foster care program.

REIMBURSEMENT LEVELS
	Level I	Level II	Level III
Room and board	$538	$538	$538
Services	$770	$970	$1190
Total	$1308	$1508	$1728

Training

Assisted living The assisted living agency shall provide appropriate training to staff to meet the needs of the consumers. The content and attendance of staff training programs shall be documented.

Rest residential homes Nurse aide/nurse assistant staff must complete a training course approved by the State Board and Nursing and the Board of Health. Aides/assistants must be certified prior to employment. Section 609 describes the curriculum and the competencies that must be measured in the following areas: nurse aide role and function; environmental needs; psycho- social needs; and physical needs. Section 59.610 describes the qualifications of instructors and the training instructors must receive.

District of Columbia

Citation

Community Residence Facilities: DC Law 5-48; DC Code § 32-1301 et seq.; Chapter 34, § 3400 et seq.

General Approach

A Long Term Care Coalition has been reviewing assisted living and is expected to make recommendations during 1998.

Definition

A facility providing safe, hygienic sheltered living arrangements for one or more individuals aged 18 years or older (except in the case of group homes for mentally retarded persons, no minimum age limitation shall apply), not related by blood or marriage to the residence director, who are ambulatory and able to perform the activities of daily living with minimal assistance. The definition includes facilities, including halfway houses and group homes for mentally retarded persons, which provide a sheltered living arrangement for persons who desire or require supervision or assistance within a protective environment because of physical, mental, familial, or social circumstances, or mental retardation. The definition does not include facilities providing sheltered living arrangements to persons who are in the custody of the Department of Corrections of the District of Columbia.

Unit Requirements

No more than 4 persons may share a bedroom. Minimum square footage and bathing and toilet facilities requirements are specified in the DC Housing Code (14 DCMR).

Tenant Policy

Prospective residents, the residence director and the resident's physician must agree that the prospective resident does not need professional care and can be assisted safely and adequately within a community residence facility. Residents must be able to perform ADLs with minimal assistance, generally be oriented as to person and place and capable of exercising proper judgement in taking action for self-preservation under emergency conditions. By special permission of the mayor, persons who are not generally oriented or who are substantially ambulatory but need minimal ADL assistance may be admitted if sufficient staff resources are available.

Services

Meals, housekeeping, laundry, dietary services are provided. Short term nursing care, 72 hours, may be provided or arranged by the facility

Medication

Facilities must provide each resident a means of storing medications. Assisting with self-administration is listed as an activity of daily living.

Background Check

The licensing agency may conduct background checks on the licensee which include contacts with the police to determine criminal convictions.

Florida

Citation

Assisted living facilities. Florida Statute chapter 400 Part 3; Florida Administrative Code Chapter 58A-5 et seq.

General Approach

Chapter 97-82, passed in 1997, revised training requirements and added new provisions for facilities serving people with Alzheimer's disease. An earlier law requires that such facilities disclose in its advertising or other documents how its services are especially applicable to people with Alzheimer's disease. Facilities serving more than 17 persons must have awake staff 24 hours a day, or if serving under 17 residents, either awake staff or mechanisms to monitor and ensure the safety of residents. These facilities must also offer special activities, maintain a physical environment that provides for the safety and welfare of residents and employ staff who have completed appropriate training. The law also removes a barrier to admitting residents who need a higher level of care.

Florida's original legislation (1975) was amended in 1987, 1989, 1992, 1995 and 1997. The 1997 legislation transferred rule authority for assisted living from the Department of Health and Rehabilitative Services to the Department of Elderly Affairs, renamed adult congregate living facilities to assisted living facilities. Extended congregate care (ECC) was created as a higher level of assisted living and new requirements were added for providing mental health services and staff training. The law and rules apply a different philosophy and training for ECC facilities than standard ALFs. Licensing authorization for ALFs remained with the Agency for Health Care Administration.

In November, 1995 there were approximately 5400 units of assisted living in 1900 facilities. About 120 of the 1900 facilities also hold a license to provide ECC services. In March 1998, 2,056 facilities with a total of 66,293 beds were licensed. This includes 235 ECC beds, 110 limited nursing services beds and 152 limited mental health beds.

Definition

"Assisted living facility means any building or buildings, section of a building or distinct part of a building, residence, private home, boarding home, home for the aged or other place, whether operated for profit or not, which undertakes to provide through its ownership or management, for a period exceeding 24 hours, housing, food service, and one or more personal services for four or more adults, not related to the owner or administrator by blood or marriage, who require such services; or to provide extended congregate care, limited nursing services, or limited mental health services, when specifically licensed to do so pursuant to s. 400.407, unless the facility is licensed as an adult family care home."

"Extended congregate care means acts beyond those authorized in subsection 16 that may be performed pursuant to chapter 464 by persons licensed thereunder while carrying out their professional duties; and other supportive services which may be specified by rule. The purpose of such services are to enable residents to age in place in a residential environment despite mental or physical limitations that might otherwise disqualify them from residency in a facility licensed under this part." This definition creates a higher level of care in assisted living which requires an additional license.

Facilities with a limited nursing services license can provide nursing assessments, assessment of the physical and mental status of residents, administration of medications, supervision of self-administration, applying heat, routine changes of colostomy bags, passive range of motion exercises, ice caps, urine tests and routine dressing that no require packing or irrigation, replacement of self-maintained indwelling catheters, enemas and digital stool removal therapies, and care of casts, braces or splints.

Facilities with an ECC license must develop policies which allow residents to age in place and which maximize the independence, dignity, choice and decision making; specify the personal and supportive services that will be provided; specify the nursing services to be provided and describe the procedures to ensure that unscheduled service needs are met.

Unit Requirements

Facilities licensed to provide extended congregate care must provide private rooms or apartments, or semi-private room or apartment shared with a roommate of choice, with a lockable entry door. Facilities that offer rooms rather than apartments must have bathrooms shared by no more than three residents.

Facilities that do not have the ECC license may offer shared rooms, maximum four per room, a bathroom for every six residents and bathing facilities for every eight residents.

Tenant Policy

Admission The regulations for "admissions" to all assisted living facilities are very detailed. New residents must:

Be able to perform ADLs with supervision or assistance (but not total assistance);
Be free of signs and symptoms of communicable diseases;
Not require 24-hour nursing supervision;
Be capable of taking their own medication or the facility has licensed staff to administer medications or the resident contracts with an outside agency for administration;
Not have bed sores or stage 2, 3, or 4 pressure ulcers;
Be able to participate in social activities;
Be capable of self-preservation with assistance;
Not be bedridden;
Non-violent; and
Cannot require 24-hour mental health care.

Continued residency Additional criteria affect continued residency. In regular assisted living facilities, people who are bedridden more than seven days or develop a need for 24-hour nursing supervision may not be retained.

In ECC facilities, residents may not be retained if they are bedridden for more than 14 days. Residents may stay if they develop stage 2 pressure sores but must be relocated for stage 3 and 4 pressure sores. Residents who are medically unstable, become a danger to self or others or experience cognitive decline to prevent simple decision making may not be retained. People who became totally dependent in 4 or more ADLs (exceptions for quadraplegics, paraplegics and victims of muscular dystrophy, multiple sclerosis and other neuro-muscular diseases if the resident is able to communicate their needs and does not require assistance with complex medical problems) may not be retained.

Residents with a diagnosis of Alzheimer's disease or advanced dementia may be retained if they have no significant health problems requiring nursing services. Terminally ill residents may continue in any assisted living facility if a licensed hospice agency coordinates services, an interdisciplinary care plan is developed and all parties agree to the continued residency.

To receive services under the Medicaid waiver, tenants must be 60 years of age or older and meet one of the following criteria:

Require assistance with four or more ADLs or three ADLs plus supervision or administration of medications;
Require total help with one or more ADLs;
Have a diagnosis of Alzheimer's disease or another type of dementia and require assistance with two or more ADLs;
Have a diagnosed degenerative or chronic medical condition requiring nursing services that cannot be provided in a standard ACLF;
Are Medicaid eligible, awaiting discharge from a nursing home but cannot return to a private residence because of a need for supervision, personal care, periodic nursing services or a combination of the three.

Services

Three levels of licensure are available: standard, limited nursing service and extended congregate care. The first level allows facilities to provide personal care and administration of medications. Facilities with an ECC license may provide a higher level of service including total care with up to three ADLs and any nursing service allowed under the scope of the nurse's license except those that are prohibited in the rule. ECC facilities must describe the personal, supportive and nursing services to be made available. Facilities may provide limited nursing services (eg., medication administration and supervision of self-administration, applying heat, passive range of motion exercises, ice packs, urine tests, routine dressings that do not require packing or irrigation and others), intermittent nursing services (eg., routine change of colostomy bag and related care, catheter care, administration of oxygen, routine care of an amputation or fracture, prophylactic and palliative skin care).

Other supportive services that may be provided include counseling, emotional support, networking, assistance securing social and leisure services, shopping, escort, companionship, family support, information and referral, transportation assistance developing and implementing self-directed activities. In addition, facilities provide ongoing medical and social evaluation, dietary management, and medication administration.

ECC facilities must make available nursing diagnosis or observation and evaluation of physical conditions, ongoing medical and social evaluation to determine when the person's conditions cannot be met within the facility, control of occurrence of infections, promotion of normal elimination patterns through diet and exercise, routine measurement and recording of vital functions, dietary management, administration of medications and treatment, preventive regimens for residents liable to develop pressure sores, provide or arrange for rehabilitation services, transportation or escort services for health related services.

ECC facilities may not provide oral or nasopharyngeal suctioning, assistance with tube feeding, monitoring of blood gasses, intermittent positive pressure breathing therapy, intensive rehabilitation services for a stroke or fracture or treatment of surgical incisions which are not clean and free from infection and any treatment requiring 24-hour nursing supervision.

The Medicaid waiver includes the following services for recipients in ECC settings: personal care, homemaker, attendant and companion, medication administration and oversight, therapeutic social and recreational programming, physical, occupational and speech therapy, intermittent nursing services, specialized medical supplies, specialized approaches for behavior management for people with dementia, emergency call systems and case management.

Financing

Services are reimbursed through SSI, SSDI, an optional state supplement to the federal SSI payment and a Medicaid home and community based services waiver. The waiver reimburses providers $750 a month for services for a total payment of $1415 less the $43 personal needs allowance. The SSI benefit is $665 a month. State officials are exploring a system to base payment on the level of care required by residents.

To be eligible for the waiver program, recipients receive SSI, have income under 300% of the federal SSI benefit or, for aged and disabled applicants, have income under 90% of the federal poverty level. Only facilities with an ECC or limited nursing services license may participate in the waiver program.

Medications

Medications may be administered by staff within the scope of their license.

Staffing

Facilities must employ sufficient staff in accordance with required ratios and based on the physical and mental condition of residents, size and layout of the facility, capabilities of trained staff and compliance with all minimum standards. Staff must be employed that are able to assure the safety and proper care of residents and implement the evacuation and emergency management plan.

Training

Administrators employed on or after October 1995 must be over 18, have a high school diploma or GED, or have been an administrator for one of the last three years. Effective July 1997, administrators must complete the core training requirements, including a competency exam and a background check. Administrators must also receive 12 hours of continuing education every two years. ECC administrators must complete six hours of initial training on the physical, psychological or social needs of frail elders or persons with Alzheimer's disease and adults with disabilities and six hours of continuing training each year.

Staff New staff must complete one hour training each on the following topics: infection control, including universal precautions; reporting major incidents and emergency procedures; resident rights and recognizing/reporting abuse, neglect or exploitation. HIV/AIDS training is required on hiring (two hours) and every two years (one hour). Staff who supervise self-administration of medications must receive two hours of training prior to assuming these responsibilities.

For direct care staff, the department shall establish a core educational requirement to be used in these programs. Staff must successfully complete a competency test. The 26 hour core educational requirement must cover at least the following topics:

State law and rules on assisted living facilities, including life safety requirements and procedures;
Identifying and reporting abuse, neglect and exploitation;
Special needs of elderly persons, persons with mental illness and persons with developmental disabilities and how to meet those needs;
Nutrition and food service, including acceptable sanitation practices for preparing, storing and serving food;
Proper techniques for assisting residents with self-administered medication, including record keeping;
Fire safety requirements, including fire evacuation; and
Four hours on Alzheimer's disease.

Effective April 20, 1998, the department will review and approve curricula for HIV/AIDS training, First Aid, and CPR.

Staff who have not taken the core training program shall receive a minimum of two hours of training within the first 30 days of employment in the following subjects:

Understanding common resident behavior, needs and rights;
Common behavior issues and how to respond;
Abuse, neglect and exploitation;
Reporting of major incidents; and
Emergency procedures including procedures for immediate evacuation such as fire, procedures for planned evacuations such as hurricanes, chain of command and staff roles.

The following training is required for staff performing specific functions:

Staff providing personal hygiene must receive training in personal hygiene care from a nurse. CNAs exempt.
Staff assistance with ADLs other than toileting shall receive a minimum of three hours of training in how to perform this care within 30 days of employment.
Persons designated to provide assistance with supervision of self-administered medications shall receive a minimum of two hours of training.

Nutrition and food service. Person responsible for total food services and day to day supervision of food services shall participate in continuing education with a minimum of two hours on an annual basis.

Six hours of initial training that addresses ECC care, concepts and requirements and delivery of personal care and supportive services is required for ECC staff.

New rules for staff in facilities serving people with Alzheimer's disease require 4 hours of initial training in areas of the disease in relation to the normal aging process, diagnosing Alzheimer's disease, characteristics of the disease process; psychological issues including resident abuse, stress management and burn out for staff, families and residents; and ethical issues. An additional four hours is required on medical information, behavior management and therapeutic approaches. Direct care staff must participate in four hours of continuing education each year.

Core training and Alzheimer's disease training may be obtained from persons approved by the Department of Elder Affairs or the Department staff. The draft rules contain a sliding fee for training that varies with the percentage of residents supported by public funds.

Background Check

A criminal history record check, AHCA form 3110-0002 September 1996, shall be obtained from the Florida Department of Law Enforcement on each applicant, administrator, offices of the corporation and general partners. Applicants must submit a Florida Abuse Hotline Information Systems background check (Form AHCA 3110-0003). Administrators may request a background check pursuant to Chapter 435 on employees.

Monitoring

Registered nurses must visit ECC facilities twice a year to monitor residents and to determine if the facility is in compliance with relevant rules.

Fees

The base biennial fee is $253 per license plus $33 per resident. Facilities providing ECC services pay an additional fee of $410.

Georgia

Citation

Personal Care Homes. Georgia Code Annotated §s 31-2-4 et seq.; 31-7-2.1 et seq.; Georgia Comp R and Regulations § 290-5-35.07 et seq.

General Approach

A Medicaid waiver provides reimbursement for group homes. The maximum size of group homes was increased from 15 to 24 or fewer clients in February 1998.

Definition

"Any dwelling, whether operated for profit or not, which undertakes through its ownership or management to provide or arrange for the provision of housing, food services, and one or more personal services for two or more adults who are not related to the owner or administrator by blood or marriage."

Unit Requirements

Bedrooms must have at least 80 square feet of usable floor space per resident. There may be no more than four residents per bedroom. Spouses may be permitted, but not required to share a bedroom. Both the occupant and the administrator or on-site manager must be provided with keys for rooms with lockable doors.

Tenant Policy

Personal Care Homes serve people 18 and older who meet the personal care definition of "ambulatory" - "a resident who has the ability to move from place to place by walking, either unaided or aided by prosthesis, brace, cane, crutches, walker or hand rails, or by propelling a wheelchair; who can respond to an emergency condition ... and escape with minimal human assistance ..." Personal Care Homes cannot admit or retain persons who need physical or chemical restraints, isolation, or confinement for behavioral control. Residents may not be bedbound or require continuous medical or nursing care and treatment.

If short term medical, nursing, health or supportive services are necessary, the resident (or representative) is responsible for purchasing them from licensed providers that are managed independently of the home. The home may assist in the arrangement for such services, but not the provision of those services. Applicants requiring continuous medical or nursing services shall not be admitted or retained.

Services

Room, meals, and personal services which include but are not limited to individual assistance with, or supervision of, self-administered medication, assistance with ambulation and transfer, and essential activities of daily living. Homes are responsible 24-hours a day for the well-being of residents.

Financing

A Medicaid HCBS waiver reimburses two models of personal care homes, group homes serving 7-24 people and the family homes serving 2-6 people. Group homes are reimbursed at $24.66 per day. The SSI payment for room and board is $494 less a personal needs allowance of $86 a month. Family homes are reimbursed by a provider agency that contracts with the Medicaid agency. Medicaid pays $23.49 to the provider agency which must then pay at least $11.52 to the family home subcontractor. In 1997, there were 117 group homes and 1,154 beneficiaries participating in the waiver and 30 family homes serving 788 beneficiaries.

Staffing

At least one administrator, on-site manager, or a responsible staff person must be on the premises 24-hours per day. The minimum on-site staff to resident ratio is one staff person per fifteen residents during waking hours and one staff person per 25 residents during non-waking hours.

Training

All employees must receive work-related training acceptable to the Department within the first 60 days of employment. This training must include: current certification in emergency first aid, except where the staff person is a currently licensed health care professional; current certification in CPR; emergency evacuation procedures; medical and social needs and characteristics of the resident population; residents' rights; and a copy of the Long Term Care Abuse Reporting Act.

Direct care staff are required to complete 16 hours of continuing education a year in courses approved by the department covering but not limited to: Working with the elderly; working with residents with Alzheimer's disease; working with the mentally retarded, mentally ill and developmentally disabled; social and recreational activities; legal issues; physical maintenance and fire safety; housekeeping; or topics as needed or determined by the department.

Background Check

All employees must obtain a satisfactory criminal records check determination from the Department. The Administrator and on-site manager must obtain a satisfactory fingerprint records check determination from the Department.

Monitoring

The Office of Regulatory Services (ORS) investigates complaints and the Division of Public Health conducts an annual inspection. Inspections may be conducted on an announced and unannounced basis. ORS is planning to hire 14 new staff in order to conduct annual reviews.

Hawaii

Citation

Assisted living facilities. (Draft) Hawaii Administrative Rules §11-90-1 et seq.

Adult residential care homes (Draft) Hawaii Administrative Rules §11-101-1 et seq.

General Approach

The Department of Health has developed proposed rules for a new assisted living category and revised rules for adult residential care homes. In 1994, a multi-member task force was created by House Concurrent Resolution 377 to make recommendations concerning assisted living and to explore the use of Medicaid waivers to support low income residents in assisted living. The report was issued in December 1994 and recommended that the Department of Health be authorized to develop regulations to establish an assisted living program. Members of the task force made site visits to facilities in Oregon and Washington. Legislation authorizing the development of assisted living regulations was passed in April, 1995. The draft regulations are expected to be finalized in 1998.

Definition

Assisted living facility means a facility as defined in §321-15.1, HRS. The facility is a building complex offering dwelling units to individuals and services to allow residents to maintain an independent assisted living lifestyle. The environment of assisted living is one in which meals are provided, staff are available on a 24-hour basis and services are based on the individual needs of each resident. Each resident, family member, and others work together with the facility staff to assess what is needed to support the resident in his or her greatest capacity for living independently. The facility is designed to maximize the independence and self-esteem of limited-mobility persons who feel that they are no longer able to live on their own.

Assisted living means encouraging and supporting individuals to live independently and receive services and assistance to maintain independence. All individuals have the right to live independently with respect for their privacy and dignity, fee from restraints.

Adult residential care facility means any facility providing 24-hourliving accommodations, for a fee, to adults unrelated to the family, who require at least minimal assistance in ADLs, but who do not need the services of an intermediate care facility. There are two types of homes. Type I homes serve five or fewer residents and Type II serve six or more residents. Adult residential care homes may obtain an extended care license to serve a limited number of residents who meet the nursing home level of care.

Unit

Assisted living The draft rules require apartment units with a bathroom, refrigerator and cooking capacity, including a sink and a minimum of 220 square feet, not including the bathroom (sink, shower and toilet). The cooking capacity may be removed or disconnected depending on the needs of the resident. Other requirements include wiring for phone and television, a private accessible mail box and a call system monitored 24 hours by staff.

Adult residential care homes The current rules require that single rooms have 90 square feet and multiple occupancy rooms 70 square feet per occupant. One toilet is required for every eight residents, one shower for every 14 residents and one lavatory for every 10 residents.

Tenant Policy

Assisted living facility Each facility must develop admission policies and procedures which support the principles of dignity and choice. The policies include a listing of services available, the base rates, services included in the base rates, services not provided but which may be coordinated and a service plan and contract. Facilities must also develop discharge policies and procedures which allow 14 days notice for behavior, other needs that exceed the facility's ability to meet or the resident's established pattern of non-compliance. The rules do not specify who may be admitted and retained. Rather, each facility may use its professional judgement and the capacity and expertise of the staff in determining who may be served.

Adult residential care homes Homes without an extended care license may not serve residents needing nursing home care. Type I extended care homes may serve no more than two residents qualifying for nursing home care and Type II homes may serve no more than 10% of its residents needing this level of care.

Services

Assisted living facilities shall provide awake, 24-hour on-site staff, three dietician approved meals a day, laundry services, opportunities for individual and group socialization, services to assist with ADLs, nursing assessment and health monitoring, housekeeping, medication administration and services for residents with behavior problems (staff support, intervention and supervision), and recreational and social activities. Facilities must also arrange or provide transportation, ancillary services for medically related care (physician, pharmacist, therapy, podiatry), barber/beauty care, hospice, home health and other services.

Service agreements are developed using negotiated risk principles.

Financing

The report suggested that land policies should be reviewed and modification of zoning requirements made to allow existing housing stock to be used. State loans and bonds would be made available to at favorable interest rates to stimulate development. The report recommended consideration of providing a higher level of service in residential care facilities as a means of maximizing existing buildings to meet new needs. A resolution passed the legislature directing the Medicaid Agency to study the feasibility of using a Medicaid Home and Community Based Services Waiver to finance services.

Medication

Assisted living facilities The draft rules allow assistance with self-administration and administration of medication as allowed under the nurse practice act.

Staffing

Assisted living facilities must have licensed nursing staff available seven days a week to meet care management and monitoring needs of residents.

Adult residential care homes Licensees must submit a plan showing how they will obtain a registered nurse and case manager. Sufficient staff must be on duty 24-hours a day to meet resident needs.

Training

Assisted living facilities

Administrators The administrator/director must have two years experience in the health and social services field and show evidence of having completed an assisted living facility administrator's course acceptable to the Department.

All staff shall be trained in CPR and first aid. The facility shall have written policies and procedures which incorporate the assisted living principles of individuality, independence, dignity, privacy, choice and home-like environment. In-service education consists of an orientation for all new employees to acquaint them with the philosophy, organization, practice and goals of assisted living; and ongoing in-service training on a regularly scheduled basis (minimum of six hours annually).

Adult residential care homes A registered nurse must train and monitor primary caregivers.

Background Check

Assisted living facilities Licensure may be denied for convictions in a court of law or substantiated findings of abuse, neglect or misappropriation of resident funds or property.

Adult residential care homes All staff, including the licensee must have no history of confirmed abuse, neglect or misappropriation of funds.

Monitoring

Assisted living facilities The rules require biannual inspection and license renewal.

Fees

Fees will be established by the Department of Health.

Idaho

Citation

Residential Care Facilities. Idaho code § 39-3301 et seq., Idaho Administrative Rules Title 3, Chapter 22., § 70 et seq.

General Approach

The Governor's long term care policy statement includes the following:

"amending the current federal waiver and make changes to state law and rules necessary to create a system of long-term care for elderly or disabled adults. Such a system will allow for the provision of client- or family-directed services whenever possible and for the provision of services in the least restrictive, most cost-effective setting (including assisted living, personal care, and other community-based services).

In 1996, the legislature passed HB 742 which made changes in the state's residential care facility rules. Regulations implementing the law are being developed. Medicaid is considering adding assisted living as a covered service under the HCBS waiver, however legislation has not passed to authorize coverage.

A task force has been to make further recommendations and a report is expected to be issued in 1999.

The supply of RCFS has increased from 175 facilities and 3,500 beds in 1996 to 227 and 4,902 in 1998.

Definition

Residential care facility means one or more buildings constituting a facility or residence, however named, operated on either a profit or nonprofit basis, for the purpose of providing 24hour non-medical care for three or more persons, not related to the owner, eighteen years of age or older, who need personal care or assistance and supervision essential for sustaining activities of daily living or for the protection of the individual.

Specialized care units/facilities for Alzheimer's/dementia residents "are specifically designed, dedicated, and operated to provide the elderly individual with chronic confusion, or dementing illness, or both, with the maximum potential to reside in an unrestrictive environment through the provision of a supervised life-style which is safe, secure, structured but flexible, stress free and encourages physical activity through a well developed activity and recreational program. The program constantly strives to enable residents to maintain the highest practicable physical, mental or psychosocial well-being."

Facilities operating without a license may be subject to six months in jail and fines up to $5,000.

Unit Requirements

Facilities licensed before July 1, 1991 must not have more than four residents per bedroom, and new facilities or conversions licensed after July 1, 1992 must not have more than two residents in each bedroom. Facilities that have been continuously licensed since before May 9, 1977 must have 75 square feet of floor space per single bed rooms and 60 square feet per resident in multi-bed rooms. Facilities licensed after May 9, 1977 must have 100 square feet of floor space per single bed rooms and 80 square feet per resident in multi-bed rooms. There must be at least one toilet for every six persons, residents or employees, and at least one tub or shower for every eight persons, residents or employees.

Tenant Policy

There are three levels of care to which a resident may be assigned: minimal assistance, moderate assistance, and maximum assistance. See table.

LEVELS OF CARE
Level I Minimum Assistance	Level II Moderate Assistance	Level III Maximum Assistance
Resident requires room, board, and supervision, and requires only verbal prompting to function independently in ADLs, is independently mobile, is capable of self preservation, and does not require medication management or supervision.	Resident requires room, board, and supervision, and requires both verbal prompting and some physical assistance with ADLs, mobility (such as transferring, climbing stairs and walking), self preservation, medication management, and behavior management.	Resident requires room, board, and supervision, and requires staff up and awake on a 24-hour basis and may require extensive hands on assistance with ADLs, non-medical personal assistance needs, mobility such that the person may be immobile without assistance, self preservation, medications such that the person needs extensive assistance with the self-administration of medications, or extensive behavior management for antisocial and aggressive behavior.

Residents may not be admitted or retained if they require ongoing skilled nursing, intermediate care or care not within the legally licensed authority of the facility for the elderly. Residents may not be admitted or retained who are unable to feed themselves; are bedfast; need nursing judgment for an ongoing unstable health condition; have decubitus ulcers or open wounds; need the ongoing technical or professional personnel to appropriately evaluate, plan and deliver resident care; are beyond the level of fire safety provided by the facility; have physical, emotional, or social needs that are not homogenous with other residents in the home; or who are violent or a danger to themselves or others. Residents who need ongoing 24-hour nursing care must be discharged. Residents who need 24-hour care for a short time for an acute condition may be retained.

Residents of specialized care units for Alzheimer's disease must be evaluated by their primary care physician for the appropriateness of placement into the unlocked specialized care unit/facility prior to admission. No resident shall be admitted to these units without a diagnosis of Alzheimer's disease or related disorder. Residents must be at a stage in their disease such that only periodic professional observation and evaluation is required. Residents in these units must be re-evaluated quarterly. No resident shall be admitted who requires physical or chemical restraints.

Services

Services include assistance with activities of daily living, arrangements for medical and dental services, provisions for trips to social functions, recreational activities, maintenance of self-help skills, special diets, arrangement for payments and medication management. A licensed nurse must visit the facility at least once a month to conduct a nursing assessment of each resident's response to medications and to assure that the medication orders are current. The nurse also assesses the health status of each resident and makes recommendations to the administrator regarding any needs.

Services in specialized care units for Alzheimer's disease include habilitation services, activity program and behavior management according to the individualized plan of care.

A uniform assessment and a negotiated service agreement must be used with residents. New rules will address qualifications of assessors, state responsibilities for public clients, time frames for completing assessments and the information to be included. The negotiated service agreement is based on the assessment and provides for coordination of services and guidance of staff. Residents shall be given the choice and control of how and what services the facility, or external vendor, will provide to the extent the resident can make choices.

Financing

Currently, residential care homes are reimbursed privately and through a state fund. The highest reimbursement rate from the state fund is $800, and the private pay rate is generally $900 to $1200. The SSI rate in Idaho in about $500.

Staffing

Facilities must have sufficient staff to serve residents in keeping with negotiated service plans. At least one staff member must be immediately available to residents at all times. Facilities admitting level III residents must have a minimum of one awake staff during sleeping hours. Waivers may be sought by small facilities.

Training

Administrators must have a valid residential care administrator's license. Personnel must be given an orientation to the facility and participate in a continuing training program developed by the facility.

Staff Orientation training. Each facility shall develop an orientation program including, but not be limited to: job responsibilities; resident rights; operational procedures; disaster preparedness; fire safety, fire extinguisher and smoke alarms; assisting residents with medications; first aid and CPR; policies and procedures; complaint investigations and survey procedures; emergency procedures; employee dress code; house keeping and proper sanitation procedures; infection control; grievance procedures; work schedules, holidays and paydays; recognizing indications of illness, change in condition, and the need for professional help including facility documentation procedures; living skills training; death, dying and the grieving process; risk management; behavior management techniques and documentation; the aging process for facilities admitting elderly residents; mental illness, facilities admitting residents with mental illness; developmental disabilities, for facilities admitting residents with a developmental disability; and other topics as outlined by the administrator.

A minimum of eight hours of job-related pre-service orientation training shall be provided to all new employees, upon being hired, who are to provide personal assistance to the resident upon being hired

Continuing training. An ongoing, planned, and written continuing training program which maintains and upgrades the knowledge, skills and abilities of the staff in relation to services provided and employee responsibilities shall be provided to employees at least every six month, to include, but not be limited to, the orientation training program as required above.

Each employee, providing personal assistance to residents, shall receive a minimum of 16 hours of job related continuing training per year.

Alzheimer's/Dementia Facilities

Staff in specialized care units for Alzheimer's/dementia residents must complete an orientation/continuing training program that includes information on Alzheimer's and dementia, symptoms and behaviors of memory impaired people, communication with memory impaired people, resident's adjustment, inappropriate and problem behavior of residents and appropriate staff response, activities of daily living for special care unit residents, and stress reduction for special care unit staff and residents. Staff must have at least six additional hours of orientation training, and four hours of the required twelve hours per year of continuing education must be in the provision of services to persons with Alzheimer's disease.

Background Check

Applicants for licensure must submit a criminal history clearance as described in IDHW rules title 05, Chapter 06 and a notarized set of fingerprints.

Monitoring

With the exception of the initial surveys for licensure, all inspections and investigations shall be made unannounced and without prior notice. Inspections are conducted at least annually.

Inspections entail reviews of the quality of care and service delivery, resident records, and other items relating to the running of the facility. If deficiencies are found, then plans of correction are made and follow-up surveys are conducted to determine if corrections have been made. Complaints against the facility are investigated by the licensing agency. A complainant's name or identifying characteristics may not be made public unless "the complainant consents in writing to the disclosure; the investigation results in a judicial proceeding and disclosure is ordered by the court; or the disclosure is essential to the investigation. The complainant shall be given the opportunity to withdraw the complaint before disclosure."

Inspections of specialized care units for Alzheimer's disease are conducted by the licensing agency with participation from the Regional Department staff who have program knowledge of and experience with the type of residents to be served and the proposed program offered by the facility. Facilities that are specialized or have specialized care units must submit a synopsis of the program of care to be offered by the unit/facility.

Enforcement options include ban on admissions, civil monetary penalties, appointment of temporary management, suspension or revocation of the license, transfer of residents, and other remedies.

Illinois

Citation

Shelter care facility 77 IAC 330 et seq.

Supported residential living Title 89, Chapter I, Subchapter d, Part 146

Community based residential facilities Public Act 89-530. 89 IAC Chapter II, §280

General Approach

The legislature has approved two assisted living projects. A "supportive living" facility model has been developed by the Department of Public Aid for Medicaid beneficiaries who are frail elderly or have disabilities and need assistance with activities of daily living. It targets lighter need nursing facility residents who are unable to remain in their homes. A supportive living facility (SLF) may be converted nursing home units or free standing buildings that integrate housing, health, personal care and supportive services in home-like residential settings. The program is consistent with the definition of assisted living used by the federal 1915 c Medicaid Home and Community Based Services Waiver program.

The SLF program was developed with the assistance of advisory groups composed of members of the nursing home industry, advocates, consumers, long term care experts and the aging network. A request for proposals was issued in October 1997. Bids were received for a total of 1486 units. Two bids were received from nursing homes seeking to create 46 units. The approved waiver can serve up to 750 Medicaid residents the first year, 1,750 Medicaid residents in the second year and 2,750 Medicaid residents in the third year.

The Department on Aging is testing a Community Based Residential Facilities service model. Services will be reimbursed as home care services through the Medicaid Home and Community Based Services Waiver or state funds. The pilot may include three facilities and serve no more than 360 people. The authorizing statute allows the programs to serve people with short or long term needs as a means of relieving family caregivers. Projects may offer, directly or through contract, services that preclude admission to a nursing home. Sites that continue to be in compliance with the demonstration project rules will be eligible for annual renewals "until an assisted living or similar licensure model is established by legislation." Two facilities have been selected, including an Alzheimer's care facility. The Department may contract with a third program involving a nursing home seeking to convert its facility. If no applicant is forthcoming, another housing setting can be chosen.

Definition

Shelter care facility means a facility licensed under the nursing home care act that provide maintenance and personal care but does not provide routine nursing care.

Supportive living facility (SLF) means a residential setting that provides or coordinates flexible personal care services, 24-hour supervision and assistance (scheduled and unscheduled), activities and health related services with a service program and physical environment designed to minimize the need for residents to move within or from the setting to accommodate changing needs and preferences; has an organized mission, service programs and a physical environment designed to maximize residents' dignity, autonomy, privacy and independence; and encourages family and community involvement.

Community Based Residential Facilities (CBRFs) provide care that combines housing, personal and health-related services in response to the individual needs of those who need help in ADLs and IADLs. Supportive and intermittent health-related services are available 24 hours per day, if needed, to meet scheduled and unscheduled needs, in a way that promotes self-direction and participation in decisions that emphasize independence, individuality, privacy and dignity in a residential surrounding. A CBRF provides sleeping accommodations to three or more unrelated adults.

Units

Shelter care facility No more than four persons may share a room. Single rooms must be 70 square feet and multiple occupancy rooms, 60 square feet per person. One lavatory is required for every 10 residents and one shower/bath is required for every 15 residents. A lavatory and shower/bath is required on each floor.

SLF To participate in the DPA program, facilities must have not less than 10 and no more than 150 apartments. Freestanding sites must provide apartments with 350 square feet of living space, including closets and bathroom. Apartments for individuals wishing to share the unit must have 500 square feet of living space, including closets and bathroom. Units must have a full bathroom, lockable doors, emergency call system, heating and cooling controls, wiring for private telephone, access to cable television or satellite dish, a sink, microwave oven or stove, refrigerator. Fifty percent of all apartments in a facility must have showers only (no bath tub) with non-skid surfaces and hand held shower heads. Nursing homes converting a portion of a facility must offer apartments with 160 square feet for single occupancy and 320 square feet if two people want to share a unit. Free standing sites must provide apartments with at least 350 square feet of living space for single occupancy. Participants willing to share an apartment must have no less 500 square feet.

CBRFs The Department on Aging's pilot does not include specifications for the living unit, and rather, expect that market forces will determine what is developed.

Tenant Policy

Shelter care facility No resident needing nursing care may be admitted or retained. Persons who have a communicable disease or are mentally ill, need treatment for mental illness, are likely to harm others, or is destructive of property or himself may not be admitted or retained.

CBRFs must execute a written contract with the tenant.

SLFs may serve frail elderly or disabled residents over age 22 who have been screened and determined to meet the nursing facility level of care criteria. Residents may be discharged if they are a danger to self or others or have needs that cannot be met by the SLF. The SLF must develop a service plan and execute a written contract with each resident that includes services the resident will receive and other terms of the agreement.

Services

Shelter care facility may provide personal care, group and individual activities, assistance with self administration of medications or administration by a physician or licensed nurse.

CBRFs must provide meals, routine housekeeping, security, emergency response system, and laundry services. One or more of the following services must be provided directly or through contract: personal care, medication management, money management and intermittent health services (medication administration, dressing changes, catheter care, therapies, and other medical, nursing or rehabilitative care provided by licensed personnel). They may, but are not required to, provide transportation, health assessment, counseling or social/educational activities.

SLFs must provide a combination of housing, personal care, health and supportive services that promote autonomy, dignity and quality of life and respond to the individual needs of residents. Room and board includes three meals per day. Services include nursing services, personal care, medication oversight and assistance in self-administration, housekeeping services, laundry service, social and recreational programs, 24-hour response/security staff, emergency call systems, health promotion and referral, exercise, transportation and maintenance services. Nursing services include completion of a resident assessment and service plan, a quarterly health status evaluation, administration of medication when residents are temporarily unable to self-administer, medication set up, health counseling and teaching self care in meeting routine and special health needs, and disease prevention. Facilities are expected, when possible, to involve family members in service planning. Residents must be assessed within 24-hours of admission and updated at least annually.

Reimbursement

SLF For Medicaid residents, participating facilities must be willing to accept the SSI rate, which is currently $494 a month less a $90 personal needs allowance, as payment for room and board. For Medicaid covered services, bidders will submit a proposed rate that may not exceed 75% of average nursing facility rate less the average amount contributed by residents. Residents may be eligible to receive food stamps and facilities may be certified as eligible vendors.

CBRFs are reimbursed based on an assessment score called a "determination of need." There are categories ranging from $236 to $1598 a month. Participants pay a share of the service costs based on their DON score and income.

Staffing

Shelter care facility Facilities must have staffing patterns that are sufficient to meet the needs of residents. At least one awake staff member is required.

SLFs must provide licensed and certified staff that are sufficient to meet the needs of residents in conjunction with contractual agreements. Personal care services and assistance with self-administration of medications must be provided by certified nurse assistants. SLFs must contract with a dietician.

CBRFs must provide sufficient staff, and maintain appropriate back up staff, to provide services.

Training

Shelter care facility
Administrators The administrator shall arrange for facility supervisory personnel to annually attend appropriate education programs on supervision, nutrition and other pertinent subjects.

Staff There shall be an ongoing planned in-service program embracing orientation to the facility and its policies, skill training and ongoing education carried out to enable all personnel to perform their duties effectively. Written records of program content and personnel attending shall be kept.

SLF
Administrators must have at least five years experience in providing health care services in assisted living settings, inpatient hospital, long term care setting, adult day care or in a related field. The manager also must have at least two years of progressive management experience.

Staff shall receive documented training by qualified individuals in their area(s) of responsibility prior to employment and semi-annual training thereafter. Nurses assistants must be certified or are enrolled in and pursuing certification. A trained staff person must be responsible for planning and directing social and recreation activities. Nurses must be licensed. Twenty-four hour response staff must be certified in emergency resuscitation.

CBRFs must provide 15 hours of initial training and three hours in-service training per calendar quarter for homemakers.

Monitoring

SLF Participating facilities will be Medicaid certified and monitored, at least annually, by DPA. Monitoring includes contract requirements, resident autonomy, resident rights, adequacy of service provision, quality assurance process, safety of the environment, program policies and procedures, information provided to low income residents, review of resident assessment and service plans, resident satisfaction surveys, check in system and food service.

Facilities must have a grievance process and a quality assurance process. Complaints may be heard informally. If not resolved or if the resident prefers, grievances may be submitted through the facility's formal process. Residents may use the Medicaid appeals process for denial or delay of service.

Internal quality assurance procedures must encompass resident satisfaction, oversight and monitoring, peer review, utilization review, procedures for preventing, detecting and reporting resident neglect and abuse and ongoing quality improvement. The committee must establish review schedules, objectives for improving service quality, including quality indicators and measures, and a mechanism for tracking improvements based on care outcomes. A system with outcome indicators must be developed that measures: quality of services; residents' rating of services; cleanliness and furnishing in common areas; service availability and adequacy of service provision and coordination; provision of a safe environment; socialization activities; and resident autonomy.

Background Check

State legislation passed during the spring of 1998 prohibits SLFs from knowingly hiring, employing or retaining any individual in a position with duties involving direct care for residents who has been convicted or committing or attempting to commit designated criminal offenses, unless a waiver as been granted by the Illinois Department of Public Health. Further, the legislation requires SLFs to check the Certified Nurse Aid Registry in the state and ensure that appropriate background criminal history record checks are initiated or have been conducted.

Indiana

Citation

Assisted living: House Enrolled Act 1630 (1997)

Residential care facilities: 410 IAC 16.2 et seq.

General Approach

The state has not adopted legislation or administrative rules governing assisted living at this time although state agencies are investigating options for regulating and reimbursing assisted living.

In 1996, the Family and Social Services Administration completed a study of assisted living and made recommendations in response to a Concurrent Resolution adopted by the legislature. In 1997, HB 1630 directed a legislative committee, the Health Finance Committee, to develop recommendations concerning licensing of assisted living. The recommendations were based on the principles of promoting resident choice, dignity, privacy, autonomy, independence and encouraging aging-in-place. The recommendations included a definition and minimum requirements for living units. HB 1630 also directed the Indiana State Department of Health to identify, contact and survey all facilities that market, advertise or identify themselves as assisted living. The survey was to determine the number and type of units, services provided, manner of service provision and the steps taken to provide for choice, dignity, privacy, autonomy, independence and aging-in-place. The survey was completed in November 1997.

HB 1630 also directed the Community Home Options to Institutional Care for the Elderly and Disabled (CHOICE) Board, which advises the Division of Disability, Aging and Rehabilitative Services, to establish long term care goals for the state that include an array of services, including assisted living, and to recommend legislation, policies and rules to implement a system and other items. The CHOICE Board adopted a vision statement, goals and objectives on September 23, 1997 which included assisted living licensure and coverage under Medicaid. The Board forwarded the recommendations on assisted living to the Health Finance Commission in August 1997.

A disclosure bill (SB 436) passed during the 1998 legislative session. The bill requires that all housing with services establishments complete a disclosure form and send the form along with a copy of the resident contract to the Division of Disability, Aging and Rehabilitation Services. An establishment may not use the term "assisted living" if it has not filed a disclosure form. The bill also lists specific information that must be included in the resident contract. This requirement goes into effect September 1, 1998. The form includes the following information: the name and address of the owner and managing agent, description of services provided and the base rate, resident contracts, additional services available and their fees, the resident contact, the process for modifying and terminating the contract, description of the complaint resolution process and criteria for determining who may continue to reside in the establishment.

A housing with service establishment is defined as an establishment providing sleeping accommodations to at least five residents and offering or providing for a fee at least one regularly scheduled health related service or at least regularly scheduled supportive services. Health related services means attendant and personal care services, professional nursing services and central storage of medications. Supportive services means personal laundry, handling or assisting with personal funds, arranging for medical services, health related services or social services.

The following summaries describe the assisted living recommendations and the current licensing requirements for residential care facilities. None of the assisted living recommendations have been adopted as yet by the legislature.

Philosophy

Assisted living must be driven by a philosophy of service that emphasizes choice, personal dignity, autonomy, independence, and privacy. It should enhance a person's ability to age-in- place in a homelike setting while services intensify or diminish as the individual's needs change.

Definition

Assisted living recommendation Assisted living provides, coordinates or arranges activities; personal and health related services; 24-hour supervision and assistance (scheduled and unscheduled) in a homelike setting; minimizes the need to move; accommodates changing needs and preferences; maximizes choice, dignity, autonomy, privacy and independence; meets federal, state and local requirements accommodates multiple funding options and encourages family and community involvement.

Residential care facilities Residential care facility means a facility that provides room, food, laundry and occasional assistance in daily living for residents who need less services than the degree of service provided by a comprehensive care facility (nursing home). There is an overall general supervision of health care, medications and diets as defined in the written policies of the facility.

Units

Assisted living recommendation Living units should include an opportunity for single occupancy, except at the request of the resident. Each unit should include a sleeping area, a living area, an accessible bathroom and a kitchenette. The kitchenette should include an area for hot and cold food preparation, sink, storage, and appliances that can be removed or disabled. There should be minimum square footage requirements, resident controlled climate controls, lockable doors, emergency call system, telephone jacks, common areas, including physical fitness options and meal service.

Residential care facilities Rules require 100 square feet for single rooms and 80 square feet per bed for multiple occupancy. No more than four people may share a room. One toilet and sink is required for every eight residents.

Tenant Policy

Assisted living recommendation Facilities should not establish restrictive occupancy policies except for people needing 24-hour skilled nursing supervision for an extended period of time. All components of the contract should be specific and clearly defined.

Residential care facilities The rules do not allow anyone needing nursing care to be admitted or retained. Residents may need only occasional assistance with activities of daily living.

Services

Assisted living recommendation Services should include housekeeping, congregate dining, assistance with ADLs and medication administration and reminders. Each resident should have a care plan which is updated regularly and negotiated risk agreements should be developed when indicated. Service provisions should not inhibit services provided through Medicare and Medicaid.

Residential care facilities Personal care, supervision of nutritional status, assistance with self-administration of medications or administration by qualified personnel are allowed services. The rules state that "each resident shall be assisted in or occasionally given personal care as needed."

Reimbursement

Assisted living recommendation The report recommends coverage through a Medicaid waiver that allows residents to retain sufficient income to cover the room and board costs (eg., 300% optional eligibility category). This would not preclude use of other publicly funded programs.

Medications

Residential care facilities Medications may be administered under physician's order by licensed nursing personnel or qualified medication aids. Other treatments may be given by nurses aides upon delegation by licensed nursing personnel.

Staffing

Assisted living recommendation Twenty four hour staffing should be required. Administrators should be licensed and initial and annual training should be required for all staff. Medical oversight should be provided by licensed nurses.

Residential care facilities Sufficient staff must be on duty to assure adequate care. At least one staff member must be on duty at all times in facilities with less than 100 residents and one additional staff member for every 50 residents in facilities with over 100 residents.

Training

Residential care facilities Administrators must be licensed.

Staff Prior to working independently, each employee shall be given an orientation of the facility by the supervisor. Orientation of all employees shall include:

Instructions on the needs of the specialized populations served in the facility;
A review of the facility's policy manual and applicable procedures including organizational chart, personnel policies, appearance and grooming and resident rights;
Instructions in first aid, emergency procedures and fire and disaster preparedness, including evacuation procedures;
A detailed review of the appropriate job description, including a demonstration of equipment and procedures required of the specific position to which the employee will be assigned;
Review of ethical considerations and confidentiality in resident care and records;
For direct care staff, personal introduction to and instruction in, the particular needs of each resident to whom the employee will be providing care; and
Documentation of orientation in the employee's personnel record.

Direct care staff must complete nurse aid training. The training program may be established by the facility and training must commence within 60 days of employment. Training includes:

30 hours of classroom instruction including orientation to the facility, policies, duties, basic nursing skills, clinical practice, resident safety and rights, and the social and psychological problems of residents; and
75 hours of supervised training under supervision of a licensed nurse.

An ongoing in-service training that includes prevention and control of infection, fire prevention, safety and accident prevention and the needs of the specialized populations is also required. In-service training programs shall contain means to assess learning by participants. These may include testing such as self-graded, before and after tests, clinical practice sessions under supervision, instructor assessment, etc. Monthly in-service training shall be conducted for nursing staff. In addition, for personnel administering medications, no less than eight programs on medication administration shall be offered per year.

Monitoring

Assisted living recommendation A quality assurance/improvement process that covers resident satisfaction, education, choice of providers and quality service should be developed. Residents who are Medicaid beneficiaries would be assessed through the preadmission screening program (a requirement for waiver services) and receive ongoing case management through an Area Agency on Aging or other appropriate agency.

Iowa

Citation

Assisted living programs Iowa Code 231C and 321 IAC Chapter 27; IAC 661--5.626 Assisted Living Housing (Life Safety)

Residential care facilities IAC Chapter 57 and Chapter 60.

Related Codes that affect but do not specifically reference assisted living: 655 IAC Chapter 6 Nurse Practice; 645 IAC Chapter 63 - Salons; Iowa Code Chapter 155A - Pharmacy; 481 IAC Chapters 30 & 32 - Food Service Establishments

General Approach

Legislation passed in 1996 created a certification process for assisted living. Regulations were effective in 1997 implementing the new category. The law allows acceptance of accreditation from other organizations but developed its own process for facilities that might not be able to afford the associated fees. Programs are certified for two years. Those with above standard or exemplary operations may be certified for three or four years.

Residential care facilities provide protective supervision and minimal assistance with ADLs to people with mental retardation or chronic mental illness.

Definition

96 Acts, Chapter 1192 "Assisted living means provision of housing with services which may include but are not limited to health related care, personal care and assistance with instrumental activities of daily living to six or more tenants in a physical structure which provides a home-like environment. Assisted living also includes encouragement of family involvement, tenant self-direction, and tenant participation in decisions that emphasize choice, dignity, privacy, individuality, shared risk and independence. Assisted living does not include the provision of housing and assistance with instrumental activities of daily living which does not also include provision of personal care or health related care."

Unit Requirements

Assisted living programs may have private dwelling units with lockable doors and individual cooking facilities. Each dwelling unit must have at least one room with not less than 120 square feet of floor area. Other habitable rooms must have at least 70 square feet. Each dwelling unit must have at least 190 square feet of floor area, excluding bathrooms. Units used for double occupancy must have at least 290 square feet, excluding bathrooms.

Tenant Policy

Programs may not admit or retain tenants who require more than part time or intermittent health related care, are dangerous to self or others, are in an acute stage of alcoholism, drug addiction or mental illness, under 18 or who meet the program's transfer criteria. Exceptions may be sought for tenants who need more than part time or intermittent health care. Managed risk statements must be used. An occupancy agreement must be signed with each tenant that describes the rights and responsibilities of the tenant and the provider, fees, charges and rates, the services covered, and occupancy and transfer criteria. It also describes the program's staffing policy, whether or not staff are available 24-hours a day, whether delegation will be used and how staffing will be adapted to meet changing needs.

Services

Programs must provide some personal care or health related services and at least one meal a day must be provided. Health related services means less than daily skilled nursing services and professional therapies for temporary but not indefinite periods of time of up to 21 days a month. Skilled services and therapies combined with personal care and nurse delegated activities may not total more than eight hours a day. Service plans must be developed for each tenant and plans for tenants needing personal care or health related services must be developed by a multidisciplinary team.

Financing

Certified or accredited assisted living programs may be providers of Medicaid home and community based waiver services. About 60%, or 18, of the programs have committed to provide Medicaid waiver covered services. Services are reimbursed on a fee for services basis according to the care plan.

Medication

Written medication plans are required. Medications may be administered in accordance with state rules governing administration.

Staffing

Programs administering medications or providing health related services must provide for a registered nurse to monitor medications, ensure physician orders are current (30 days) and assess and monitor health status (90 days). Sufficient staff are required to meet tenant needs. Each program must provide access to a 24-hour emergency response system.

Training

Administrators The owner or sponsor of the assisted living program is responsible for ensuring that both management and direct service employees receive training appropriate to the task.

Staff The assisted living program shall have a training and staffing plan on file and shall maintain documentation of training received by staff. All personnel of the assisted living program shall be able to implement the assisted living program's accident, fire safety and emergency procedures.

Monitoring

Programs are monitored at least once during the certification period and on complaint.

Residential Care Facilities

A maximum of four people may share rooms providing 80 square feet per bed. Services include personal care, assistance with self-administration and administration of medications by qualified staff. Residents may be admitted if a physician signs a statement that the resident requires no more than personal care and supervision but does not require nursing care. Medications may be administered by approved registered nurses who have passed a medication administration course.

Kansas

Citation

Assisted living §28-39-144 et seq.

General Approach

The Kansas legislature passed a law creating an assisted living licensure category in 1995. The law created an overall framework of adult care homes which includes nursing facilities, nursing facility for mental health, intermediate care facility for the mentally retarded, assisted living facility, residential health care facility, home plus, boarding care home and adult day care facility. The regulations were effective 3/1/97 and differentiate among the categories of adult care homes. By March 1998, 66 assisted living facilities with a total of 3,510 units have been licensed. Thirty eight nursing home with 952 beds have converted to assisted living facilities. The regulations are being reviewed and refinements may be issued by the end of 1998.

A 1915(c) waiver to include assisted living and residential care facilities as providers of waiver services has been approved.

Definition

"Assisted living facility" means any place or facility caring for six or more individuals not related within the third degree of relationship to the administrator, operator or owner by blood or marriage and who, by choice or due to functional impairments, may need personal care and may need supervised nursing care to compensate for activities of daily living limitations and in which the place or facility includes apartments for residents and provides or coordinates a range of services including personal care or supervised nursing care available 24-hours a day, seven days a week for the support of resident independence. The provision of skilled nursing procedures to a resident in an assisted living facility is not prohibited by this act. Generally, the skilled services provided in an assisted living facility shall be provided on an intermittent or limited term basis, or if limited in scope, on a regular basis.

The rules provide that the administrator or operator of facilities ensure that written policies and procedures are developed and implemented which incorporate the principles of individuality, autonomy, dignity, choice, privacy and a home-like environment.

Unit Requirements

Each facility must offer apartments which include areas for sleeping, living, storage, kitchen (with sink, refrigerator, stove or microwave and space for storage of utensils and supplies) and bathroom. At least 200 square feet of living space, excluding bathroom, closets, lockers wardrobes, other built-in fixed items, alcoves and vestibules. Facilities licensed prior to January 1, 1995 as an intermediate personal care facility are not required to offer kitchens and private baths.

Tenant Policy

Each facility develops admission, transfer and discharge policies which protect the rights of residents. Facilities may not admit or retain people with the following conditions unless the negotiated service agreement includes hospice or family support services which are available 24 hours a day or similar resources:

Incontinence where the resident cannot or will not participate in management of the problem;
Immobility requiring total assistance in exiting the building;
Any ongoing condition requiring two person transfer;
Any ongoing skilled nursing intervention needed 24 hours a day for an extended period of time; or
Any behavioral symptom that exceeds manageability.

Services

Facilities must develop a negotiated service agreement with each resident in collaboration with the resident, the resident's legal representative, family, if agreed to by the resident, or case manager. The agreement describes the services to be provided, the provider of service, and the parties responsible for payment when services are provided by an outside agency. The agreement supports the dignity, privacy, choice, individuality and autonomy of the resident. The agreement is reviewed at least annually or when requested by any of the participating parties.

Services may include meals, health care services based on an assessment by a licensed nurse, housekeeping, medical, dental and social transportation, and other services necessary to support to health and safety of the resident. Health care services include personal care, supervised nursing care, and wellness and health monitoring. The service agreement contains the skilled nursing services to be provided and the licensed person or agency providing services.

The Medicaid waiver includes assisted living facilities as a provider of respite and health care attendant services. The services covered by the waiver include respite care, sleep cycle support, health care attendant (Level I and Level II), adult day care and wellness monitoring. Sleep cycle support means "non-nursing physical assistance and supervision during the consumer's normal sleeping hours in the consumer's place of residence, excluding nursing facilities" and includes "physical assistance or supervision with toileting, transferring and mobility, prompting and reminding of medication."

Health care attendant "provides physical assistance with activities of daily living and instrumental activities of daily living for individuals who are unable to perform one or more activities independently. IADLs, excluding medication management or medication administration, may be performed without nurse supervision. These services are limited to 12 hours a day.

Level I activities include assistance with ADLs and IADLs (bathing, grooming, toileting, transferring, feeding, mobility, accompanying to obtain necessary medical services, shopping, house cleaning, meal preparation, laundry and life management).

Level II activities are health maintenance activities and include monitoring vital signs, supervision and/or training of nursing procedures, ostomy care, catheter care, enteral nutrition, medication administration/assistance, wound care, range of motion and reporting changes in function or condition. These services must be authorized by a physician or a nurse.

Reimbursement

Medicaid waiver services are available to elderly recipients who meet the nursing home level of care criteria and have income below 300% of the federal SSI payment. Rather than a flat per diem, payments are made to assisted living facilities as a provider of home and community based services. The amount of payment is based on the development of an individual care plan by a case manager. Services based on the care plan are billed fee for service. The maximum rate for health care attendant services is $12.00 per hour for Level I tasks and $13.25 per hour for Level II tasks. Care plans requiring a mix of both levels are reimbursed at the Level II rate.

Medications

Appropriate facility staff may assist with self-administration and administer medications.

Staffing

Sufficient numbers of qualified personnel must be available to ensure that residents receive services in accordance with negotiated service agreements.

Training

Administrator The licensee shall appoint an administrator or operator who holds a Kansas license as an adult care home administrator or has successfully completed an operator training program as designated by the secretary.

Staff Facilities shall provide orientation to new employees and regular in-service training for all employees to ensure that services provided assist residents to attain and maintain their individuality, autonomy, dignity, independence and ability to make choices in a home-like environment.

In-service education must include: principles of assisted living; fire prevention and safety; disaster procedures; accident prevention; resident rights; infection control; and prevention of abuse, neglect or exploitation of residents

In-service education on treatment of behavioral symptoms shall be provided to all employees of facilities which admit residents with dementia.

Background Check

Not described.

Fees

$50 plus $15 for each resident.

Kentucky

Category

Assisted living residence 905 KAR 5:080

Personal care homes 902 KAR 20:036

General Approach

SB 162, signed into law April 10, 1996, created a voluntary certification program for assisted living residences. Regulations were finalized in 1997. The law specifically exempts assisted living residences from the certificate of need law.

There were 199 facilities and 6,926 beds in 1998.

Definition

Assisted living residence (ALR) means an apartment or home-style housing unit residence which provides assisted living to two or more adult persons who are not related within the third degree of consanguinity to the owner or operator of the apartment or residence, and which provide supportive services within the residence or on the grounds of the residence.

Personal care home Personal care homes are establishments with permanent facilities including resident beds. Services provided include continuous supervision, basic health and related services, personal care services, residential care services and social and recreational activities.

Unit Requirements

ALR An apartment is defined as a residence which shall offer at least one unfurnished room, a private bathroom with a bathtub or shower, a kitchenette, a lockable door, and individual thermostat controls. A home-style housing unit means a residence which shall offer at least one unfurnished room, a semi-private bathroom with a bathtub or shower, free use of kitchen facilities and a lockable door to the room entrance. Units may be shared only by choice.

PCH No requirements are specified for room size. The maximum number of beds per room is four. At least 66% of the beds in the facility must be located in rooms designed for one or two beds. Facilities using central bathing areas must bathrooms and showers/baths for each sex on each floor. One toilet is required for every eight residents, a lavatory for every sixteen residents and a shower/bath tub for every twelve residents.

Tenant Policy

ALR Not specified.

PCH Personal care homes may admit persons who are sixteen or older and who are ambulatory or mobile non-ambulatory. Persons who are non-ambulatory or non-mobile may not be admitted to a personal care home. Residents must be able to manage most of the activities of daily living. Residents must have a complete medical evaluation upon admission or within 14 days prior to admission. Residents whose care is not within the scope of services of a personal care home must be transferred to an appropriate facility.

Services

ALR Supportive services may include personal care, congregate meals, barber and beauty services, sundries for personal consumption, and supervision of self-administration of medications. The law says supportive services "means, but is not limited to, transportation services; assistance with eating, bathing and dressing; assistance with personal and household activities or chores; organized social and recreational activities; assistance with self-administration of medications; monitoring of nutrition or health; and protective assistance or supervision necessary to prevent posing a health or safety hazard to the individual or others."

PCH All homes must provide basic health and health related services including: continuous supervision and monitoring; supervision of self-administration of medications, storage and control when necessary; and making arrangements for obtaining therapeutic services ordered by the resident's physician which are not available in the facility.

Financing

No Medicaid funds are available for either category.

Staffing

ALR Not specified.

PCH Based on the needs of residents.

Training

ALR Not specified.

PCH All personal care home employees shall receive in-service training to correspond with the duties of their respective jobs. Documentation of in-service training shall be maintained in the employee's record and shall include: who gave the training, date and period of time training was given and a summary of what the training consisted of. In-service training shall include but not be limited to the following:

Policies of the facility in regard to the performance of their duties;
Services provided by the facility;
Record keeping procedures;
Procedures for reporting of case of adult and child abuse, neglect or exploitation;
Patient rights;
Methods of assisting patients to achieve maximum abilities in activities of daily living;
Procedures for the proper application of physical restraints;
Procedures for maintaining a clean, healthful and pleasant environment;
The aging process;
The emotional problems of illness;
Use of medication; and
Therapeutic diets.

Background

ALR Applicants must assure that no officer, director, trustee, limited partner or shareholder has ever been convicted of felony, class A misdemeanor or abuse of a person.

Monitoring

Not specified.

Fee

ALR $100 inspection fee.

Louisiana

Citation

SB 1560 (1997). Adult residential care facility, Louisiana Revised Statutes Annotated § 2151 et seq.; LA administrative code title 48, § 8901 et seq.

General Approach

A public hearing on draft rules was scheduled for May 29, 1998. The proposed rules would create core requirements for adult residential care facilities plus three modules for assisted living facilities, personal care homes and shelter care facilities. The modules contain separate requirements for administrators, staff training and living units. The draft states that the purpose of the regulations is to promote the availability of appropriate services for elderly and disabled persons in a residential environment, enhance the dignity, independence, privacy, choice and decision-making ability to the residents; and promote the concept of aging-in-place.

SB 1560, passed in 1997, creates a pilot program to test the feasibility of covering assisted living under Medicaid. The project will be implemented by the Department of Health and Hospitals. A task force was appointed to draft guidelines for the project. The project will include two assisted living facilities. Medicaid funds are approved for the pilot. The project "shall maximize the independence of the elderly while providing the assistance that the special needs of this population require." The bill defines assisted living as "a residential congregate housing environment combined with the capacity by in-house staff or others to provide supportive personal services, twenty four hour supervision and assistance, whether or not such assistance is scheduled, social and health related services to maximize residents' dignity, autonomy, privacy, and independence and to encourage facility and community involvement."

One rural and one urban site will be selected through an RFP. Each facility may serve up to 30 Medicaid beneficiaries. Residents must be offered a chance to live in private quarters with a lockable door, bedroom, kitchenette and bathroom.

The Louisiana Advisory Committee on Assisted Living was created which includes five state agency representatives, the state fire Marshall, two legislators, and 10 public members representing associations, consumers, providers and architects. An interim report is to be filed with the legislature by October 1, 1998 and a final report in January 2001.

The summary below is based on the draft rules.

Definition

Adult residential care home means a publicly or privately operated residence that provides personal assistance, lodging and meals for compensation to two or more adults who are unrelated to the residence licensee, owner or director.

Assisted living home/facility means an adult residential care facility that provides room, board and personal services, for compensation, to two or more residents that reside in individual living units which contain, at a minimum, one room with a kitchenette and a private bathroom.

Personal care home means an adult residential care facility that provides room, board and personal services, for compensation, to two but not more than eight residents in a congregate living setting and is in a home that is designed as any other private dwelling in the neighborhood.

Shelter care home means an adult residential care facility that provides room, board and personal services, for compensation, to nine or more residents in a congregate living and dining setting.

Unit Requirements

Assisted living facilities Efficiency/studio units must provide 250 square feet excluding bathrooms and closets and may be shared by no more than two people by choice. Units with separate bedrooms shall have a living area of at least 190 square feet, excluding bathroom and closets. Each separate bedroom must have 120 square feet.

Shelter care facilities must have 100 square feet in single occupancy rooms and 160 square feet for double occupancy rooms. No more than two residents may share a room and they must agree in writing to share a room. Facilities must have adequate toilet, bathing and hand washing facilities in conformance with the state sanitary code.

Tenant Policy

Residents may include those who need or wish to have available room, board, personal care and supervision due to age, infirmity, physical disability or social dependency. Residents with advanced or higher care needs may be accepted or retained if the resident can provide or arrange for care through appropriate private duty personnel, residents do not need continuous nursing care for more than 90 days and the provider can meet the resident's needs. Facilities may not enter into contracts with outside providers to deliver health related services. These services must be arranged by the resident, family members or the resident's representative. Residents must be discharged if a physician certifies that more than 90 days of continuous care is needed or the resident is a danger to themself or others.

Services

Basic services provided include assistance with ADLs and IADLs, three meals a day, personal and other laundry, opportunities for individual and group socialization, housekeeping, services for residents who have behavior problems and recreation services and assistance with self-administration of medications. Providers must plan or arrange for health assessments, health care monitoring and assistance with health tasks as needed or requested. Facilities must have the capacity to provide transportation for medical services, personal services (barber/beauty), personal errands and social/recreational activities.

Reimbursement

(SB 1560) The pilot project was designed to serve elderly Medicaid beneficiaries who can no longer live at home because they need additional care with ADLs but do not require continuous nursing care and have no alternative under the traditional model except institutional care.

Medication Administration

Facilities may provide assistance with self-administration of medications, however, residents may be assisted with pouring or otherwise taking medications only if they are cognitive of what the medication is, what it is for and the need for the medication. Residents may contract witih an outside source for medication administration. Staff assisting with medications must have training on the policies and procedures for assistance.

Staffing

Providers must demonstrate that sufficient staff are scheduled and available to meet the 24-hour scheduled and unscheduled needs of residents and show adequate coverage for each day and night. Assisted living facilities and shelter care facilities must have at least one awake staff on duty at night.

Training

Administrators must be 21 years of age. Assisted living administrators must have a bachelor's degree plus two years of experience in the field of health, social, management administration or in lieu of a degree, six years of experience and education or a master's degree in geriatrics, health care administration or a human service related field.

Shelter care home administrators must have two years of college and two years experience or four years experience in lieu of college or a bachelor's degree. Personal care home administrators must have two years of college training plus one year experience or three years of experience in lieu of college or a bachelor's degree.

Staff An orientation program shall include but not be limited to thorough coverage of the following areas: facility policies and procedures, emergency and evacuation procedures, resident's rights, procedures for and legal requirements concerning the reporting of abuse and critical incidents, and instruction in the specific responsibilities of each employee's job. Direct care staff orientation must cover training in resident care services (personal care), infection control and any specialized training to meet resident needs. All direct care staff must receive certification in first aide.

An annual training plan must be developed that includes the topics covered by the orientation.

Background Check

Licenses may be denied based on a criminal conviction of any board member, owner or staff if the act that caused the conviction would cause harm to a resident if repeated. Providers must include the results of a criminal history check in each employee's personnel file.

Monitoring

The Department of Health shall make at least annual inspections. Complaints are to be reviewed and investigated by the appropriate state agency.

Fee

The proposed licensing fee would be $75 plus an initial fee of $25.

Maine

Citation

Assisted living facilities Title 22, MRSA §7902

General Approach

Governor King signed legislation April 11, 1996 which revised the state's assisted living program. Emergency rules were effective in October 1997 and the rules will be finalized in the Spring of 1998. The bill created several levels of assisted living with varying licensing based on the level of service provided. Assisted living services may be provided by residential care facilities and congregate housing providers. However, the licensure requirements do not apply to congregate housing settings offering only meals and housekeeping services. Licensing is optional for congregate housing providers offering personal care. Licensure is required for congregate housing providers offering personal care and administration of medication, and/or offering nursing services. Full licenses may be issued for two years if the facility is in substantial compliance with the rules and has no history of health or safety violations.

The number of residential care facilities has increased significantly since Maine tightened the nursing home level of care criteria in 1994. Thirty one nursing homes have converted wings and 5 entire facilities have converted to residential care. Four nursing homes have closed. While there is no CoN requirement, the state agency issues an RFP for residential care facilities interested in contracting with the Medicaid program. In 1996, the legislature also passed a bill that creates an expedited certificate of need review for nursing facilities which convert and de-license beds and later seek to re-license the beds as part of the nursing facility within four years.

Definition

Assisted living services means the provision by a single entity of housing and assistance with ADLs and IADLs. Assisted living services must be provided by the provider of housing either directly by that provider or indirectly through written or verbal contracts with persons, entities or agencies. Services may include, but are not limited to, personal supervision; protection from environmental hazzards; ADLs; administration of medication; diversional, motivational or recreational activities; dietary services; and nursing services.

Congregate housing services program means a comprehensive program of supportive services, including meals, housekeeping and chore assistance, case management and other services that are delivered on the site of congregate housing and assist occupants to manage ADLs. Congregate housing services may also include personal care assistance, with or without supervision, or assistance in the administration of medication and nursing services subject to the licensing requirements.

Level I residential care facility (formerly known as adult foster homes or certain six bed boarding homes) means a residential care facility with a licensed capacity of six or fewer residents.

Level II residential care facility means "a house or other place that is licensed to care for seven or more residents that is maintained wholly or partly for the purpose of providing residents with assisted living services. These are facilities with three or more employees who are not owners and not related by blood or marriage to the owner.

Unit Requirements

CHSPs are multi-unit residential buildings and state and local building codes for such buildings are applied. The regulations require that all licensed CHSPs be inspected using Chapter 18, New Apartment Buildings, NFPA, Life Safety Code. These rules require a food service area, bathroom and bedroom. The statute indirectly addresses requirements for living units in congregate housing. The definition of personal care assistance implies that only facilities consisting of private apartments can be licensed as CHSPs. definition states:

"Personal care assistance means services provided in group residential settings consisting of private apartments including assistance with activities of daily living and the instrumental activities of daily living and supervision of residents self-administering medication."

In addition, the definition of nursing services also requires that they be provided in "group residential settings consisting of private apartments." However, these definitions do not apply to residential care facilities.

Level I residential care facilities must offer 100 square feet for single room and 80 square feet for double rooms. Bathrooms and showers/tubs must be based on the needs of residents. No more than two residents may share a room. Level II residential care facilities must offer 100 square feet for single room and 80 square feet per resident for double rooms. No more than two residents may share a room. Facilities offering apartment style units must have a fire extinguisher. Facilities in which the bedroom and kitchenette are not physically separate have 30 square feet deducted from usable floor space to determine if the bedroom meets code. Bathrooms are required for every six residents and shower/tubs for every 15 residents.

Tenant Policy

The rules encourage aging in place and have very flexible policies to do so. In its application, facilities must describe who may be admitted and the types of services to be provided. Facilities may discharge tenants who pose a direct threat to the health and safety of others, damage property or whose continued occupancy would require modification of the essential nature of the program. The rules also require facilities to permit reasonable modifications at the expense of the tenant or other willing payer to allow persons with disabilities to reside in licensed facilities. Facilities shall make reasonable accommodations for people with disabilities unless they impose an undue financial burden or result in a fundamental change in the program.

RCF II facilities may care for people who qualify for nursing home care, but professional or skilled services for these residents must be provided by a home health agency or a private duty nurse. Nursing needs of residents who do not meet the nursing home criteria may be met by registered and licensed nurses employed by the facility.

Services

Assisted living services include a wide range of care (see definition above). Congregate housing sites licensed as assisted living providers must offer at least coordination, housekeeping, personal care assistance, at least one meal a day, chore services and other goods and services identified in the service plan.

CHSPs may offer personal assistance services, assistance with administration of medication and nursing services that are provided by licensed nurses and certified medication aides.

Facilities with Alzheimer's disease/dementia units must provide individual and/or group activities covering gross motor activities, self care activities, social, crafts activities, sensory enhancement activities, outdoor activities and spiritual activities.

Reimbursement

The FY 97 state budget included funds to support a demonstration project for 75 CHSP units. State officials developed a reimbursement methodology for the demonstration.

The Medicaid program provides reimbursement for personal care services in RCFs under the state plan in "Private Non-Medical Institutions" (Residential Care Facilities). Reimbursement is also available under the HCBS waiver for people living in congregate housing facilities.

A case mix system is expected to be implemented for residential care facility residents based on functional and other data collected on residents. The state developed an MDS for Residential Care Assessment (MDS-RCA). Data is collected at admission, annually, semi-annual reviews, and upon discharge. The annual MDS-RCA form contains the following sections: identification information; oral/nutritional status; demographic information; oral/dental status; customary routine; skin condition; mood and behavior patterns; activity pursuit patterns; psycho-social well-being; medications; physical functioning; special treatments and procedures; continence; discharge potential; diagnoses; assessment information; and health conditions.

Quality indicators will be used to identify problem areas, exemplary care, and support care decisions. Some of the quality indicators overlap with those developed for nursing facilities, but others provide more emphasis on relationships and psycho-social well-being. The quality indicators include the following: prevalence of self/family participation in assessment; positive psycho-social well-being; bladder incontinence; bowel incontinence; bladder incontinence without scheduled toileting plan; occurrence of injury and falls; prevalence of behavioral symptoms toward others; behavioral symptoms toward others without behavior management; residents using nine or more prescription medications; residents using more than the state average number of medications; prevalence of cognitive impairment; cognitive impairment; level of activity; anti-psychotic drugs; awake at night; communication difficulties; signs of distress or sad/anxious mood; absence of positive psycho-social well-being; and prevalence of unsettled relationships.

Medications

A separate level of licensure is required for administration of medications in residential care facilities and congregate housing sites.

Staffing

CHSP The sponsor must assure that services will be provided to residents in accordance with individual service plans. Since these facilities may house residents who do not require assisted living services, staffing standards are not needed.

Level I RCFs Operators are responsible for assuring that residents have an opportunity to receive individualized services that help them function and restore them to an optimal state of health or opportunities for constructive activity. There are no other staffing standards. Level II RCFs. Staffing must be adequate to implement service plans. RCFs serving over 10 residents must have two awake staff on duty at night. The rules require a ratio of 1:12 residents from 7 AM to 3 PM; 1:18 from 3-11 PM and 1:30 from 11 PM to 7 AM.

Training

Administrators must successfully complete a department approved training program. Ongoing training of at least 10 classroom hours annually is required in areas related to care of the population served.

Staff

Congregate Housing CHSPs providing personal care assistance and administration of medications must be licensed. Licensure is optional for CHSPs providing personal care. Qualifications are described for the CHSP sponsor and the services director. The CHSP sponsor is responsible for hiring and training qualified, capable staff. Staff must be 18 years of age or older.

Level I Residential Care Facilities All staff, other than certified nursing assistant (CNAs), whose job responsibilities include direct service to residents for at least twenty hours per week, shall successfully complete a Residential Care Specialist I certification course within one hundred twenty days of hiring. Caregivers shall attend and show evidence of successful completion of any training sessions which the Department determines to be necessary.

Level II Residential Care Facilities Administrator certification and training. For facilities serving six or more residents, the administrator must successfully complete a department approved training program. Ongoing training of at least 10 classroom hours annually is required thereafter in areas related to care of the population served by the facility.

All staff, other than certified nursing assistant (CNAs), whose job responsibilities include direct service to residents for at least twenty hours per week shall successfully complete a Residential Care Specialist I certification course within one hundred twenty days of hiring. Additional training specific to a facility's programs may be identified and required by the Department for any staff.

Pre-service training for Alzheimer's/Dementia Care Units For pre-service training, all facilities with Alzheimer's/Dementia Care Units must provide a minimum of eight hours classroom orientation and eight hours of clinical orientation to all new employees assigned to the unit. The trainer(s) shall be qualified with experience and knowledge in the care of individuals with Alzheimer's disease and other dementias. In addition to the usual facilities orientation, which should cover such topics as resident rights, confidentiality, emergency procedures, infection control, facility philosophy related to Alzheimer's disease/dementia care, and wandering/egress control, the eight hours of classroom orientation should include the following topics: a general overview of Alzheimer's disease and related dementias; communication basics; creating a therapeutic environment; activity focused care; dealing with difficult behaviors; and family issues.

Background Check

During the licensure process, a criminal background check is done for the applicant and the administrator.

Monitoring

The state ombudsman program is authorized to visit and receive and investigate complaints concerning assisted living.

Fees

Residential care facilities will pay a fee of $10 per licensed bed. The fee for congregate housing services program is $50 to provide personal care assistance, $100 to provide personal care and administration of medications and $200 to provide nursing services.

Maryland

Citation

Assisted living programs Title 10.07.14

General Approach

A legislative hearing on proposed rules combining multiple licensing categories was held on March 23, 1998. They were expected to be final by July 1998. The rules are based on a 1996 statute, SB 545, which created a licensing category for assisted living. The bill was based on the report of a 19 member task force created by the Governor. The task force report acknowledged that a number of programs are viewed as assisted living and found a lack of coordination among programs and differences in definitions. The report recommended creation of a uniform definition, consolidation of regulatory authority under the Department of Health and Mental Hygiene, a review of state and local fire and building codes and streamlined licensing procedures. The report recommended that the task force continue and address issues related to people with disabilities, accreditation, reimbursement and the fiscal impact, and the relationship among community based assistance services, traditional nursing homes and assisted living.

Definition

Assisted living program means "a residential or facility-based program that provides housing and supportive services, supervision, personalized assistance, health related services, or a combination thereof to meet the needs of residents who are unable to perform, or who need assistance in performing the activities of daily living or instrumental activities of daily living in a way that promotes optimum dignity and independence for the residents."

Unit Requirements

Programs licensed after the effective date of the regulations must provide a minimum of 80 square feet of functional space for single occupancy and 120 square feet for double occupancy rooms. No more than two residents may share a room. Facilities previously licensed as domiciliary care homes must provide a minimum of 70 and 120 square feet for single and double occupancy, respectively. Buildings with one to eight occupants must have one toilet for every four occupants and larger buildings must also have at least one toilet on each floor. Showers/baths must be available for every eight occupants.

Tenant Policy

Facilities are licensed by the level of impairment if residents. In general, programs may not serve anyone who, at the time of admission, requires more than intermittent nursing care; treatment of stage 3 or 4 skin ulcers; ventilator services; skilled monitoring, testing and aggressive adjustment of medications and treatments where there is the presence of, or risk for, a fluctuating acute condition; monitoring of a chronic medical condition that is not controllable through readily available medications and treatments; treatment for an active reportable communicable disease; or treatment for a disease or condition which requires more than contact isolation. Residents may not be admitted if they are a danger to self or others and the danger cannot be eliminated through appropriate treatment modalities or are at risk for health or safety complications which cannot be adequately managed.

Programs may request a waiver to care for residents with needs that exceed the licensure level and demonstrate that it can meet the resident's needs and others will not be jeopardized. Waivers for Level I and Level II programs may not be granted for more than 50% of the licensed bed capacity. Level III programs may not receive waivers for more than 20% of capacity or 20 beds, whichever is less.

Services

Three meals in a common dining area, special diets, personal care, laundry, housekeeping, social and spiritual activities, medication management. The program must facilitate access to health care and social services (social work, rehabilitation, home health, skilled nursing, physician services, oral health, counseling, psychiatric care and others).

Reimbursement

Medicaid is not currently planning to develop reimbursement for assisted living beyond the existing Senior Assisted Housing Program, which was considered assisted living prior to passage of the new law. State-subsidized participants with incomes no greater than 60% of the statewide median income and assets no greater than $11,000 apply their income (less a $60 needs allowance) toward costs. State-funded subsidies may cover the difference between the participant's contribution and the monthly fee, up to a maximum of $550 a month. Those eligible for the State's Medicaid waiver may have incomes no greater than 200% of the federal SSI payment and assets no greater than $2000.The maximum monthly fee which may be charged for assisted living services for a Medicaid waiver participant is $1200/month (an increase to $1400 a month is planned at a future date). Medicaid covers the full amount between the participant's contribution and the $1200 fee. Of the 2500 residents in group homes, about 47 are covered by the waiver and an additional 350 residents are covered by a state-only subsidy.

The state Medicaid agency is considering an 1115 demonstration waiver proposal to integrate acute and long term care for dual eligibles (Medicaid and Medicare). However, the Medicaid agency believes that an expansion of assisted living will increase Medicaid spending. Elders are more likely to choose alternatives that are available, more attractive and less expensive than nursing homes which will delay spend down. Market forces may lead to lower nursing home occupancy rates and closure of some facilities which also reduces Medicaid's exposure to future spending.

The law directs the Office of Aging to develop assisted living programs in conjunction with public or private profit or non-for profit entities, maximizing the use of rent and other subsidies available from federal and state sources. These activities can include finding sponsors; assisting developers formulating design concepts and meeting program needs; providing subsidies for congregate meals, housekeeping and personal services; developing eligibility requirements in connection with the subsidies; adopting regulations governing eligibility; and reviewing compliance with relevant regulations.

Medications

The regulations allow for the delegation of medication administration with on-site review every 45 days by the delegating nurse. Staff who administer medications and are not health care professionals must complete a medication management course which is updated every two years.

Staffing

Programs must have staff capacity to deliver the care for which it is licensed. See table.

Training

Administrators Assisted living managers must have adequate knowledge of the health and psycho-social needs of the population served; resident assessment process; use of service plans; cuing, coaching and monitoring residents who self-administer medications with and without assistance; providing assistance with ambulation personal hygiene, dressing, toileting and feeding; residents' rights; fire and life safety; infection control; basic food safety, basic first aid; basic CPR; emergency disaster plans; and individual job requirements of all staff.

Staff must participate in an orientation and ongoing training program to ensure that residents receive services that are consistent with their needs and generally accepted standards of care for the specific conditions of those residents to whom staff will provide services. Staff must receive initial and on-going training in: fire and life safety, infection control, including standard precautions; basic food safety; basic first aid; emergency disaster plans; and individual job requirements as appropriate to their job.

Staff must have knowledge in: health and psycho-social needs of the population served as appropriate to their job responsibilities; resident assessment process; use of service plans; and resident rights

If job duties involve the provision of personal care services, staff must have knowledge in cuing, coaching and providing assistance with ADLs.

Background Check

Applicants must document any felony conviction of the applicant, assisted living manager or household member. Management must conduct either a criminal history records check or a criminal background check consistent with §19-1901 et seq. Annotated Code of Maryland.

Monitoring

Under the law, the Department of Health and Mental Hygiene may delegate monitoring and inspection of programs to the Office on Aging and the Department of Human Resources or local health departments through an interagency agreement.

Fees

$25 a year for programs monitored by the Department of Human Resources or the Office on Aging; $100 a year for programs inspected and monitored by the Department of Health and Mental Hygiene. For programs with 16 beds or more, $100 a year plus $6 per each bed over 15.

MARYLAND LEVEL OF CARE DIFFERENCES
Area	Level I - Low	Level II - Moderate	Level III - High
Health and wellness	Ability to recognize the cause and risks associated with a resident's health condition once these factors are identified by a health care professional. Provide occasional assistance in accessing and coordinating health services and interventions.	Ability to recognize and accurately describe and define a resident's health condition and identify likely causes and risks associated with the resident's condition. Provide or ensure access to necessary health services and interventions.	Ability to recognize and accurately describe and define a resident's health condition and identify likely causes and risks associated with the resident's condition. Provide or ensure ongoing access to coordination of comprehensive health services and interventions.
Functional	Provide occasional supervision, assistance, support, set up, or reminders with some but not all ADLs.	Provide or ensure substantial support with some, but not all, ADLs or minimal supports with any number of ADLs.	Provide or ensure comprehensive support as frequently as needed to compensate for any number of ADLs.
Medication and treatment	Ability to assist with taking medications or coordinate access to necessary medications and treatments.	Provide or ensure assistance with taking medications, and to administer necessary medications and treatments, including monitoring their effects.	Provide or ensure assistance with taking medication, or to administer necessary medications and treatments, including monitoring or arranging for monitoring the effects of complex medication and treatment regimens.
Behavioral	Monitor and provide uncomplicated intervention to manage occasional behaviors that are likely to disrupt or harm the resident or others.	Monitor and provide or ensure intervention to manage frequent behaviors which are likely to disrupt or harm the resident or others.	Monitor and provide or ensure ongoing therapeutic intervention or intensive supervision to manage chronic behaviors which are likely to disrupt or harm the resident or others.
Psychological	Monitor and manage occasional psychological episodes or fluctuations that require uncomplicated intervention or support.	Monitor and manage frequent psychological episodes or fluctuations that may require limited skilled interpretation or prompt intervention or support.	Monitor and manage a variety of psychological episodes involving active symptoms, condition changes or significant risks that may require some skilled interpretation of immediate interventions.
Social and recreational	Occasional assistance in accessing social and recreational services.	Ability to provide or ensure ongoing assistance in accessing social and recreational services.	Provide or ensure ongoing access to comprehensive social and recreational services.

Massachusetts

Citation

Assisted living 651 CMR 12.00

General Approach

Chapter 354 (Acts of 1994) was signed into law in January 1995 and creates a process for the certification of assisted living facilities by the Executive Office of Elder Affairs. The law provides that the regulations "shall be sufficiently flexible to allow assisted living residences to adopt policies and methods of operation which enable residents to age-in-place." To be certified, residences must submit information such as the number of units and number of residents per unit, location of units, common spaces and egress by floor; base fees to be charged; services to be offered and arrangement for delivering care; number of staff to be employed and other information required by the Executive Office of Elder Affairs. The buildings are considered residential use for applying appropriate building codes.

In 1996, sixty assisted living residences received deemed certification and 20 residences were fully certified with a total of 3700 units. By March 1998, 93 residences with 5,116 units had been certified.

The Massachusetts Housing Finance Agency (MHFA) and the Massachusetts Industrial Finance Agency (MIFA) provide loans for assisted living. The MHFA "Elder CHOICE" program is designed to support development of appropriate housing and ADL assistance for frail elders. The agency's RFP indicates that assisted living offers a supportive residential environment which maximizes the ability of elders to live independently and reduces the need for costly institutionalization. MHFA has approved 14 projects with 900 units. Most projects require that 20% of the units be set aside for low income residents and two projects have a 50% set aside.

The Medicaid Group Adult Foster Care program, which reimburses assisted living for Medicaid recipients, has certified 70 programs of which 30 are located within certified assisted living residences and serve 312 beneficiaries.

Definition

Assisted living residence is any entity, however organized, whether conducted for profit or not for profit, which meets all of the following criteria:

Provides room and board; provides, directly by employees of the entity or through arrangements with another organization which the entity may or may not control or own, assistance with activities of daily living for three or more adult residents who are not related by consanguinity of affinity to their care provider and; collects payments or third party reimbursements from or on behalf of residents to pay for the provision of assistance with the activities of daily living.

Unit Requirements

Units must be single or double occupancy with lockable doors. New construction must provide for private baths. Existing buildings may qualify if they provide private half baths and one bathing facility for every three persons. All facilities must provide, at a minimum, either a kitchenette or access to cooking capacity for all living units. Cooking capacity is defined as each resident having access to a refrigerator, sink, and heating element. Facilities must comply with all federal and state laws and regulations regarding sanitation, fire safety, and access by persons with disabilities. The Secretary of Elder Affairs is authorized to waive the requirements for bathrooms and bathing facilities when determined to meet public necessity and to prevent undue economic hardship as long as the residence provides a home-like environment and promotes privacy, dignity, choice, individuality and independence.

Tenant Policy

The statute does not allow people needing 24-hour skilled nursing supervision to be admitted or retained in an assisted living residence. Facilities may admit and retain residents in need of skilled nursing care only if the care will be provided by a certified provider of ancillary health services or by a licensed hospice and the provider does not train the facility staff to provide skilled nursing care.

To qualify for reimbursement under the Medicaid Group Adult Foster Care program, tenants must require daily assistance with at least one ADL and assistance with managing medications as documented by a physician and a nursing assessment; be at risk of requiring nursing home placement; be chronically disabled; and require 24-hour supervision.

Services

Chapter 354 requires that residences all provide or arrange for opportunities for socialization and access to community resources; supervision or assistance with ADLs identified in a plan of care (at a minimum residences must offer support for bathing, dressing and ambulation); instrumental activities of daily living; self-administered medication management; timely assistance to urgent or emergency needs by 24-hour per day on-site staff, personal emergency response systems, or any additional response systems required by the Executive Office of Elder Affairs; up to three regularly scheduled meals per day (minimum of one meal per day). The administrator may arrange for the provision of ancillary health services in the facility but may not use facility staff for these services unless the staff is an employee of a certified provider of ancillary health services and/or an employee of a licensed hospice. Nursing services provided by a certified provider of ancillary health services such as injection of insulin or other drugs used routinely for maintenance therapy of a disease may be provided to residents.

All residents must have an individual services plan that is developed prior to admission and reviewed/reassessed at least every six months or when health status or family circumstances change.

Twenty-four hour nursing services are not allowed. Skilled services may only be provided by a certified home health agency on a part time or intermittent basis. Medical conditions requiring services on a periodic, scheduled basis are also allowed. In addition, residents may "engage or contract with any licensed health care professional and providers to obtain necessary health care services ... to the same extent available to persons residing in private homes." The initial draft of the regulations limited the provision of skilled services to 90 days in a one year period. The attorney general's office issued an informal opinion that such a limit was contrary to the fair housing rules and the limitation was withdrawn in the final regulations.

The MHFA Elder CHOICE program requires, at a minimum, personal care (assistance with bathing, dressing, continence, ambulation, toileting, eating and transfers); housekeeping and maintenance, laundry, medical monitoring and transportation, up to three meals a day, twenty- four hour emergency response and service coordination and case management.

Financing

The Massachusetts Housing Finance Agency and the Massachusetts Industrial Finance Agency provide loans for the construction of assisted living projects.

Services for low income tenants are subsidized through Medicaid's Group Adult Foster Care (GAFC) which is a service available under the "state plan" rather than a Medicaid waiver. GAFC provides an average of $33.70 per day for services and administrative costs. To support low income residents who do not have sufficient income to pay for room and board, the state has created a special SSI living arrangement for assisted living residences. The SSI payment standard is $948 a month for a single individual. The regular community payment standard for an aged person living alone is approximately $620 a month.

Medications

Residence staff are allowed to remind residents to take medications, open containers, open prepackaged medications, read the label, observe, check dosage against the label and reassure residents that the proper dosage has been taken.

Staffing

No staffing specific guidelines are included concerning the type and number of staff. However, the residence must maintain an ability to provide timely assistance to residents and to respond to urgent or emergency needs through on site staffing, personal emergency response or other means.

Training

Administrators The manager of an ALR must be at least 21 years old and have demonstrated administrative experience. The manager must have a Bachelor's degree or equivalent experience in human services management, housing management and/or nursing home management. The service coordinator of a residence must have a minimum of two years of experience working with elders or disabled individuals and a Bachelor's degree or equivalent experience.

Staff Prior to active employment, all staff and contracted workers having direct contact with residents and all food service personnel must receive a six hour orientation covering the following topics:

Philosophy of independent living in an ALR,
Resident bill of rights,
Elder abuse, neglect and financial exploitation,
Communicable diseases,
Communication skills,
Review of the aging process,
Dementia/cognitive impairment, resident health and related problems,
Job requirements and
Sanitation and food safety.

A minimum of 6 hours per year of ongoing education and training is required for all employees. All employees and providers shall receive ongoing in-service education and on the job training aimed at reinforcing the initial training. ALR staff and contracted providers of personal care services must complete an additional 54 hours of training prior to providing personal care services to a resident (34 hours general training and 20 hours of training specific to the provision of personal care). The 20 hours of personal care training must be conducted by a qualified registered nurse with a valid Massachusetts license. The 54 hours of training must include, but not limited to, the following topics:

Personal hygiene;
Self-administration of medications;
Elimination;
Nutrition;
Human growth and development;
Family dynamics;
Grief, loss, death and dying;
Mobility;
Maintenance of a clean, safe and healthy environment; home safety; and
Assistance with appliances.

Background Check

Applicants must assure that none of officers, directors, trustees, limited partners or shareholders have ever been found in violation of any local, state or federal statute, regulation, ordinance or other law by reasons of the individual's relationship to an assisted living residence.

Monitoring

The Executive Office of Elder Affairs conducts compliance reviews of assisted living residences every two years. The reviews include inspections of the common areas, living quarters (by consent of the resident), inspection of the service plans, and a review of the resident satisfaction survey.

Board and Care

Rest homes provide room and board and personal care services to persons not requiring skilled nursing services. Residents who need skilled nursing services may not be retained. Home health care services may be provided in the home as long as the services are not skilled and the resident does not require 24-hour supervision. Medication administration is available, however, most residents are able to self-administer their own medications. The "responsible person" for the facility must be at least 18 years old and have a high school diploma or GED. A license is not required for this position. If the home provides medication administration, the responsible person must take a course in this area. The home must have nursing and dietary consultants. Care staff are not required to have training, although they must have access to consultations with professional disciplines.

Michigan

Citation

Homes for the aged: Michigan Comp. Law § 333.20106(3); 333.21301 et seq.; Michigan administrative code r.325.1801 et seq.

Adult foster care: Large group homes R400.15101 et seq.

General Approach

The state licenses homes for the aged and adult foster care homes. In 1995, a work group established by the Directors of Human Services Agencies and headed by the Department on Aging reviewed current trends in assisted living and supported updating and combining existing regulations in a single category of assisted living. Following a reorganization of state agencies in 1996, responsibility for licensing was shifted to the Department of Consumer and Industry Services. The Department formed a 40 member assisted living task force in the fall of 1997. The task force is examining issues in four areas: consumer information and protection, fire and safety protections, services and affordability. A report is expected in the summer of 1998.

Medicaid HCBS waiver will pilot test coverage of care in assisted living facilities in one county as long as services are delivered by community agencies rather than the facility's staff. Thus far one provider is participating and 4 beneficiaries are being served.

Definition

Homes for the aged "A supervised personal care facility, other than a hotel, adult foster care facility, hospital, nursing home, or county medical care facility, that provides room, board, and supervised personal care to 21 or more unrelated, non-transient, individuals 60 years of age or older. Home for the aged includes a supervised personal care facility for 20 or fewer individuals 60 years of age or older if the facility is operated in conjunction with and as a distinct part of a licensed nursing home."

Adult foster homes There are two levels of adult foster homes, those that serve 12 or fewer and those that serve between 13 and 20 residents. An adult foster care facility is a governmental or non-governmental establishment that provides foster care to adults. Adult foster care facilities include facilities and foster care family homes for adults who are aged, mentally ill, developmentally disabled, or physically handicapped who require supervision on an ongoing basis but who do not require continuous nursing care.

Unit Requirements

Homes for the aged Homes constructed, converted or expanded after 1981 must provide 100 square feet of usable space for single rooms and 80 square feet per resident in shared rooms. Rooms may not be shared by more than four people. Homes licensed prior to 1981 must offer at least 80 square feet of usable floor space for single rooms while shared rooms must provide 70 square feet per resident. The regulations do not limit the number of residents that may share a room. Toilet facilities are required for every eight residents per floor and bathing facilities for every 15 residents.

Adult foster homes A single bedroom must have at least 80 square feet of usable floor space; a multi-bed room must have at least 65 square feet of usable floor space per bed. A maximum of two beds are allowed per bedroom unless the facility has been continuously licensed since the effective date of the rules or unless the resident (or the resident's representative) has agreed to reside in the multi-occupancy room, the home is in compliance with all state fire safety and environmental standards, and the bedroom provides no less than 70 square feet (65 square feet from homes licensed on or before December 31, 1976) of usable floor space per bed.

Tenant Policy

Homes for the aged Residents requiring nursing care that cannot be provided by a home health agency may not be admitted. Residents requiring 24-hour nursing care or intensive nursing care may not be retained. Physicians must certify that new residents are free from communicable diseases. Residents with a mental condition disturbing to others may not be admitted or retained.

Adult foster homes may not accept, retain, or care for residents who require continuous nursing care. This does not preclude the accommodation of a resident who becomes temporarily ill while in the home, but who does not require continuous nursing care. All residents must be assessed by the facility as to the amount and type of services required by the resident. Facilities may not accept or retain residents who require isolation or restraint.

Services

Homes for the aged provide personal care. The rules require that residents wash their hands before meals and receive a bath or shower at least once a week.

Services in adult foster homes include supervision, protection, personal care, medication administration, social activities, and assistance with instrumental activities of daily living. Homes must arrange for transportation services.

Medications

No provisions.

Staffing

Homes for the aged A sufficient number of attendants are required for each shift to assist residents with personal care under direction from a supervisor.

Adult foster homes The ratio of direct care staff in facilities for between 13 and 20 residents must be no less than one staff to 15 residents during waking hours and one staff to 20 residents during normal sleeping hours. The ratio for facilities for 12 or fewer residents must be no less than one staff per 12 residents. In all facilities there must be sufficient direct care staff on duty at all times for the supervision, personal care, and protection of residents and to provide the services specified in the resident's care agreement and assessment plan.

Training

In adult foster homes, administrators must have at least one year of experience working with persons who are mentally ill, developmentally disabled, physically handicapped, or aged. Both the licensee of the home and the administrator must complete either 16 hours of training approved by the Department of Social Services or six credit hours at an accredited college or university in an area approved by the Family Independence Agency. Direct care staff must be at least 18 years old. The licensee or administrator must provide in-service training or make training available through other sources for direct care staff in the following areas: reporting requirements, first aid, CPR, personal care, supervision, protection, resident rights, safety and fire prevention, and prevention and containment of communicable disease.

Staff

Homes for the aged A licensee or administrator shall provide in-service training or make training available through other sources to direct care staff. Direct care staff shall be competent before performing assigned tasks, which shall include being competent in all of the following areas: reporting requirements; first aid; cardiopulmonary resuscitation; personal care, supervision and protection; resident rights; safety and fire prevention; and prevention and containment of communicable diseases.

Adult foster homes (Large Group Homes) Before a license is issued, an applicant and an administrator shall be competent in all of the following areas: nutrition, first aid, CPR, foster care, safety and fire prevention, financial and administrative management, needs of the population to be served, resident rights, and prevention and containment of communicable diseases. A licensee and an administrator shall annually participate in, and successfully complete, 16 hours of training designed or approved by the department that is relevant to the licensee's admission policy and program statement.

Background Check

Homes for the aged No provision.

Adult foster care Large group homes must submit to the licensing agency the name of employee or volunteer who is on a court-supervised probation or parole or who has been convicted of a felony.

Monitoring

Adult foster care homes are inspected by the Family Independence Agency or the Department of Consumer and Industry Services or a local health department at the request of the Family Independence Agency.

Minnesota

Citation

Elderly housing with services. MS § 144D.01 et seq.

Home care licensure: MS 114A.43 to 144A.48.

Minnesota rule, Chapter 4468 et seq.

General Approach

The Housing with Services Registration Act was effective in August 1996. It requires registration for all facilities providing housing and services to elderly persons. Services are provided through licensed home care provider agencies. Draft rules for these agencies were released in February 1998 and were not expected to be final until the fall of 1998. The Housing with Services agency may obtain such a license or contract with a licensed agency.

The state covers assisted living through its state funded Alternative Care (AC) program and the Medicaid Home and Community Based Services Waiver program. The Alternative Care Program serves nursing home eligible residents whose income exceeds Medicaid eligibility levels but who would spend down to Medicaid levels within six months if admitted to a nursing home. The HCBS waiver covers aged and disabled Medicaid recipients who meet the nursing home criteria.

Definition

Housing with services establishment means "an establishment providing sleeping accommodations to one or more adult residents, at least 80% of which are 55 years of age or older, and offering or providing for a fee, one or more regularly scheduled health-related services and two or more regularly scheduled supportive services, whether offered or provided directly or by another entity arranged for by the establishment."

The state's Medicaid waiver defines assisted living services as "up to 24-hour oversight and supervision, supportive services, home care aide tasks and individualized home management tasks provided to residents of a residential center living in their own units/apartments with a full kitchen and bathroom. A full kitchen includes a conventional stove with an oven, refrigerator, food preparation counter space and a kitchen utensil storage compartment.

Unit Requirements

Housing with services No requirements stated. Must meet appropriate building and fire codes for the structure.

Medicaid Assisted living policies under the waiver require full apartments with kitchens.

Tenant Policy

Housing with services The statute requires written contracts between the facilities and tenants that describe the registration status, terms, a description of services to be provided directly or through other arrangements, fee schedules and a description of the process through which the contract may be modified, amended or terminated, complaint procedures, retention policies and other items.

Medicaid waiver Participants for the AC and Medicaid waiver programs must be screened by the county preadmission screening team and must meet the nursing home level of care criteria. Most residents fall into case mix categories A through D (see table).

Services

Assisted living home care providers must deliver at least one of the following and may deliver nursing services, delegated nursing services, other services performed by unlicensed personnel or central storage of medications.

Home care rules define health related services as professional nursing services or home health aide tasks such as administration of medication, routine delegated medical, nursing or assigned therapy procedures, assisting with body positioning or transfers of people who are not ambulatory, feeding clients who are at risk of choking, assistance with bowel and bladder control, devises and training programs, assistance with therapeutic or passive range of motion exercises, providing skin care and providing services to maintain hygiene during episodes of illness. Home care aide tasks include preparing modified diets, medication reminders, household chores in the presence of sophisticated medical equipment or when care requires prevention of exposure to infectious or contagious disease and assisting with ADLs for ambulatory clients with no serious acute illness.

The Medicaid regulations allow the provision of assisted living services which include home care aide and home management tasks provided to clients of a residential center within living units and provided by management or by providers under contract with the center. Home care aide tasks are differentiated from home health aide and include assisting with dressing, oral hygiene, hair care, grooming and bathing, if the client is ambulatory and has no serious illness or infectious disease, preparing modified diets, medication reminders, household chores in the presence of technically sophisticated medical equipment or episodes of acute illness of infectious disease.

The Medicaid waiver defines services as "supportive services include socialization (when socialization is part of the plan of care, has specific goals and outcomes established and is not diversional or recreational in nature), assisting clients in setting up meetings and appointments, and providing transportation (when provided by the residential center only). Individuals receiving assisted living services will not receive both homemaking and personal care and assisted living services. Individualized means that services are chosen and designed specifically for each resident's needs, rather than provided or offered to all residents regardless of their illness, disabilities or physical conditions. Under the AC and Waiver programs, residents may also receive home health and skilled nursing which are reimbursed separately from the payment for assisted living services.

Financing

Rates for services are negotiated between the client and the provider with limits based on the client's case mix classification. Service rates under the state funded AC program cannot exceed the state's Medicaid share of the average monthly nursing home payment. The client pays for room and board (raw food costs only - meal preparation is covered as a service). The cost of services in addition to assisted living services may not exceed 75% of the average nursing home payment for the case mix classification.

Under the HCBS waiver, rates for assisted living services are also capped at the state share of the average nursing home payment and the total costs, including skilled nursing and home health aide in addition to assisted living services, cannot exceed 100% of the average cost for the client's case mix classification. For room and board, the SSI and state supplement payment in 1998 is $667 and the resident retains a personal needs allowance of $54 a month. Residents whose income exceeds the SSI and state supplement level must "spend down" to the Medicaid Medically Needy level of $420 a month. To allow spend down beneficiaries to meet the room and board allowance, all costs below $667 are considered as a "remedial care cost" and are therefore eligible expenses for meeting spend down requirements.

The statewide maximum FY 98 service rates assisted living services for elderly recipients ranged from $684 a month to $1595 a month depending upon the case mix classification. Rates in a particular county could be higher or lower than the averages. In addition to the assisted living rates, the waiver has caps for all waiver services including assisted living. The Alternative Care Program rates for all services including assisted living ranged from $1072 to $200 a month. Medicaid waiver maximum costs ranged from $1429 to $333 a month depending upon the case mix classification. These rates are effective from October 1, 1997 to July 1, 1998 (see table). Approximately 92.6% of the Elderly Waiver participants fall into categories A through E.

The state is implementing the 300% Medicaid eligibility option for waiver participants. The maintenance level will remain at $667 and all excess income will be applied to the cost of waiver services. The state will also revise the payment rates for services.

Medications

The assisted living home care provider rules allow medication administration. Staff administering medications must be instructed by a registered nurse, the instructions must be written and the person must demonstrate competence in following the instructions.

Staffing

The Department of Health's standards for home care services licenses do not apply to the building itself. Housing with services providers may not accept anyone for whom services cannot be provided and must staff to meet the needs of clients/residents.

Training

Staff Orientation and training are required based on the tasks performed by the worker.

Training requirements are specified for staff performing home care aide tasks, home management tasks and delegated nursing tasks. Each person who applies for a license, provides direct care, supervision of direct care or manages services for a licensee must receive an orientation to home care requirements covering: an overview of the statute and regulations, handling of emergencies, reporting abuse/neglect, home care bill of rights, handling and reporting of complaints and services of the ombudsman.

Training and a competency evaluation are required for unlicensed people who perform assisted living home care tasks. The curriculum includes: an overview of the Minnesota statutes; recognition and handling of emergencies and use of emergency services; reporting the maltreatment of vulnerable adults; home care bill of rights; handling of complaints; services of the ombudsman; observation, reporting and documentation of client status and of the care or services provided; basic infection control; maintenance of a clean, safe and health environment; communication skills; basic elements of body functioning and changes in body function that must be reported to an appropriate health care professional; and the physical, emotional and developmental needs of clients.

Staff who provide medication administration and active assistance with medications must complete the above training program, pass a competency test and be instructed by a registered nurse in the procedures to administer the medications to each client/residents. The instruction is specific to each resident.

Staff providing home management tasks (housekeeping, meal preparation and shopping) must receive training on the bill of rights and orientation on the aging process and the needs and concerns of elderly and disabled persons.

Background Check

A license may be denied or suspended for conviction of any of 15 types of crimes listed in the regulations. Each employee with direct contact with clients must sign a statement disclosing convictions of all crimes, except minor traffic violations. Employees may be required to sign a release statement authorizing local authorities to provide the commissioner a history of criminal convictions.

Fee

Housing with Services buildings must pay a registration fee of $35 per address.

MINNESOTA CASE MIX CATEGORIES AND MAXIMUM STATEWIDE RATE LIMITS FOR ASSISTED LIVING AND ALL OTHER WAIVER SERVICES--EFFECTIVE 10/1/971
Case Mix	Assisted Living Payment	Total Rates for all Services2		Description
Case Mix	Assisted Living Payment	AC Program	Elderly Waiver	Description
A	$684	$1072	$1429	Up to 3 ADL dependencies3
B	$771	$1209	$1612	3 ADLs + behavior
C	$871	$1356	$1820	3 ADLs + special nursing care
D	$962	$1507	$2010	4-6 ADLs
E	$1055	$1654	$2205	4-6 ADLs + behavior
F	$1061	$1663	$2217	4-6 ADLs + special nursing care
G	$1140	$1786	$2382	7-8 ADLs
H	$1289	$2020	$2693	7-8 ADLs + behavior
I	$1341	$2102	$2803	7-8 ADLs + needs total or partial help eating (observation for choking, tube or IV feeding and inappropriate behavior)
J	$1423	$2320	$2974	7-8 ADLs + total help eating (as above) or severe neuro-muscular diagnosis or behavior problems
K	$1595	$2500	$3333	7-8 ADLs + special nursing
The maximum rate limits vary by region of the state but cannot exceed the maximum statewide limits. Rates include assisted living and all other waiver services which the residence is responsible for providing or arranging. ADLs include bathing, dressing, grooming, eating, bed mobility, transferring, walking and toileting.

Mississippi

Citation

Personal care homes Miss regulations §1201.1 et seq.

General Approach

Regulations are being revised and the licensing agency has formed a task force to make recommendations. A report was expected in July 1998.

Definition

"A personal care home" is a home or institution which is licensed to give personal care to ambulatory residents who are not in need of nursing care but who, because of advanced age and/or physical/mental infirmities, are in need of assistance with their activities of daily living ordinarily provided by responsible family members. This assistance extends beyond providing shelter, food, and laundry. Examples of such assistance include but is not limited to the bathing, walking, excretory functions, feeding, personal grooming, dressing and financial assistance of such residents."

There were 168 facilities with 3,175 beds in 1996 and 180 facilities with 3,000 beds in 1998.

Unit Requirements

There must be at least 80 square feet for each resident in a bedroom. Residents shall not have to enter one bedroom through another bedroom. Resident bedrooms must not have more than four beds. Separate toilet and bathing facilities shall be provided on each floor for each sex.

Tenant Policy

Residents must be ambulatory, have a regular diet, continent of bowel and bladder (no indwelling or external catheters are permitted), nonviolent to self and others, not require care beyond the capabilities of a personal care home and free from communicable disease. Residents who need further care or those whose medical and/or psychiatric condition(s) are not adequately controlled shall not be admitted or retained.

Residents must have a thorough medical evaluation five days prior to or at the time of admission.

Services

Personal care services, activities and room and board are provided.

Financing

Medicaid funding is not available.

Staffing

The administrator must be at least 21 years of age and able to read and write. There must be a responsible staff member present at all times who is at least 21 and represents the operator in his/her absence. There must be one attendant per 10 residents from 7:00 am to 6:00 pm and sufficient staff on hand to meet the personal care needs of residents at all other times.

Training

Administrator Must be full time and at least 21 years old.

Staff Personnel shall receive on a quarterly basis appropriate training in the care of the aged or infirm. This shall be documented by a narrative of the training and the signatures of those attending.

Monitoring

Facilities are inspected by the Mississippi State Department of Health at such intervals as the department may direct.

Missouri

Citation

Residential care facilities. Missouri revised statutes § 198.003 et. seq.; Missouri. code of regulations, title 13 § 15-10.010 et seq.

General Approach

State agencies started to explore developing new regulations for assisted living in 1997. No formal work group or plan has been established. The state Division of Aging licenses two levels of residential care facilities. RCFs must obtain a certificate of need.

Definition

Type I RCFs means any premises, other than a residential care facility II, intermediate care facility or skilled nursing facility, which is utilized by its owner, operator or manager to provide twenty-four hour care to three or more residents, who are not related within the fourth degree of consanguinity or affinity to the owner, operator or manager of the facility and who need or are provided with shelter, board and with protective oversight, which may include storage and distribution or administration of medications and care during short term illness or recuperation.

The definition of Type II RCFs adds supervision of diets, assistance in personal care, and supervision of health care under the direction of a licensed physician to the definition of Type I RCFs. Facilities can be licensed to provide both levels of care within the same facility.

Tenant Policy

RCFs may admit or retain only residents who are capable mentally and physically of negotiating a normal path to safety using assistance devices or aides when necessary. The rules allow RCFs to admit any resident who can be cared for by the facility directly or in cooperation with community resources or other providers of care with whom it is affiliated or has contracts. Residents must be able to evacuate without physical assistance.

Unit Requirements

Homes licensed after 1987 must provide 70 square feet of space per resident in both private and multiple occupancy rooms. A maximum of four residents may share a room. Homes licensed prior to 1987 could provide 60 square feet per resident. One tub/shower must be provided for every 20 residents and one toilet and lavatory for every six residents.

Services

Personal care services are reimbursed through Medicaid for residents who have chronic, stable conditions. Tasks include bathing, hair care, oral hygiene, nail care, dressing, assistance with toileting, walking or transfers, meal preparation, and light housework. Advanced personal care services include assistance for persons with altered body functions who have a catheter or ostomy, require bowel and bladder routines, range of motion exercises, applying prescription lotions or ointments and other tasks requiring a highly trained aide.

Reimbursement

Personal care and advanced personal care services are reimbursed as a Medicaid state plan service in residential care facilities. The payment varies by resident based on an assessment and a plan of care completed by a case manager from the Division of Aging. Facilities are reimbursed at an hourly rate of $11.37, for the number of hours authorized in the plan of care. The actual number of hours authorized ranges from 5-6 hours to 70 or 80 hours a month. The average number of hours authorized is 25-30 hours a month. The payment rate is $11.37 an hour for personal care aides, $13.41 for advanced personal care aide services and $26.30 an hour for nursing visits. The maximum payment is $1962 a month for people receiving advanced personal care services. No more than one nursing visit a week can be authorized. Very few residents receive advanced personal care and nursing visits.

The room and board rate is paid through the federal SSI payment and a state "cash grant" or SSI supplement payment. Type I facilities receive a combined room and board payment of $645 a month and Type II facilities receive a combined payment of $776 a month. With an average personal care payment of $302.10, the total payment would equal $947 in Type I facilities and $1078 in Type II facilities. The maximum payments are $2607 and $2738 respectively for room and board and services.

The state is interested in developing a per diem rate with seven tiers based on an assessment by the facility and monitoring by the Division of Aging.

Training

Administrators of RCF II facilities must be licensed nursing home administrators or attend at least one continuing education workshop each calendar year given or approved by the Division on Aging. They must also successfully complete a state approved Level I Medication Aide course unless a full time licensed nurse is available. Licenses are not required for administrators of RCF I facilities although annual attendance at in-service training sessions is required.

Staff Prior to or on the first day that a new employee works in the facility, s/he shall receive orientation of at least one hour appropriate to his/her job function. This shall include, at a minimum, job responsibilities, how to handle emergency situations, the importance of infection control and hand washing, confidentiality of resident information, preservation of resident dignity, how to report abuse/neglect to the Division on Aging, information regarding the employee Disqualification List and instruction regarding the rights of residents and protection of property.

A statement must be included in the personnel record of each employee that the employee was instructed on resident's rights, facility's policies, job duties and other orientation received.

Staff administering medications receive a certificate after completing a designated course developed by the University of Missouri-Columbia.

Background Check

Administrators must not have been convicted of an offense involving the operation of a long term facility or similar facility.

Staff No person on listed on the employee disqualification list maintained by the Division shall work or volunteer in the facility in any capacity.

Fees

Licensing fees are $100 for facilities of 3-25 beds; $300 for 25-100 beds; and $600 for 100+ beds.

Montana

Citation

Personal care facilities Subchapter 9 §16.32.902

Adult foster care homes Chapter 16 Subchapter 1 §11.16

General Approach

The state's Medicaid HCBS waiver reimburses services provided in personal care facilities and adult foster care homes. Neither the licensing rules nor the waiver uses the term assisted living. About 130 participants are covered in personal care facilities and adult foster care homes in 1998.

Definition

Personal Care Facilities A facility in which personal care is provided for residents in either a category A facility or a category B facility. A facility must have a license for either category A or category B. Category A means the residents can self medicate, are mobile, continent and generally in good health. Category B means residents may be ventilator dependent, incontinent, under chemical or physical restraint, or IV dependent. A facility that does not have a category B license may obtain one if the residents in the facility decline in health. Facilities may have up to five residents who fall in this category.

There were 58 facilities and 892 beds in 1996.

Unit Requirements

No more than four residents may reside in a single bedroom. Each single bedroom must contain 100 square feet and each multi-bedroom must contain at least 80 square feet per bed, excluding toilet rooms, closets, lockers, wardrobes, alcoves or vestibules. Each resident must have access to a toilet room without entering another resident's room or the kitchen, dining, or living areas. There must be one toilet room for every four residents and one bathing facility for every 12 residents.

Tenant Policy

PCFs may provide personal care services to a resident who is 18 or older and in need of the personal care for which the facility is licensed. A resident in a facility licensed as a category A facility may obtain third party provider services for skilled nursing care for no more than 20 consecutive days at a time.

A resident of a category B facility must have a signed statement from a physician agreeing to the resident's admission to the facility if the resident:

Needs skilled nursing care;
Needs medical, physical, or chemical restraint;
Is non-ambulatory or bedridden;
Has no bowel or bladder control; or
Is unable to self-administer medications.

Category B facility residents must have a signed statement renewed every quarter by a physical, physician assistant, nurse practitioner, or a registered nurse who visited the facility within the calendar quarter covered by the statement and has certified that the resident's need can be met in the facility. Category B facilities may serve five or fewer residents with the needs defined above.

Standards for operating a category B facility must include the standards for a category. A facility (standards for physical, structural, environmental, sanitary, infection control, dietary, social, staffing, and record keeping components of the facility) as well as standards for assessment of residents, care planning, qualifications, and training of staff, restraint use and reduction, prevention and care of pressure sores, incontinence care, and the storage and administration of drugs.

Residents of category B facilities must be assessed upon admission for mobility, mental status, physical status, self-medication, dietary needs, personal hygiene needs, and social needs. Within three days after admission a care plan must be developed that is prepared by a licensed health care professional, and to the extent practicable, with the participation of the resident, the resident's family, or the resident's legal representative. Care plans must be updated at least quarterly.

Services

Services include residential services, such as laundry, housekeeping, food service, and either providing or making available provision for local transportation; personal assistance services with ADLs; recreational activities; and supervision of self-medication. Personal care assistance is provided while encouraging residents to maintain independence and a sense of self-direction.

Reimbursement

The room and board payment under SSI is $589 a month and residents retain a personal needs allowance of $100. The Medicaid waiver reimburses adult foster care home and personal care facilities between $520 and $1800 a month depending on the level of care needed by residents. State agency field staff complete the assessment and determine the payment rate. In addition to the room and board component, the basic service payment for residents is $520 a month.

Additional payments are calculated based on ADL and other impairments. Points are calculated for each impairment. The functions measured are: bathing, mobility, toileting, transfer, eating, grooming, medication, dressing, housekeeping, socialization, behavior management, executive cognitive functioning and other. Each function is rated:

With aides/difficulty--means people who need consistent availability of mechanical assistance or expenditure of undue effort;
With help--means requires consistent human assistance to complete the activity but the individual participates actively in the completion of the activity; or
Unable--means the individual cannot meaningfully contribute to the completion of the task.

Each point equals $33 a month. For example, a resident consistently needing help with toileting would be scored a two and would earn $66 a month for that impairment. Residents with severe impairments, totally dependent in more than three ADLs, can receive $44 a month for each point. The total payment (services and room and board) ranges from $1084 to $2363 a month although very few participants have been approved at the highest rate. About 40 recipients are receiving this service under the HCBS program. The average payment is $42 a day

Medications

Staff may assist with self-administration of medications. Licensed health care professionals may set up daily dose containers, verify physician's orders, and set up injectable medications.

Staffing

There must be sufficient staff on duty 24-hour a day to provide proper resident care and all related services.

Training

Administrator Each PCF must employ an administrator who must at all times be responsible for the PCF and ensure 24-hour supervision of the residents and have completed high school or have a general education development (GED) certificate. Administrators must also evidence at least six hours of annual continuing education in one of the following areas: resident and provider rights and responsibilities, abuse/neglect, or confidentiality; basic principles of supervision; skills for working with residents, families, and other professional service providers; characteristics and needs of residents; community resources; accounting and budgeting; or basic and advanced emergency first aid.

Staff Direct care staff shall receive orientation as specified in the facility's policies and procedures manual and that is appropriate to the position, addresses the facility's policies in regard to performance of duties, and, in addition to the information required by ARM 16.32.903(9), includes at a minimum:

Basic personal care procedures, including grooming and personal hygiene, and methods to foster residents' maximum independence in activities of daily living;
Basic techniques in observation of resident's mental and physical health;
Bowel and bladder care, in a category B facility;
Assisting resident mobility, including transfer;
Techniques in lifting;
Food nutrition and diet planning;
Health-oriented record keeping, including time/employment records and resident records; and
Assistance with medications.

Background Check

All staff may not have convictions for a crime involving violence, fraud, deceit, theft, other deception or a violation of 52-3-825 MCA for which the person is still under state supervision.

Monitoring

Unannounced on-site surveys are conducted annually, biannually, or triennially depending on whether the facility has been granted an extended license. Individuals served under the HCBS program are reassessed every six months or more frequently if needed.

Fees

$70 per bed for category A facilities and $90 a bed for category B facilities.

Nebraska

Citation

Assisted living facilities NAC Title 175, Chapter 4.

General Approach

Rules for a new assisted living category are effective in 1998.

Grants for nursing home conversions Legislation providing $40 million in grants or loan guarantees to nursing homes to convert wings or entire facilities was approved by the legislature and signed by the governor in April 1998. The program will be administered by the Department of Health. Grants will be made when it is efficient and economical. Grantees must agree to maintain specified occupancy levels of Medicaid beneficiaries for a period of 10 years. The Department will develop rules specifying minimum occupancy rates, allowable costs and refund methods. Grants may cover capital or one time costs and operating losses for the first year to facilities that have participated in the Medicaid program for at least three years. Facilities must provide 20% of the cost of conversion.

Facilities may convert existing space or construct additional space to include assisted living or other alternative services. Construction of a new assisted living facility may be funded if the nursing home beds are de-licensed and it is more cost effective than conversion of existing space.

LB 608, passed in 1997, replaces residential care facilities and domiciliary facilities with a new assisted living program. Regulations developed by the Department of Health and Human Services will be effective July 1, 1998.

Definition

Assisted living facility means any institution, facility, place or building in which there are provided for a period exceeding twenty-four consecutive hours, through ownership, contract or preferred provider arrangements, accommodation, board, and an array of services for assistance with or provision of personal care, activities of daily living, health maintenance activities or other supportive services, for four or more non-related individuals who have been determined to need or want these services. Assisted living promotes resident self-direction and participation in decisions which emphasize independence, individuality, privacy, dignity and residential surroundings. This definition does not include (a) those homes, apartments, or facilities providing casual care at irregular intervals and (b) those homes, apartments or facilities in which a competent resident provides or contracts for his or her own personal or professional services in no more than twenty-five percent of the residents receive such services. A competent resident is someone who has the capability and capacity to make an informed decision.

No facility may hold itself out to be assisted living unless it is licensed.

Unit Requirements

Existing facilities may have single bedrooms with 80 square feet and multiple occupancy rooms with no more than 4 beds per room and 60 square feet per bed. Bathing facilities are required for every 16 residents. Toilet facilities may be provided adjacent to each bedroom or shared facilities must be available for no more than six residents.

New facilities must provide rooms of 100 square feet for a single resident in an apartment of dormitory-like room; 80 square feet per resident in rooms occupied by more than one residents with a maximum of two residents; and 60 square feet per resident in rooms occupied by more than one resident in an apartment, maximum of two residents. Facilities must provide a bathing facility adjacent to each room or central bathing facilities. Central bathing facilities must be available for every eight residents. A toilet and sink must be provided adjoining each resident's bedroom.

Tenant Policy

Anyone needing complex nursing interventions or whose conditions are not stable and predictable may not be admitted unless:

The resident, or the resident's designee if the resident is not competent, the resident's physician or the registered nurse agree that admission or retention is appropriate;
Care is arranged through private duty personnel, a licensed home health agency, or a licensed hospice agency; and
The resident's care does not compromise the facility operations or create a danger to others in the facility.

The administrator has discretion regarding admission or retention of residents.

Services

Services are to be provided in accordance with resident agreements which maximize resident's dignity, autonomy, privacy and independence. The rules list several indicators that measure whether resident needs are being met. Services include personal care, health maintenance activities, transportation, laundry, housekeeping, financial assistance/management, behavioral management, case management, shopping, beauty/barber and spiritual services. Health maintenance activities are defined as non-complex nursing interventions which can safely be performed according to exact directions, which do not require alteration of the standard procedure and for which the results and resident responses are predictable.

Facilities serving special populations must assess each resident to identify their abilities and needs, provide specially trained staff, prepare service agreements and provide a physical environment that conforms to and accommodates the special needs.

Reimbursement

A Medicaid waiver will be developed when the regulations are effective.

Medications

Medications may be administered by licensed staff or medication assistants approved by the department.

Staffing

The facility must maintain a sufficient number of staff with the required training and skills necessary to meet the resident population's requirements for personal care, activities of daily living, health maintenance activities, supervision and other supportive services.

Training

Staff Orientation must be given within two weeks to each direct care staff person of the facility and shall include as a minimum, but is not limited to, residents rights; resident service agreement; emergency procedures including information relating to availability, notification and advance directives; information on abuse, neglect and misappropriation of money or property of a resident; information on any physical and mental special care needs of the residents of the facility; and disaster plan preparedness.

Ongoing training must be given to each direct care staff person and shall consist of at least twelve hours per year on topics appropriate to the employee's job duties including meeting the physical and mental special care needs of residents.

Background Check

Criminal background checks must be completed on all direct care staff. Evidence of contact with the nurse registry, adult central registry of abuse and neglect and the child central registry of abuse and neglect must be obtained to verify no adverse findings concerning abuse, neglect or misappropriation of resident property.

Monitoring

Facilities will be inspected bi-annually or more frequently for cause.

Fees

$50 plus $1 for each bed.

Nevada

Citation

Residential Facilities for Groups: Nevada Revised Statutes § 449.017 et seq.; Nevada administrative code § 449.156

General Approach

Revised regulations went into effect in 1997 which replace rules for small facilities (<7 beds) and larger facilities (7 or more). A small Medicaid waiver reimburses homes for personal care in residential facilities for groups.

Definition

An adult group home for the elderly or disabled means a residential facility which provides care to three or more elderly or disabled persons requiring assistance and protective supervision due to infirmity or disability.

An Alzheimer's group home means a residential facility which provides care and protective supervision for three or more persons with Alzheimer's disease or related diseases to include: senile dementia, organic brain syndrome or other cognitive impairments.

Unit Requirements

Single occupant rooms must have 80 square feet of floor space and multiple resident rooms must have 60 square feet of floor space per resident. No more than three residents may share a room. One toilet and lavatory is required for every four residents. A tub or shower is required for every six residents. Doors of bedrooms may be equipped with locks for use by residents if the doors may be unlocked from the corridor and keys are readily available. Provisions must be made for privacy in all bathrooms and for all toilets located in bedrooms for use by more than one resident.

Facilities serving people with Alzheimer's disease must be sprinklered, and have 24-hour awake staff. Exit doors must have alarms or time-delay locks. Local audible alarming units must be installed. Facilities serving people with Alzheimer's disease must have a secure yard, completely fenced and gated with locking devices.

Tenant Policy

Residents are considered "care category 1," ambulatory, and "care category 2," non-ambulatory. Ambulatory residents are physically and mentally capable of moving from an unsafe area to an area of safety within four minutes unassisted. Non-ambulatory residents require the assistance of at least one other person to move to a safe area within four minutes. Facilities licensed prior to January 1, 1997 are not required to meet requirements for installing automatic sprinkler systems unless they seek to serve category 2 residents. Sprinklers must be installed prior to a change of ownership, an increase in licensed beds or admission of non-ambulatory residents. Requirements for hard wired smoke detectors with battery back up are also waived for small homes unless the above changes are proposed.

People who are bedfast, require 24-hour killed nursing or medical supervision, require restraints, or confinement in locked quarters may not be admitted. The rules do not allow facilities to admit or retain residents with a lengthy list of health conditions with some exceptions. Residents with (or needing) catheters, colostomies, contractures, pressure ulcers, diabetes, incontinence, enemas/suppositories, incontinence, oxygen, injections or wound care may not be admitted or retained unless the resident is physically and mentally capable of performing the required care or if the care is provided or supervised by an appropriately skilled medical professional. Residents needing gastronomy care, naso-gastric tubes, or have staph or other serious infections or tracheotomies cannot be admitted or retained unless a written request is submitted by the administrator documenting the resident's condition and how care can be provided and the request is approved by the licensing agency.

Services

Services provided include personal care, at least 10 hours of activities a week, three meals a day, protective supervision, laundry, assisting with access to dental, optical, social and related services as needed by residents. Assistance with medical needs described in the tenant policy section may be provided through a contract with a community agency or directly by staff hired by the facility.

Facilities serving people with Alzheimer's disease must offer activities related to gross motor activities, social activities, sensory enhancement activities and outdoor activities.

Medication

Facilities may assist with self-administration of medications when the resident's condition is stable and following a predictable course, the amount of medication is at a maintenance level and does not require daily assessment, and a written plan of care has been prepared by a physician or registered nurse. The staff assisting with self-administration must complete a training program in medications.

Reimbursement

Personal care services are reimbursed through a Medicaid HCBS in group residential settings if they meet the SSI eligibility criteria. Facilities receive a total payment of approximately $1000 a month which includes $781 from SSI for room and board and $9.09 a day ($277.20 a month) for personal care. Fifty four facilities currently contract with Medicaid and serve 52 beneficiaries. Participation has been lower than expected. Because the residential care program was designed to serve people needing an hour of personal care a day, participants have preferred to remain in their homes and participate in a similar waiver. As needs increase, facilities have not felt prepared to provide a higher level of care.

Staffing

Facilities must maintain staffing patterns that are sufficient to meet the care needs of residents and to enable residents to achieve and maintain their functioning, self care and independence. Facilities with more than 20 residents must have at least one awake staff member and an additional person available within 10 minutes. Staff of all facilities must receive 8 hours of training annually directed toward meeting the needs of group care residents. Facilities licensed for 20-49 residents must have one staff member designated to organize, conduct and evaluate activities. Facilities with 50 or more beds must have a full time person for activities.

Facilities serving people with Alzheimer's disease must have a licensed administrator with no less than three years of experience in licensed facilities caring for people with Alzheimer's disease or education and training comparable to the three year requirement. Staff in these facilities shall successfully complete eight hours of training in rendering care, emergency procedures and family support services. Facilities must plan to maintain interaction groups with a ratio of no more than six residents to one staff member during times when residents are awake.

Training

Administrators must have the necessary skills to meet or direct staff to meet the needs of residents unless such skills are met by appropriately skilled medical professionals who are employed by or contract with the facility. Administrators must receive eight hours of training annually directed toward meeting the needs of group care residents.

Staff All staff must possess the necessary skills to meet the needs of the residents in the residential facility with the exception of those needs/skills which are to be met in a contract with other service providers. Staff must receive 8 hours of training annually directed toward meeting the needs of group care residents.

Background Check

Caregivers must have no prior convictions or history of previous findings of abuse, neglect or exploitation or other serious convictions relating to the ability to care for dependent persons. All other staff must not have any convictions or history of abuse, neglect or exploitation. Reference checks may be used for documentation.

Monitoring

Facilities are subject to on-site inspections and complaint investigation.

Fees

Initial license, $500 and $50 per bed. Renewal, $300 and $35 per bed.

New Hampshire

Citation

Supported Residential Care Facilities Chapter He-P 805

Residential Care Home Facilities Chapter He--804

General Approach

State policy does not use the term assisted living, however, state contacts indicated that their approach supports assisted living in a number of settings. Home health agencies provide assisted living services in apartments and a number of apartment complexes advertize themselves as assisted living. In addition to home care services, two residential levels of care are licensed. Residential Care Home Facilities and Supported Residential Care Facilities. Supported Residential Care Facilities provide a higher level of care than Residential Care Home Facilities. The latter are not allowed to provide nursing services and provide guidance for assistance with ADLs rather than hands on assistance. There are 84 residential care facilities with 1,071 beds and 49 supported residential care facilities with 1,390 beds.

Regulations will be revised in 1998.

Definition

"Residential care facilities, whether or not they are private homes or other structures built or adapted for the purpose of providing residential care, offering services beyond room and board to two or more individuals who may or may not be elderly or suffering from illness, injury, deformity, infirmity or other permanent or temporary physical or mental disability. Such facilities include those:

Offering residents home-like living arrangements and social or health services including, but not limited to, providing supervision, medical monitoring, assistance in daily living, protective care or monitoring and supervision of medications; or
Offering residents social, health, or medical services including, but not limited to, medical or nursing supervision, medical care or treatment, in addition to any services included under subparagraph (1). Such homes or facilities shall include, but not be limited to, nursing homes, sheltered care facilities, rest homes, residential care facilities, board and care homes, or any other location, however, named, whether owned publicly or privately or operated for profit or not.

The statute indicates that residential care requires a minimum of regulation and reflects the availability of assistance in personal and social activities with a minimum of supervision or health care, which can be provided in a home or home-like setting. Supported residential health care reflects the availability of social or health services, as needed, from appropriately trained or licensed individuals, who need not be employees of the facility, but residents shall not require nursing services complex enough to require 24-hour nursing supervision. Such facilities may also include short-term medical care for residents of the facility who may be convalescing from an illness and these residents shall be capable of self-evacuation. Supportive residential care serves residents who do not need 24-hour nursing care except on a short term basis. Residents need help with ADLs but must be able to evacuate with assistance. Residential care homes are a step below supported residential care facilities and provide supervision and some ADL assistance.

Unit Requirements

Units must have at least 80 square feet per one bed room and 140 square feet per room with two beds, exclusive of space required for closets, wardrobe, dressers and toilet room. Rooms may be shared by two people. Sinks, toilets, tubs and showers shall be available for every six residents.

Tenant Policy

Residential care homes can accept only those persons who are (1) mobile and can self evacuate; (2) able to initiate and accomplish most activities of daily living but may require supervision or physical assistance; (3) not in need of licensed or professional nursing or monitoring except for temporary episodic illness.

Persons admitted for short stays must have a health examination conducted within 30 days prior to admission and include any orders and medications required by the resident; an assessment focused on the services needed by the resident; and an admission agreement which lists the services to be provided during the residence.

Persons admitted for more than a short term stay must have a health exam conducted within 30 days prior to admission which addresses medical requirements; functional activities and limitations; medication needs and orders; and dietary needs; the administrator or designee in conjunction with the resident's provider and family/guardian must complete an initial assessment prior to admission; the administrator must ensure that assessments are completed at least every six months; and the resident must receive a written list of services that will be provided; a list of services for which additional payment is required; rules of the home; information on, and procedures for, reserving a place in the home when the resident is hospitalized or out of the home for a period of time; grounds for termination of agreement; and notification required for involuntary transfer for reasons other than emergency situations.

Residential care homes may not accept any resident whose assessment indicates services are required which the facility cannot provide.

Supported residential care facilities may accept only residents who are mobile and can self-evacuate; are able to initiate and accomplish some ADLs with help but require physical assistance and prompting with others; require intermittent, short term 24-hour nursing care or less than 24-hour nursing care on an ongoing basis; require consultation or direct care for therapeutic services (physical, occupational, recreational therapy and mental health services); or require administration of medications.

Services

Residential care homes Services include protective services including supervision, arrangement of appointments, crisis intervention, supervision in activities of daily living, nutrition and medications, and provision of or arrangement for transient medical care with licensed home health care providers; access to community services; and room and board.

If a resident's health status changes permanently to non-mobile or the resident requires medical or nursing care on an ongoing basis, the home must either provide medical or nursing care from a licensed home health care provider on a contract basis; seek licensure to provide a higher level of care; or transfer the resident to another facility where medical and nursing care are available.

The home is responsible for arranging the provision of additional services to residents requiring care during a temporary episodic illness or convalescence following acute hospital care.

Supported residential care facilities provide housekeeping, verbal and physical assistance with ADLs, nutrition monitoring, meals, personal supervision when required to offset cognitive deficits that pose a risk to self or others, assistance with medications (verbal prompting, reminding and some physical assistance) and provision for administration of medications by appropriately licensed persons directly or by contract with a licensed home health agency and for treatments ordered by a physician. Facilities shall provide or arrange with a licensed home health agency for short term intermittent nursing care and less than 24-hour nursing or other medical monitoring care on an ongoing basis.

Medication

Administration of medications by licensed staff is allowed.

Financing

A Medicaid waiver is expected to be submitted in 1998.

Staffing

Administrators must be at least 21 and never convicted of a misdemeanor or felony. Administrators of facilities licensed for 4 to 16 beds must have a high school diploma or GED plus one year of work experience in a health field; or an associates degree from an accredited college or university in a health field.

Administrators of residential care homes licensed for 17 or more residents must have a high school diploma plus five years of direct care experience; an associate's degree from an accredited college or university plus three years of experience in a health or human services field; or a bachelor's degree in a health field.

Residential care homes do not require medical directors or directors of nursing. Other staff must be at least 18 years old if they provide direct care.

Training

Administrators must have 12 hours of continuing education each year.

Staff Personnel shall have orientation and training in the performance of their duties and responsibilities which includes job description requirements, fire safety and evacuation, medical emergency protocol, resident rights and facility tour and familiarization.

Ongoing in-service training or continuing education must be provided to address areas of weakness identified during annual performance review. In-service training shall also address new or special needs of residents and shall include training in: medication supervision or administration; first aid; behavior management; personal care; fire safety and evacuation; socialization and resident rights.

Background Check

Staff may not have been convicted of a felony and never have been convicted of abuse, assault, neglect, or exploitation of any person. A signed statement by the employee is acceptable documentation for conviction of abuse, assault, neglect or exploitation.

Monitoring

The licensing agency conducts annual inspections of facilities.

Fees

$2.50 per bed.

New Jersey

Citation

Assisted living Chapter NJAC 8:36

General Approach

Regulations took effect in December 1993 governing the provision of assisted living services in assisted living residences and comprehensive personal care homes. The regulations promote aging in place in homelike, apartment style settings for frail elders. The purpose section of the regulations describes the goals of assisted living to "maintain independence, individuality, privacy, dignity" in an environment that "promotes resident self direction and personal decision making while protecting health and safety." The NJ Board of Nursing approved applying a medication administration rule for all three categories of assisted living, which allow unlicensed staff, who are certified and under the supervision of a licensed registered nurse, to administer medications, in specific circumstances, to assisted living residents.

Regulations creating assisted living programs in subsidized housing sites were effective in August 1996. ALP regulations permit licensing of a service agency to deliver services in subsidized elderly housing projects.

Licenses have been issued for 57 facilities containing 3,919 beds. Of these 33 are ALRs with 2,772 beds, 20 are CPCHs with 1,147 beds and 4 are ALPs. One nursing facility with 51 beds has converted to assisted living. Another 233 have been approved but not yet licensed and 43 applications are under review.

Eighteen ALRs/CPCHs and three ALPs currently contract with Medicaid and serve 120 beneficiaries.

All new construction is purpose built, apartment style units. Only facilities licensed by the Department of Health and Senior Services prior to December 1993, the effective date of the assisted living regulations, can convert to comprehensive personal care homes and offer bedrooms rather than apartment style units with a kitchenette. The state has adopted an expedited certificate of need review for assisted living residences.

Definition

Assisted living "means a coordinated array of supportive personal and health services, available 24-hours per day to residents who have been assessed to need these services, including residents who require formal long term care. Assisted living promotes resident self direction and participation in decisions that emphasize independence, individuality, privacy, dignity and homelike surroundings."

Assisted living residence means a facility which is licensed by the Department of Health and Senior Services to provide apartment-style housing and congregate dining and to assure that assisted living services are available when needed, for four or more adult persons unrelated to the proprietor. Apartment units offer, at a minimum, one unfurnished room, a private bathroom, a kitchenette and a lockable door on the unit entrance.

Comprehensive personal care home means "a facility which is licensed by the Department of Health and Senior Services to provide room and board and to assure that assisted living services are available when needed, to four or more adults unrelated to the proprietor. Residential units may house no more than two residents and have a lockable door on the unit entrance."

Assisted living program (ALP) "means the provision of or arrangement of meals and assisted living services, when needed, to the tenants of publicly subsidized housing which because of federal, state or local housing laws, regulations or requirements cannot become licensed as an assisted living residence. An assisted living program may also provide staff resources and other services to a licensed assisted living residence and a licensed comprehensive personal care home." In these instances, ALPs must comply with the licensing standards that are appropriate to the setting.

Unit Requirements

Each assisted living residence unit must offer a minimum 150 square feet (single occupancy) of clear and useable floor area (excluding closets, bath and kitchen), private bathroom, a kitchenette and a lockable door on the unit entrance. The kitchenette must include a small refrigerator, cabinet for food storage, sink, and space with outlets suitable for cooking appliances such as a microwave, cook top or toaster oven." An additional 80 square feet of floor space must be provided for a second person occupying a unit. No more than two people may occupy a unit.

Comprehensive personal care home units must provide 80 square feet for single occupancy units and 130 square feet if the unit is occupied by two people. While a locked door is required, private baths and kitchenettes are not required.

Assisted living programs are licensed as a service. Requirements for the apartments in subsidized housing projects are specified by the source of financing and the building code.

Tenant Policy

Assisted living is not appropriate for people who are not capable of responding to their environment, expressing volition, interacting or demonstrating independent activity. Each resident receives an assessment and a care plan by a registered nurse. The residence may, but is not required to, care for people who require 24-hours, seven day a week nursing supervision, are bedridden longer than 14 days, consistently and totally dependent in four or more ADLs, have cognitive decline that interferes with simple decisions, require treatment of stage three or four pressure sores or multiple stage two sores, are a danger to self or others or have a medically unstable condition and/or special health problems. The admission agreement has to specify if the facility will retain residents with one or more of these characteristics and the additional costs which may be charged. The facility must also describe the assessment process and the manner in which the resident and/or their family will be involved. Managed risk agreements are negotiated, when appropriate, based on resident actions, choice or preferences. Within 36 months of licensing, at least 20 percent of the residents in each licensed facility must have nursing home level of care needs.

Services

The residence must provide personal care and provide or arrange for other services. The minimum service capacity must include personal care, nursing, pharmacy, dining, activities, recreation, and social work services to meet the individual needs of residents. Supervision, assistance with and administration of medications by trained and supervised personnel is also required. Facilities must also be capable of providing or arranging for the provision of nursing services to maintain residents.

Rules ALPs require contracts between service providers and the housing entity. The contracts provide that tenants will not be barred from participation because of the location of a unit, tenants cannot be moved because of their participation. Housing owners/managers must agree to the provision of services. ALPs shall be capable of providing or arranging for assistance with personal care, nursing, pharmaceutical, dietary and social work services, transportation and recreational activities.

Financing

A Medicaid home and community based services waiver effective in 1996 allows the state to serve 1500 residents. In April 1998, 120 residents were being served. Rates have been developed for each of the three settings. Assisted living residences receive $571.55 for room and board from SSI and $1800 a month for Medicaid services. Assisted living programs receive $1200 a month for services. Residents are charged a percentage of their income for room and board. Comprehensive personal care homes receive $571.55 for room and board and $1500 a month for services. Medicaid officials plan to review their methodology.

NEW JERSEY RATE SCHEDULE
	Assisted Living Residences	Assisted Living Programs	Comprehensive Personal Care Homes
Room and board	$571.55	NA*	$571.55
Medicaid waiver services	$1800.00	$1200.00	$1500.00
Total	$2371.55	$1200.00	$2071.55
NOTE: Assisted living program residents live in subsidized housing and are charged a percentage of their income for rent. Residents in ALRs and ALPs retain a personal needs allowance of $72.50 a month.

Medications

Residences are allowed to provide supervision of and assistance with self-administration of medications and administration by trained and supervised personnel. Registered nurses may delegate medication administration to personal care assistants who have completed required training and passed a written test.

Staffing

The regulations require at least one awake personal care assistant and one additional staff at all times and sufficient staffing to provide the services indicated by the assessments of resident needs. A registered nurse must be available on staff or on call 24-hours a day. ALPs must have policies which assure that at least one staff member of the ALP or the housing program is on-site 24-hours a day.

Training

Administrators in all three licensed settings must be licensed as a nursing home administrator or complete an assisted living training course, or other equivalent training, as approved by the department and shall pass a state examination. The course includes 40 hours of classroom training and a 16 hour curricula. The administrator must also participate in at least 10 hours of continuing education annually regarding assisted living concepts and related topics, as specified and approved by the Department of Health and Senior Services or the NJ Nursing Home Administrators Licensing Board.

Staff Each personal care assistant shall have completed:

A nurse aide training course approved by the Department and shall have passed the Nurse Aide Certification exam; or
A homemaker-home health aide training program approved by the Board of Nursing and shall be so certified; or
Other equivalent training program approved by the Department.

Each PCA shall receive orientation prior to or upon employment and ongoing in-service education regarding the concepts of assisted living, emergency plans and procedures and the infection and prevention program.

Background

Administrators must be of a good moral character. Facilities shall exercise good faith and reasonable efforts to ensure that staff have not been convicted of a crime relating adversely to the person's ability to provide resident care such as homicide, assault, kidnapping, sexual offenses, robbery, and crimes against family, children or incompetents, except where the applicant has demonstrated rehabilitation.

Fees

Licensure fees are $500 plus $10 per bed. Assisted living programs pay a fee of $750.

New Mexico

Citation

Adult residential care NMAC Title 7 Chapter 8 Part 2

Assisted living (Medicaid)

General Approach

The state has added assisted living as a Medicaid waiver service. Providers may be licensed adult residential care homes or new or innovative programs. The program has signed agreements with 6 contractors although few recipients have joined the program. State contacts indicate that most facilities are part of or attached to nursing homes and residents prefer to remain in their own homes. Residential care facilities may not provide 24-hour supervision and residents who may be appropriate for admission but are able to remain in their own homes with waiver services.

Definition

Adult residential care facility means any congregate residence, maternity shelter or building for adults, which provides and primary purpose is to provide to residents, within the facility, either directly or through contract services, programmatic services, room, board, assistance with activities of daily living, in accordance with the program narrative, and/or general supervision to two or more adults who have difficulty living independently or managing their own affairs.

Medicaid Assisted living is a special combination of housing and personalized health care service designed to respond to the individual needs of waiver recipients who require assisting with activities of daily living (ADL's e.g., ability to perform tasks that are essential for self care, such as bathing, feeding oneself, dressing, toileting, and transferring) and instrumental activities of daily living (IADL's, e.g., ability to care for household and social tasks to meet individual needs within the community). Assisted living is based on the following fundamental principles of practice: individuality, independence, privacy, dignity, choice and a home-like environment. Assisted living services are packaged per individual recipient needs.

Unit Requirements

Private rooms must have at least 100 square feet of floor area, not including closets and locker areas. Semi-private rooms shared by no more than two people must have at least 80 square feet of floor area per bed, not including closets and locker areas. Dormitories or wards must have sixty feet of floor area for each bed. Toilets, sinks, tubs, and showers must be provided in ratios of one for every eight residents.

Medicaid Services must be provided in "home-like" environments which are defined as:

A minimum of 220 square feet of living and kitchen space (not including bathroom) for newly constructed units (rehabilitated units must provide a minimum of 160 square feet).
Adult residential shelter care homes must provide 100 square feet of floor area in a single bedroom (excluding closet/locker). Recipients must have access to a common living area, kitchen and bathroom which are handicapped accessible. 80 square feet is required for semi-private bedrooms.

Tenant Policy

Facilities may not admit anyone requiring continuous nursing care which includes ventilator dependency, stage III or IV pressure sores, intravenous therapy or injections directly to veins, airborne infectious diseases, conditions requiring physical or chemical restraints, nasogastric tubes/gastric tubes, tracheotomy care, individuals presenting an imminent physical threat or danger to self or others or individuals whose physician certifies that placement is no longer appropriate. Exceptions are allowed when a team (director, resident, agent, advocate, physician, other health professionals) jointly agree and approve a service plan identifying needs and how they will be met, ensuring maintenance of the facility's evacuation rating, and the well-being of others.

Services

Facilities must supervise and assist residents as necessary with health, hygiene and grooming needs to include but not be limited to eating, dressing, oral hygiene, bathing, grooming, mobility and toileting. Individual service plans may be prepared as needed but are required for residents who need nursing services. Three meals, laundry, and housekeeping must be provided.

Medicaid An inter-disciplinary team develops an individualized service plan which is approved by the Department of Health waiver staff. Staff from the facility participate as a member of the team and attend team meetings.

Core services provide minimum to moderate assistance and include at a minimum: bathing, dressing, eating, personal hygiene, behavior management, opportunities for individual and group interaction, housekeeping, laundry, transportation, meal preparation and dining, twenty-four hour response capability to meet routine scheduled care as well as unscheduled, unpredictable needs of the recipients, capacity to provide on-going supervision of the waiver recipient within a twentyfour hour period, service coordination capability to arrange access to services not provided directly, provider participation in the interdisciplinary team meetings for development of the individualized service plan and demonstrated capability to address the most common dementia related problems (e.g., memory loss, depression, sleep disorders).

In addition to the above core services, providers may provide personal services (specialized bowel and bladder program and catheter care); private duty nursing (medication management, nursing services such as injections, wound care, health status monitoring and assessment); skilled maintenance therapies (PT, OT, speech); emergency response services; and other support services authorized by the Department of Health designed to maintain independence.

Services may be provided by the facility or another approved waiver provider.

Reimbursement

The Department of Health has established an interim service rate of $47.50 per day (excluding room and board) for approved provider agencies. The Department of Health and Department of Human Services reviews reports filed during the first quarter to determine a final rate. The Department will consider setting a base rate with add-ons for other services (eg., therapies) as well as negotiated rates. Room and board charges must be submitted to the Department of Health prior to the provision of services. The waiver set eligibility at 200% ($988 a month) of the federal SSI payment and recipients may keep income below $988 to cover maintenance needs. The maintenance allowance was set based on recipients living in their own home/apartment and an adjustment may be made for recipients in assisted living.

Medications

Medications may be administered by licensed health care professionals.

Staffing

The waiver guidelines require staffing ratios and patterns that will meet the individual recipient's needs as identified in the ISP.

Training

Staff training, appropriate to staff responsibilities, includes, at a minimum, an orientation and an on-going, but at least annual, program which includes: fire safety, first aid, safe food handling practices, confidentiality of records and resident information, infection control, resident rights, reporting requirements on abuse, neglect and exploitation, and providing quality resident care based on current resident needs.

Subchapter: §836-1.8 Qualifications of personal care assistants.

Each personal care assistant shall have completed:

A nurse aide training course approved by the Department and shall have passed the Nurse Aide Certification exam; or
A homemaker-home health aide training program approved by the Board of Nursing and shall be so certified; or
Other equivalent training program approved by the Department.

Each PCA shall receive orientation prior to or upon employment and ongoing in-service education regarding the concepts of assisted living.

Background

No specific provisions. May be addressed in facility personnel policies.

New York

Citation

Adult care facilities 18 NYCRR §487

Enriched housing programs 18 NYCRR §488.1 et seq.

Assisted living program. NY Social Service Law §461-1 et. seq.; NY Comp. Codes R & Regulations title 18, §485.1 et seq.

General Approach

A complete review of the multiple regulations and categories is underway. Regulation activities are being consolidated under a new Office of Continuing Care that was created in January 1998 and includes responsibility for residential care, adult homes and enriched housing programs. The Long Term Care Omnibus Act of 1997 directs the Commissioner on Health to conduct a study on utilization in and the future development of assisted living, including demographic information on current residents and the population that could be served; service utilization patterns; options for further development and program financing; and an oversight structure. The report was expected to be completed in the summer of 1998.

A Task Force on Long Term Care Financing issued a report in 1996 that makes broad recommendations on long term care. A section of the report recognized that assisted living has been developed "as an alternative for low income people who would otherwise require nursing facility placement." The report recommends that the program be reformed "to require licensure of assisted living as a specific type of enhanced home care service under the auspices of one State agency." Currently, the program falls under two laws, one licensing adult care facilities and the other licensing home care agencies. The report recommended allowing the residential component to be provided in any type of residential setting, including adult care facilities that meet building requirements such as the State Uniform Fire Prevention and Building Code. A series of outcome based program requirements would be set for fire safety, nutrition, medication management and case management.

The New York Task Force saw assisted living taking a prominent place in the state's overall long term care strategy and affecting the need for nursing home beds. The report recommended a reexamination of all components of the nursing facility bed need methodologies for long term care that reflects projected demographic trends, expected changes in utilization patterns based on increases in managed care penetration, addition of new services options (eg., assisted living) and potential changes in utilization based financing recommendations.

In 1991, the state legislature created a 4,200 bed assisted living program (ALP). Since the program substitutes for nursing home beds, the nursing home bed need formula was reduced by an equivalent amount. Three rounds of bidding have resulted in the award of approximately 4,000 units. A fourth round was expected that will award 200 units in Long Island. Of the approved units, about 3,000 are operating and 2,100 are filled.

The state approaches assisted living as a service option in existing housing. Assisted living programs must be licensed as an adult home or enriched housing program (which addresses housing) and licensed as either a home care services agency, a certified home health agency or a long term home health care agency (which addresses home care service delivery).

Until January 1998, oversight was provided by two state agencies. The Department of Health reviews licenses for licensed home care agencies and the Department of Social Services licenses adult homes and enriched housing. Responsibilities were being consolidated in 1998.

Adult homes and enriched housing programs are both licensed under the state's adult care facility regulations. Both models serve five or more people and provide long term residential care, room, board, housekeeping, personal care and supervision. Adult homes represent the state's board and care model while enriched housing programs operate in community integrated settings resembling independent housing units. While the majority of Assisted Living Program beds are in adult homes, the demand from "enriched housing" providers is increasing among purpose built facilities rather than conventional elderly housing sites.

Definition

Adult care home is established and operated for the purpose of providing long term residential care, room, board, housekeeping, personal care and supervision to five or more adults unrelated to the operator. Adult homes may be either proprietary, public or non-profit.

Enriched housing program means an adult care facility established and operated for the purpose of providing long term residential care to five or more adults, primarily persons 65 years of age or older (no more than 25% under 65 and all are 55 or older), in community integrated settings resembling independent housing units. Such programs must provide or arrange for the provision of room and board, housekeeping, personal care and supervision.

Assisted Living Program (ALP) (Medicaid program) is available in some adult home and enriched housing programs, combines residential and home care services. It is designed as an alternative to nursing home placement for individuals who have historically been admitted to nursing homes for social rather than medical reasons. The operator of the ALP is responsible for providing or arranging for resident services that must include room, board, housekeeping, supervision, personal care, case management and home health services.

Unit Requirements

Adult homes provide single or double occupancy bedrooms and have one toilet and lavatory for every six residents and one tub/shower for every 10 residents.

Enriched housing programs must provide single occupancy units, unless shared by agreement, and each unit must include a full bathroom, living and dining space, sleeping area and equipment for storing and preparing food. Shared units must provide for toilets, lavatory, shower or tub shared by not more than three residents.

Assisted living programs comply with the relevant requirements under which the contracting facility is licensed.

Tenant Policy

Enriched housing programs Operators may not accept or retain anyone who: requires continual nursing or medical care; suffers from a serious and persistent mental disability sufficient to warrant placement in an acute care or residential treatment facility; is a danger to self or others; requires continual skilled observation; refuses or is unable to comply with treatment; is chronically bedfast or chairfast and requires assistance from another person to transfer; regularly needs assistance from another person to walk or climb and descend stairs unless on the ground floor; has chronic un-managed urinary or bowel incontinence; has a communicable disease; is dependent on medical equipment (with exceptions); has chronic personal care needs which cannot be met by the staff; is not self-directing and engages in drug or alcohol use which results in aggressive or destructive behavior.

Medicaid To receive Medicaid reimbursement for home care services provided in an ALP, applicants must be determined by a physician to be appropriate for this level of care. The applicant must then be assessed by the ALP to determine the care required and the program's ability to meet those needs. Participants must have stable medical conditions and are able to assure self-preservation in an emergency.

Services

Adult homes and enriched housing programs can provide supervision, personal care, housekeeping, case management, activities, food service assistance with medication and activities under their adult care facilities license. To operate as an assisted living program, additional services and licenses are needed. The facility may seek a license to provide nursing care and therapies or they may contract with a home health agency or a long term home health care program. A care plan is jointly developed by the ALP and the CHHA/LTHHCP which is based on the physician's orders and the assessment process.

The Medicaid ALP capitation rate covers personal care, home health aide, personal emergency response services, nursing services, physical therapy, occupational therapy, speech therapy, medical supplies that do not require prior authorization and adult day health care, if needed.

Financing

For Medicaid recipients, the home care service reimbursement is set at 50% of the resident's Resource Utilization Group (RUG) which would have been paid in a nursing home. The state has created 16 RUG categories for 10 geographic areas of the state. The attached chart includes rates in use for 1998. Facilities must comply with the adult home retention criteria. However, the full array of rates are shown since facilities receive a higher rate when a resident deteriorates and is retained until a nursing home placement can be made.

The reimbursement category is determined through a joint assessment by the Assisted Living Program and the designated home health agency or long term home health care program. The assessment and the RUG category are reviewed by the Department of Social Services district office which must prior authorize the Medicaid home care payment.

The residential services (room, board and some personal care) are covered by SSI which also varies by region. In 1998, the SSI rates were $929 in New York City, Nassau, Suffolk and Westchester counties and $899 in the rest of the state. Using the four lowest RUG categories and the SSI rates, the total monthly rate in New York City ranges from $1706 to $2516.

Medication

Assistance with self-administration is allowed including prompting, identifying the medication for the resident, bringing the medication to the resident, opening containers, positioning the resident, disposing of used supplies and storing the medication.

Staffing

Adult homes must have a case manager and staffing that is sufficient to provide the care needed by residents.

Training

Administrators Program coordinators must be 21 or older, have a master's degree in social work and one year experience, or a bachelor's degree and three years of acceptable experience.

Staff providing personal care must complete a personal care aide or home health aide training course or other examination approved by the state Department of Health. Enriched housing programs must provide an orientation and in-service training in the characteristics and needs of the population served, resident rights, program rules and regulations, duties and responsibilities of all staff, general and specific responsibilities of the individual being trained and emergency procedures.

Background Checks

Applicants for a license must disclose and submit a history of legal actions including criminal actions.

RUG RATES IN NEW YORK STATE

RUG

Albany

NYC

Syracuse

Rochester

Orange

Long
Island

Erie

Westchester

Utica

Poughkeepsie

$44.81

$64.16

$47.99

$45.27

$48.84

$59.66

$41.83

$56.06

$41.78

$45.61

$44.47

$63.76

$47.65

$44.86

$48.47

$59.28

$41.52

$55.63

$41.52

$45.24 - hour

$37.91

$53.47

$40.84

$38.45

$41.12

$49.62

$35.50

$47.11

$35.58

$38.69

$48.13

$69.71

$51.53

$48.41

$52.51

$64.87

$44.82

$60.49

$44.77

$48.96

$67.80

$100.54

$72.07

$67.79

$74.42

$93.83

$62.78

$86.19

$62.41

$68.83

$73.60

$109.87

$78.21

$73.47

$80.80

$102.61

$68.02

$93.88

$67.56

$74.75

$66.25

$98.11

$70.48

$66.31

$72.65

$91.56

$61.34

$84.24 - hour

$60.96

$67.34

$72.62

$107.45

$76.98

$72.80

$79.79

$100.32

$67.23

$92.41

$66.65

$73.78

$57.39

$84.40

$61.28

$57.52

$62.79

$78.68

$53.24 - hour

$72.68

$53.06

$58.36

$61.07

$90.22

$65.11

$61.10

$66.89

$84.16

$56.61

$77.47

$56.38

$62.05

$69.63

$103.59

$74.06

$69.57

$76.40

$96.71

$64.40

$88.69

$64.01

$70.74

$53.35

$78.12

$57.05

$53.48

$58.30

$72.79

$49.56

$67.36

$49.47

$54.23

$59.18

$87.41

$63.19

$59.22

$64.76

$81.51

$54.84

$75.07

$54.66

$60.17

$53.35

$78.12

$57.05

$53.48

$58.30

$72.79

$49.56

$67.36

$49.47

$54.23

$57.05

$84.02

$60.95

$57.13

$62.42

$78.32

$52.93

$72.24 - hour

$52.78

$58.00

$63.36

$94.23

$67.65

$63.30

$69.36

$87.92

$58.63

$80.64

$58.38

$64.45

NOTE: ALPs receive one half the rate listed.

CA = Clinically complex A
BA = Severe behavioral A
PA = Reduced physical functioning A
PB = Reduced physical functioning B
RA = Heavy rehab A
RB = Heavy rehab B
SA = Special care A
SB = Special care B

CB = Clinically complex B
CC = Clinically complex C
BB = Severe behavioral B
BC = Severe behavioral C
PC = Reduced physical functioning C
PD = Reduced physical functioning D
PE = Reduced physical functioning E

North Carolina

Citation

Assisted living residences NCAC Title 10 Chapter 42 Subchapter 42B, 42C and 42D; General statute 131D-2

General Approach

A one year moratorium on the construction of new assisted living residences was passed in 1997. The bill allows a waiver of the moratorium for counties with high occupancy rates.

Legislation passed the end of July 1995 established the umbrella term of "assisted living residences" for two types of long term residential care settings: (1) adult care homes, formerly called domiciliary homes, which must be licensed by the state; and (2) multi-unit assisted housing with services, a new housing category effective July 1, 1996, which must be registered with the state.

Multi-unit assisted housing models have to register with the Division of Facility Services and provide a disclosure statement to residents based on requirements established by the state. The statement describes the emergency response system, charges for services offered, limitations of tenancy and services, resident responsibilities, financial relationships between housing management and home care or hospice agencies, a listing of all home care or hospice agencies in the area, an appeal process and procedures for annual screening and referrals for service.

Definition

"Assisted living residence" means a group housing and services program for two or more adults, by whatever name it is called, which makes available, at a minimum, one meal per day and housekeeping services and provides personal care services directly or through a formal written agreement with one or more licensed home care agencies. Assisted living residences are to be distinguished from nursing homes subject to the provisions of G.S. 131E-102. Effective October 1, 1995 there are two types of assisted living residences: adult care homes and group homes for developmentally disabled adults.

"Adult care home" is an assisted living residence in which the housing management provides 24hour scheduled and unscheduled personal care services to two or more residents, either directly or, for scheduled needs, through formal written agreement with licensed home care or hospice agencies. There are three types of adult care homes.

Adult care homes licensed for seven or more beds;
Family care home,--an adult care home licensed for 2-6 beds; and
Group home for developmentally disabled adults--an adult care home which is licensed for 2-9 beds for developmentally disabled adult residents.

"Multi-unit assisted housing with services" means "an assisted living residence in which hands on personal care services and nursing services which are arranged by housing management are provided by a licensed home care or hospice agency, through an individualized written care plan." Multi-unit assisted housing with service programs are required to register with the Division of Facility Services and to provide a disclosure statement.

Unit Requirements

Settings in which services are delivered may include self-contained apartment units or single or shared room units with private or common baths. Residential building codes apply to adult care homes serving six or fewer residents and institutional codes to adult care homes service more than six residents.

Adult homes may serve up to four residents per bedroom. Bedrooms must be 100 square feet, excluding vestibule and closet, for single rooms and 80 square feet per bed for multiple occupancy rooms. One bathroom must be provided for every five residents and a shower for every 10 residents.

Tenant Policy

Unless a physician determines otherwise, adult care homes may not care for people who are ventilator dependent, or require continuous licensed nursing care. Individuals whose physician certifies that placement is no longer appropriate, individuals whose health needs cannot be met in the specific adult care home as determined by the residence and people with such other medical and functional care needs as the Social Services Commission determines cannot be properly met cannot be served.

The disclosure statement for multi-unit assisted housing with services programs is required to be part of the rental agreement and covers the emergency response system, charges for services, limitations of tenancy, limitations of services, resident responsibilities, the financial and legal relationships between the housing management and home care or hospice agencies, a listing of all home care or hospice agencies in the area, an appeals procedure and procedures for initial and annual resident screening and referrals for services.

Unless the individual's physician determines otherwise, multi-unit assisted housing with services may not care for people who are ventilator dependent, have dermal ulcers stage III and IV, except stage III ulcers that are healing, take psychotropic medications without appropriate diagnosis and treatment plans, have nasogastric tubes or gastric tubes except when the individual is capable of independently feeding themself or is managed by a home care or hospice agency, individuals requiring continuous nursing care, and individuals who require maximum assistance with four or more ADLs and who meet the nursing home level of care criteria.

Services

At a minimum residences must provide one meal a day and housekeeping services. Personal care may be provided directly or through contracts. Nursing services may be provided by the residence on a case by case exception basis approved by the Department of Health and Human Services. However, nursing services can be provided through licensed home care agencies. The Social Services Commission has the authority to limit nursing services provided by assisted living residences.

Financing

Personal care in adult care homes is reimbursed as a state plan service through Medicaid. The maximum State/County Special Assistance (SA) payment [this is an OSS payment that includes the federal SSI payment] for room and board is $893 a month plus a $31 personal needs allowance. The Medicaid payment varies with the needs of the residents. The basic payment is $8.07 a day which assumes each resident receives one hour of personal care a day. Homes receive higher payments for residents with extensive or total impairments in three specific ADLs: eating, toileting or both. The rate for residents who need extensive assistance or are totally dependent in eating is $16.00 per day, toileting $10.87 per day and for both eating and toileting, $18.80 per day. These three payment levels include the basic rate of $8.07 per day. Eligibility for the added payment is based on an assessment by the adult care home which is then verified by a county case manager.

NORTH CAROLINA MEDICAID RATES--MONTHLY
	Basic Rate	Eating	Toileting	Eating and Toileting
Room and board	$893.00	$893.00	$893.00	$893.00
Personal care	24-hour $2.70	$480.00	$326.10	$564.00
Total	$1135.70	$1373.00	$1219.10	$1457.00

Medication

Medications must be administered in adult care homes by staff designated by the administrator who must assure the provision of appropriate training.

Staffing

These requirements vary by the size of the facility and shift. Larger facilities (> 20) must have 0.4 aide hours per resident or eight hours per each 20 residents plus three hours for all other residents, whichever is greater, for the first and second shift. On the third shift, eight hours of aide duty is required per 50 or fewer residents. Residences of 12 or fewer residents must have one person on staff at all times and at least 12 hours must be spent providing personal care, health services, activities, medication management and other services needed by residents. Rules for homes serving 13-20 residents require at least one person on duty in the home to perform direct personal care and supervision. Food service and housekeeping functions must also be staff.

Training

Administrators The administrator must verify that he earns 15 hours per year of continuing education credits related to the management of adult care homes and care of aged and disabled persons in accordance with procedures established by the Department of Health and Human Services. The requirement does not apply where the administrator is also a currently licensed nursing home administrator. The administrator must verify that he has worked in a licensed adult care home for at least 90 days (for an adult care home of 7+ beds) or 30 days (for family care homes) in an approved on the job training program or have appropriate education, training and experience.

Staff providing or directly supervising staff who provide basic personal care must successfully complete a 40 hour training program (for adult care homes 7+ and homes for developmentally disabled adults), or a 20 hour program (for family care homes), including a competency exam, approved by the department. This curriculum includes classroom training and supervised practical experience. The training and competency exam covers five areas: basic nursing skills; personal care skills; cognitive, behavioral and social care; basic restorative services; and residents' rights

Staff in any adult care home who perform certain health-related personal care tasks, as specified in rule, must successfully complete a 75 hour training program, including competency exam. This includes at least 30 hours of classroom instruction and at least 30 hours of supervised practical experience. The areas of competency include: observation and documentation; basic nursing skills, including special health related tasks; personal care skills; cognitive, behavioral and social care; basic restorative services; and residents' rights.

Staff with experience according to the rule may take the competency exam without undergoing training.

Monitoring

County Departments of Social Services monitor adult care homes at least every other month. State staff provide consultation, technical assistance and training to the county monitors. State staff also provide monitoring oversight and perform selected surveys of homes based on compliance history or lack of previous county monitoring.

Background Check

Administrators must provide written documentation about convictions of criminal offenses from the clerk of court in the county in which the conviction occurred, and about any driving offenses other than minor traffic violations. Criminal history record checks through the State Department of Justice are required for applicants for employment who do not have an occupational license.

North Dakota

Citation

Basic Care Facility Chapter 23-09.3

Assisted living Chapter 50-24.5

General Approach

A task force has been created to study and make recommendations on creating an assisted living category. The task force is approaching assisted living as an opportunity to provide more choices and options for consumers. A two year moratorium was established in 1997 to halt new construction of nursing homes and basic care facilities. Recommendations will be submitted to the legislature in 1999.

The state reimburses assisted living primarily through two state funded service programs. Assisted living is viewed as a service in an apartment setting. Licensing is not required, however, the public welfare statute contains a definition of assisted living. The state funded assisted living program operates in two buildings. The program assists fifteen of the eighteen residents in one building which is funded by HUD for people with mobility impairments. Another 24-hour unit building also plans to participate in the program.

Definition

Assisted living means an "environment where a person lives in an apartment like unit and receives services on a twenty-four hour basis to accommodate the person's needs and abilities and maintain as much independence as possible."

Basic care facility means "a facility licensed by the department ... whose focus is to provide room and board and health, social and personal care to assist the residents to attain or maintain their highest level of functioning, consistent with the resident assessment and care plan, to five or more residents not related by blood or marriage to the owner or manager. These services shall be provided on a 24-hour basis within the facility, either directly or through contract, and shall include assistance with ADLs and IADLs; provision of leisure, recreational and therapeutic activities; and supervision of nutritional needs and medication administration.

Unit Requirements

Assisted living The state funded assisted living program guidelines require an apartment setting.

Basic care facility single rooms provide 100 square feet, double rooms at least 80 square feet per bed and rooms for three or more, 70 square feet per bed. At least one toilet is required for every four residents and one bath for every 15 residents.

Tenant Policy

Assisted living Participants in the Service Payments for Elderly and Disabled (SPED) program must have needs that can be met through the program. To qualify for services, residents must have impairments in four ADLs, or impairments in five IADLs totaling eight points or six points if the person lives alone, and is not eligible for the Medicaid HCBS waiver.

Basic care facility While an admission policy was not outlined in the regulations, a "resident" was defined as "an individual admitted and retained in a facility in order to receive room and board and health, social, and personal care who is capable of self-preservation, and whose condition does not require continuous, twenty-four-hour a day on site availability of nursing or medical care."

Services

Basic care facilities provide personal care (ADLs, IADLs, and observation and documentation of changes in physical, mental, and emotional functioning, as needed); arrangements to seek health care when needed; arrangement for transfer and transportation as needed; assistance with functional aids, clothing, and personal effects as well as maintenance of personal living quarters; assistance with medication administration; and social services. Nursing services must be available to meet the needs of residents either by the facility directly or arranged by the facility through an appropriate individual or agency.

Basic care facilities may also provide adult day care and respite care services under the Medicaid waiver.

Financing

Basic care facilities The state has two state funded programs covering services to resident in basic care facilities - SPED and the expanded SPED. The state funded programs pay providers a rate based on the care needs of the resident. The maximum rate is $56.66 a day. A point system is used to convert unmet service functional needs to a rate (see table). The total points are multiplied by a factor of eight and divided by 30 to obtain a monthly payment rate. These facilities may receive funding under the Medicaid HCBS waiver for adult day care and respite care.

Assisted living apartments Residents in these buildings may receive Medicaid HCBS waiver services if they meet the nursing home eligibility requirements.

The state also pays for services in two buildings that are called assisted living.

Medications

Medicaid waiver. The state's nurse practice act allows assistance with self-administration but not the direct administration except by licensed staff. No separate requirements outside the nurse practice act are included.

Basic Care Facilities must make available medication administration services.

Staffing

Assisted living Staff must be able to deliver the necessary services required by plans of care.

Basic care facilities There must be awake staff on duty 24-hours a day.

Training

Basic care facilities

Administrators must attend at least 12 hours of continuing education annually. No other requirements are stated.

Staff The facility shall design, implement and document educational programs to orient new employees and develop and improve employees' skills to carry out their job responsibilities. On an annual basis, all employees shall receive in-service training in at least the following: fire and accident prevention and safety; mental and physical health needs of the residents, including behavior problems; prevention and control of infections, including universal precautions; and. resident rights. The staff responsible for food preparation shall attend a minimum of two dietary educational programs per year. Staff responsible for activities shall attend a minimum of two activity-related educational programs per year.

Background Checks

Basic care facilities Each facility's personnel policies must include checking state registries and licensure boards prior to employment for findings of inappropriate conduct, employment, disciplinary actions and termination.

Monitoring

Basic care facilities On site, unannounced surveys are conducted by the department to determine compliance with regulations. Plans of correction must be developed by the facility if deficiencies are found. Corrections must be completed within 60 days of the survey completion date unless the department has approved an alternative schedule. The department will follow up on all plans of correction. Enforcement actions include a ban or limitation on admissions, suspension or revocation of license, or denial of license.

NORTH DAKOTA POINT SYSTEM
Activity	Value	Activity	Value
Taking medication	1	Foot care	10
Temp\Pulse\Resp\BP	1	Nail care	10
Managing money	1	Change dressings	10
Communication	1	Apply elastic bandage	10
Shopping	15	Care of prosthetic	10
Housework	10	Medical gases	10
Laundry	10	Meal preparation	20
Mobility	6	Exercise	20
Transportation	6	Water bath/heat	20
Bathing	10	Ostomy care	20
Teeth/mouth care	20	Bowel program	20
Dress/undress	15	Indwelling catheter	20
Toileting	15	Bronchial drainage	20
Transfer	10	Feeding/eating	20
Continence	15	Supervision Level I	15
Eye care	10	Supervision Level II	30
Skin care	10

Ohio

Citation

Residential care facilities: Ohio Revised Code Annotated § 3721 et seq.; Ohio administrative code § 3701-17-50 et seq.

Adult care facilities: Ohio Revised Code Annotated 3722 et seq.; Ohio Administrative Code Chapter 3701-20-01 et seq.

General Approach

The majority of assisted living facilities in Ohio are licensed as residential care facilities, however some are licensed as adult care facilities. Earlier legislation creating an assisted living licensing category was repealed by the 1995 budget bill before regulations were ever finalized. The budget bill, in an effort to accommodate some of the assisted living philosophies, amended the existing rest home licensing law to change the licensing nomenclature to residential care facility and to expand the scope of services that the RCFs may provide. The adult care facility licensing law, which became effective in 1990, requires licensing of what is commonly known as board and care homes.

Residential care facilities provide supervision, personal care services, and may administer medications, supervise special diets and perform dressing changes. Residential care facility residents may also receive up to 120 days of nursing services on a part-time intermittent basis.

Adult care facilities provide supervision and personal care services. Unlike residential care facilities, ACFs are prohibited from administering medications, supervising special diets or performing dressing changes. However, ACF residents with short-term illnesses may receive up to 100 days of these and other needed nursing services.

Legislation (SB 60) requiring criminal background checks for staff working with elders was passed by the legislature in 1996.

Definition

Residential care facility means a home that provides either of the following:

Accommodations for seventeen or more unrelated individuals and supervision of personal care services for three or more of those individuals who are dependent on the services of others by reason of age or physical or mental impairment.
Accommodations for three or more unrelated individuals, supervision and personal care services for at least three of those individuals who are dependent on the services of others by reason of age or physical or mental impairment and to at least one of those individuals, any of the skilled nursing care authorized by section 3721.011 of the revised code.

Adult care facility means an adult family home or an adult group home. An adult family home is a residence or facility that provides accommodations to three to five unrelated adults and supervision and personal care services to at least three of those adults. Adult group homes provide accommodations to six to sixteen unrelated adults and supervision and personal care to at least three of the unrelated adults.

If a residence, facility, institution, hotel, congregate housing project or similar facility provides services that meet the definition of a residential care facility or an adult care facility then it must be licensed accordingly, regardless of how the facility holds itself out to the public.

Unit Requirements

RCFs must offer 100 square feet for single occupancy rooms and 80 square feet per person in multiple occupancy rooms. No more than four people may share a room. A toilet, sink, tub/shower is required for every eight residents except if there are more than four persons of one sex to be accommodated in one bathroom on a floor, a bathroom must be provided on that floor for each sex residing on that floor.

ACFs must offer 80 square feet for single occupancy rooms and 60 square feet per person in multiple occupancy rooms. No more than three people may share a room. A toilet, sink, tub/shower is required for every eight residents.

Tenant Policy

The statute allows residential care facilities to admit and retain residents requiring part time, intermittent nursing care for up to 120 days. RCFs may also admit and retain residents who require dressing changes, special diets and medication administration beyond the 120 day limit if the facility provides those services itself.

ACFs may not provide but may admit and retain individuals who need part time, intermittent nursing care to treat a short-term illness.

Services

RCFs may provide supervision and personal care, and nursing services that include supervision of special diets, application of dressings and administration of medication, and may also provide other nursing services on a part time, intermittent basis for a total of not more than 120 days in any twelve month period. Part time, intermittent is defined as less than eight hours a day or less than 40 hours a week. The skilled nursing services may be provided by the RCF, a licensed hospice agency or a certified home health agency. In ACFs, part time, intermittent nursing services may be provided by either a licensed hospice or a certified home health agency to residents with short-term illnesses.

Financing

Medicaid payments are not available. An earlier budget proposal included $4.4 million for the Department of Aging to develop an assisted living program through a Medicaid Home and Community Based Services waiver and to subsidize room and board payments. In 1995, the Department of Aging developed a five tiered system for determining the level of reimbursement with rates ranging from $200 to $1400 a month for services. A Residential State Supplement (SSI) of $700 a month would have covered room and board costs. A decision on submission of the waiver was postponed pending an overall review of the entire Medicaid program.

Medications

Trained non-licensed staff of both RCFs and ACFs may assist with self-administration. Assisting with self-administration requires the resident to be mentally alert and able to participate in the medication process and includes reminders, observing, handing medications to the resident, verifying the resident's name on the label and, for physically impaired residents, removing oral or topical medications from containers, applying medication upon request, and placing containers with medication to the mouth of the resident. Medications may be administered by a licensed hospice agency, certified home health agency or a member of the RCF's staff who is qualified to do so. Adult care facility staff may not administer medications.

Staffing

For RCFs, at least one staff member must be on-site at all times. An RN, LPN or physician must be on duty when medications are being administered. Staff may be shared with other licensed facilities in the same building or in the same lot as long as staffing requirements for all facilities are met. A dietitian's services are required if the facility elects to supervise special diets or perform enteral tube feedings, and sufficient nursing staff are required if the RCF elects to perform dressing changes or part time intermittent nursing care.

ACFs, which include some semi-independent living homes, must have one staff member on site whenever a resident who requires ongoing supervision, assistance with walking, moving, bathing, toileting dressing, eating, evacuation, or PRN medications is present.

In addition, for both RCFs and ACFS, sufficient additional staff must be available to meet, in a timely manner, the residents' care, supervisory and emotional needs and reasonable requests for service, including ongoing supervision of residents with increased emotional needs or presenting behaviors that cause problems for the resident or other residents and to properly provide dietary, housekeeping, laundry and facility maintenance services and recreational activities.

Training

RCF administrators must be a licensed nursing home administrator or have 2000 hours of operational responsibility in related facilities, successfully complete 100 credit hours of post high school education in gerontology, be a licensed health professional or hold a baccalaureate degree. RCF administrators also must receive nine hours annually continuing education in gerontology, health care, business administration or residential care facility operation. ACF managers are required to have basic orientation and training applicable to job duties including emergency response training.

Staff Both ACFs and RCF must provide orientation and training for all staff in job responsibilities, facility procedures, securing emergency assistance and resident rights. ACF and RCF staff who provide personal care must have currently valid documentation of a successfully completed first aid course. In addition, RCF staff providing personal care must have met one of the following:

Successfully completed training or continuing education covering the correct techniques of providing personal care services, observational skills such as recognizing changes in residents' normal status and the facility's procedures for reporting changes and communication and interpersonal skills provided by an RN or LPN;
Successfully completed the training and competency evaluation program approved or conducted by the Director under §3721.31 of the revised code; or
Successfully completed the training or testing requirements in accordance with the Medicare Conditions of Participation of home health aide services.

If an RCF serves people with emotional and behavior needs, training or continuing education in the appropriate interventions for meeting these needs and for handling and minimizing such problems must be completed.

ACF staff that provide personal care must also have successfully completed training or continuing education cover the correct techniques of personal care services.

Background Check

Criminal background checks are required for any individual used by an ACF or RCF in a position that provides direct care to older adults.

Monitoring

RCFs must be inspected once every 15 months by the Department of Health and the fire marshal (state or local). ACFs must be inspected annually by the Department. Adult group homes must also undergo an annual fire inspection.

Fees

RCF licensing and renewal fee of $100 for every 50 persons, or part thereof of licensed capacity. AGH license fee is $50, and AFH is $25. AGHs and AFHs must also pay an inspection fee of $10 for each licensed bed.

Oklahoma

Citation

Residential care homes: 63 Oklahoma statute § 1-819 et. seq.; Oklahoma rules, § 310:680:1:1 et seq.

Continuum of care and assisted living rules Chapter 663

General Approach

Legislation, HB 1540, was passed during the 1997 session creating an assisted living category. The nine member State Board of Health appointed a 27 member Continuum of Care and Assisted Living Standards Council to develop recommendations to implement the law. Each member of the Board of Health appointed three members which included a nursing home owner/operator, a residential care facility owner/operator and a member representing the public. The regulations were expected to be effective July 1, 1998.

Definition

Assisted living center means any home or establishment offering, coordinating or providing services to two or more persons who:

Are domiciled therein;
Are unrelated to the operator;
By choice or functional impairments, need assistance with personal care or nursing supervision;
May need intermittent or unscheduled nursing care;
May need medication assistance; and
May need assistance with transfer and/or ambulation.

No facilities may call themselves an assisted living center or a continuum of care facility unless they are licensed. The bill allows assisted living centers to be licensed as a component of a nursing facility.

A continuum of care facility means a home, establishment or institution providing nursing facility services and assisted living center services or adult day care center services.

Residential care home means any establishment or institution other than a hotel, motel, fraternity or sorority house, or college or university dormitory which offers or provides residential accommodations, food services and supportive assistance to any of its residents or houses any resident requiring supportive assistance who are not related to the owner or administrator of the home by blood or marriage. Said residents shall be ambulatory and essentially capable of managing their own affairs, but do not routinely require skilled nursing care or intermediate care.

Unit Requirements

Assisted living centers No more than two residents may share a bedroom. Each Center shall ensure privacy and independence and no more than 4 residents may share bathing and toilet facilities. The assisted living portion of continuum of care facilities must be physically separate from the nursing home.

Residential care home Single rooms must have 80 square feet and multiple occupancy rooms 60 square feet per bed. The regulations do not limit the number of resident who may share a bedroom. Toilet facilities must be provided for every six residents and a tub/shower for every 10 residents.

Tenant Policy

Assisted living centers must describe the population to be served based on their need for personal care, nursing supervision, intermittent or unscheduled nursing care, medication administration, assistance with cognitive orientation and care or service for Alzheimer's disease and assistance with transfer or ambulation. Each Center's admission criteria must be included in the application for licensing.

Centers may not serve anyone whose needs are inconsistent with the services provided by the facility, the resident's physician determines that restraints are needed, the resident is a threat or danger to self or others, or the facility is unable to meet the resident's need for privacy and dignity.

Residential care home
The regulations do not contain a section on admission/retention criteria. The definition states that residents may not need services provided in a skilled or intermediate care facility. Residents must be ambulatory and essentially capable of managing their own affairs.

Services

Assisted living centers may provide personal care, meals, housekeeping, laundry, intermittent or unscheduled nursing care, nursing supervision, medication administration, assistance with cognitive orientation, specialized services for people with Alzheimer's disease, assistance with transfer or ambulation, planned programs for socialization, and activities and exercise. Nurses are allowed to delegate tasks that are within the scope of their license to perform.

Nurses remain responsible for all nursing care that a person receives under their direction. Nurses may use their professional judgement in determining which tasks may be delegated. Tasks which may not be delegated include those which require nursing assessment, judgement, evaluation and teaching during implementation such as physical, psychological and social assessment which require nursing judgement, intervention, referral or follow up; formulation of a plan of nursing care and evaluation of responses to the care; administration of medications except as authorized by regulations.

An admission assessment must be implemented 30 days before or at admission and a comprehensive assessment must be completed within 30 days after admission and updated at least annually thereafter or whenever a significant change occurs. The rules describe the content of the assessment. Assessments must be conducted or coordinated by a registered nurse and signed by the resident's physician.

A managed risk process is required when resident preferences or decisions create risk or are likely to lead to adverse consequences. The Center identifies the cause for concern, attempts to negotiate an agreement that minimizes risk and offers alternatives. Any lack of agreement must be documented.

Residential care homes provide assistance with personal care, medications, three meals a day and supportive assistance which includes housekeeping, assistance in the preparation of meals, and storage, distribution and assistance with medications.

Reimbursement

Medicaid coverage may be considered at a later date.

Medications

Assisted living centers
Each center must develop a policy for administering medications that are at least equivalent as those for nursing homes. Unlicensed personnel administering medications must complete a training program approved by the Department.

Residential care homes may provide administer medications and assist with self-administration of medications. Medications must be reviewed monthly by a registered nurse.

Staffing

Assisted living centers Staffing shall be available based on the needs of residents. Nursing staff shall be provided or arranged supervise skilled interventions, document the resident's physician of choice, and document the resident's living will or DNR order. Centers must have a dietary consultant, pharmacy consultant and nurse consultant if their is no nurse on staff.

Residential care homes must have a minimum of 3/4 hour of personnel per day per resident based on the average daily census.

Training

Assisted living centers Administrators must either hold a state license, a residential care home administrators license from an institution of higher learning approved by the Department or a national recognized assisted living certificate of training and competency reviewed and approved by the Department.

Staff providing socialization, activity and exercise services must be qualified by training. Centers offering specialized units must ensure that staff are trained to meet the specialized needs of residents and all direct care staff must be trained in first aid and CPR.

Residential care homes Administrators must be 21 and obtain a certificate of training which includes 50 hours of which at least 15 cover administration of medications, administration, supervision, reporting, record keeping, independent or daily living skills, leisure skills and recreations and public relations. Administrators shall have 16 hours of job related training annually, not counting first aid and CPR training.

Staff All employees must be currently certified in first aid. All direct care staff must receive eight hours of in-service training within 90 days of employment and eight hours annually. Staff responsible for administering or monitoring medications must receive 8 hours of training annually in: patient reporting and observation; record keeping; independent or daily living skills; leisure skills and recreation; human relations; and such other training that is relevant to residential care program and operations. Direct care staff shall begin eight hours of in-service by the administrator within 90 days of employment. Eight hours of in-service shall be required annually thereafter.

New employee orientation programs must include: policies and procedures on abuse and neglect; resident rights, confidentiality, handling emergencies and job descriptions.

Background Check

Assisted living All employees are subject to requirements for criminal arrest checks applicable to nurses aides under 63 O.S. Supp. 1997, Section 1-1950.1. Employers must pay a fee of $10 to the Bureau of Investigation for checks. Reports are provided for felonies and misdemeanors for crimes against a person, public indecency or morality, domestic abuse, controlled substances, and crimes against property. Employees may not be hired if they have been convicted of crimes listed in the statute.

Residential care homes Same provisions.

Monitoring

Assisted living centers Each center must have a quality assurance committee that meets at least quarterly to monitor trends, monitor customer satisfaction and document quality assurance efforts and outcomes. The committee must include an RN or physician, the administrator, a direct care staff member or person responsible for administering medications and a pharmacist consultant if a medication problem is to be monitored or investigated. The Department may inspect centers whenever it deems it necessary.

Fee

Assisted living centers There is a $2000 application fee for each facility seeking a license.

Residential care homes $50 per application.

Oregon

Citation

Assisted living OAR Division 56: 411-056-0000

Residential care facilities OAR Division 56:411-55-000

General Approach

The state adopted assisted living regulations and policies in 1992 to substitute for nursing home care and offer home-like environments which enhance dignity, independence, individuality, privacy, choice and decision making. Facilities are required to have written policies and procedures which describe how they will operationalize these principles. The regulations were being reviewed in 1998 and changes are expected to be made in the first quarter of 1999.

Residential care facility rules were revised in 1994 and the principles of assisted living were included in the revised rules.

Definition

"Assisted living means a program approach, within a physical structure, which provides or coordinates a range of services, available on a 24-hour-hour basis, for support of resident independence in a residential setting. Assisted living promotes resident self-direction and participation in decisions that emphasize choice, dignity, privacy, individuality, independence and home-like surroundings."

"Residential care facility means a facility that provides care for six or more persons over the age of 18 on a 24-hour basis in one or more buildings on contiguous property."

Unit Requirements

Assisted living Each unit must provide 220 square feet of space, not including a private bathroom. Units in pre-existing structures may provide 180 square feet. Units must have kitchen with a sink, refrigerator, cooking appliance and space for food preparation and storage, individual heat controls, lockable doors and a phone jack. Buildings must meet applicable zoning and building codes. Pre-existing structures must provide 160 square feet excluding the bathroom.

Residential care facility Rooms must be 80 square feet per resident and are limited to two residents. Toilets must be provided for every six residents and a tub/shower for every 10 residents.

Tenant Policy

Assisted living Facilities may care for residents for whom they are able to provide appropriate services. There are no other limitations. The state's "move out" criteria allow residents to choose to remain in their living environment despite functional decline. Facilities may ask residents to leave if the resident's behavior poses an imminent danger to self or others, if the facility cannot meet the resident's needs or services are not available, for non-payment or if the resident has a documented pattern of non-compliance with agreements necessary for assisted living.

RCF Two levels of licensure are available for residential care facilities. A Class I license is needed to serve residents who require only assistance with ADLs. These facilities cannot serve anyone who is non-ambulatory, requires feeding or is dependent in any ADL. Class II facilities provide assistance with ADLs and wish to serve people who are aging in place, have higher medical acuity, or are dependent in one more ADLs.

Services

Assisted living An interdisciplinary team conducts an assessment with each resident and develops a plan that responds to their needs and reflects the principles of dignity, choice, individuality and independence and home-like environment. Services include assistance with ADLs, nursing assessment, health monitoring, routine nursing tasks, medication assistance, housekeeping, three meals a day, laundry, and opportunities for socialization that utilize community resources. Each facility must also have the capability to provide or arrange for medical and social transportation, ancillary services for medically related care, barber/beauty services, social/recreational, hospice, home health care and maintenance of a personal financial account for residents.

RCF
A screening and assessment are required for each resident and a service plan consistent with the assessment must be developed that reflects the principles of dignity, choice, individuality and independence and home-like environment. Services include personal services (assistance with ADLs), laundry, three meals a day, housekeeping, activities and health services. Facilities must assure that needed health services are obtained. Nursing tasks may be delegated.

Financing

Assisted living The state provides five levels of payment for services to Medicaid recipients residing in assisted living settings. Residents must meet the nursing home level of care criteria. A room and board payment of $420.70 is paid in addition to the service rate. The levels are assigned based on a service priority score determined through an assessment (see table below). ADLs include eating/nutrition, dressing/grooming, bathing/personal hygiene, mobility, bowel and bladder control and behavior.

Medications

Assisted living The regulations allow residents to keep medications in their unit if they are capable of self-administration. Facilities are allowed to administer medications and they must have policies and procedures which assure all administered medications are reviewed every 90 days.

RCFs may provide assistance with and administration of medications.

Staffing

Assisted living Each facility must have sufficient staff to deliver the services specified in resident plans of care.

RCF The regulations contain staff ratios for Class I and Class II facilities that vary by time of day and the number of residents.

Training

Assisted living administrators shall have 20 hours of continuing education credits each year. Each administrator shall serve an internship in an established assisted living facility. Facilities must demonstrate their competency concerning the provisions of services and principles of assisted living.

RCF administrators must provide satisfactory evidence regarding education, experience, special training and knowledge. Administrators of Class I facilities must have 12 hours of training providing care in long term care settings. Class II administrators must have two years of successful experience or equivalent education in providing care.

Staff

Assisted living Each facility administrator shall document that staff have received assisted living training as prescribed by the division. The facility administrator shall be accountable for training all facility staff in provision of services and principles of assisted living. The facility staff shall demonstrate competency in the provision of services and the principles of assisted living.

RCF
Direct care staff must complete 6 hours of job related pre-service orientation covering the philosophy of residential care, review of resident's unique needs, use of the service plan, nurse delegation, fire evacuation plans and instruction in universal precaution.

Background Check

Assisted living and RCF owners, administrators and staff must satisfy a criminal records clearance under OAR Chapter 411, Division 9 and sign a criminal record authorization, form SDS 303. A fingerprint check may be required.

Monitoring

Assisted living State or Area Agency on Aging staff conduct periodic monitoring visits. Staff review compliance with state rules and written outcome measures which reflect planned and actual results covering functional abilities, psycho-social well being, stability of medical conditions and client/family satisfaction.

RCFs Facilities are inspected at least every two years.

Fees

A licensing fee of $60 is required.

OREGON SERVICE PRIORITY CATEGORIES AND PAYMENT RATES--ASSISTED LIVING
Impairment Level	Service Priority	Service	R&B	Total Rate
Level V	Service priority A or priority B and dependent in the behavior ADL.	$1643.48	$420.70	$2064.18
Level IV	Service priority B or priority C with assistance required in the behavior ADL.	$1330.48	$420.70	$1751.18
Level III	Service priority C or priority D with assistance required in the behavior ADL.	$1016.48	$420.70	$1437.18
Level II	Service priority D or priority E with assistance required in the behavior ADL.	$767.48	$420.70	$1188.18
Level I	Service priority E or F or priority G with assistance required in the behavior ADL.	$579.48	$420.70	$1000.18

OREGON SERVICE PRIORITY CATEGORIES AND PAYMENT RATES--RCFs
Impairment Level	Service Priority	Service	R&B	Total Rate
Level V	At minimum, dependent in behavior, continence and mobility	$772.00	$420.70	$1192.70
Level IV	Dependent in 2 of the 3 critical needs (behavior, continence or mobility) or dependent in 1 or 3 critical needs and have night needs.	$636.00	$420.70	$1058.70
Level III	Dependent in 1 ADL.	$508.00	$420.70	$928.70
Level II	Needs assistance in 2 of the 3 critical needs or assistance in any 3 ADLs.	$384.00	$420.70	$794.70
Level I	Needs assistance with any 2 ADLs and night needs.	$262.00	$420.70	$682.70

SERVICE PRIORITY CATEGORIES
Category	Impairments
A	Dependent in 3-6 ADLs
B	Dependent in 1-2 ADLs
C	Requires assistance in 4-6 ADLs
D	Requires assistance in 3 critical ADLs
E	Requires assistance in 2 critical ADLs
F	Requires assistance in 3 ADLs
G	Requires assistance with 1 critical ADL and meets conditions of at least 1 other essential factor or requires assistance with 1 critical ADL and 1 less critical ADL.
NOTE: Critical ADLs are bowel and bladder control, eating/nutrition, behavior/cognition; less critical ADLs are dressing/grooming, bathing/personal hygiene, mobility.

Pennsylvania

Citation

Personal care homes PC Title 55 Chapter 2620 and Chapter 20.

General Approach

A task force has been formed by the Department of Aging and the Department of Public Welfare and is considering options for creating a new licensure category. A report was presented to the Interagency Long Term Care Council in June with recommendations dealing with regulation, funding and quality. The next step is to determine whether additional legislation is needed and to determine the fiscal impact of the recommendations.

The Department of Public Welfare currently licenses 1,696 personal care homes with a total of 62,24-hour1 beds. The Department of Aging has certified 925 domiciliary care homes with 2,900 beds.

Definition

Personal care homes "A premises in which food, shelter and personal assistance or supervision are provided for a period exceeding 24-hours for four or more adults who are not relatives of the operator, who do not require the services in or of a licensed long term facility, but who do require assistance or supervision in matters such as dressing, bathing, diet, financial management, evacuation of a residence in the event of an emergency or medication prescribed for self-administration."

Unit Requirements

The regulations require single occupancy rooms to have at least 80 square feet of floor space. If closets are built, they must be at least nine square feet and can be counted in the total required space. Multiple occupancy rooms must have at least 60 square feet per person. No more than four people may share a bedroom. Toilets must be available for every six residents, and tubs or showers for every 15 residents.

Tenant Policy

Homes may serve immobile residents who do not need nursing home care but do need personal care, if they meet building, fire safety and staffing requirements. Homes may discharge anyone who is a danger to self or others and residents for whom a physician or the local assessment agency determines needs a higher level of care.

Services

Services include personal care services provided by trained, qualified staff and with ongoing oversight and general supervision by the administrator. Personal care tasks include hygiene (bathing, oral hygiene, hair grooming and shampooing, dressing and care of clothes and shaving), and tasks of daily living (securing transportation, shopping, making/keeping appointments, care of personal possessions, correspondence, personal laundry, social and leisure activities, securing health care, ambulation, use of prosthetic devices and eating. Home health services may be provided by a certified agency, including hospice care, as long as the physician indicates that the person is appropriate for a personal care home and the service is needed for a temporary period.

Medication

Assistance with self medication includes storing, reminders and offering the resident the medication at the prescribed times.

Staffing

Facilities must provide a sufficient number of trained persons to provide the necessary level of care required by residents.

Training

Administrators must complete 40 clock hours of Department approved training which includes the following: fire prevention and emergency planning; first aid, medication procedures, medical terminology, personal hygiene, CPR and the Heimlich maneuver; local, state and federal laws and regulations pertaining to the operation of a PCH; nutrition, food handling and sanitation; recreation; mental illness; gerontology; community resources and social services; staff supervision; development of orientation and training guidelines for the staff; and financial record keeping and budgeting.

After the 40 hour training is completed, administrators must complete a minimum of six clock hours of ongoing training through courses approved by the Department and relating to the care and management of elderly and disabled persons or the operation and maintenance of a PCH facility or both.

Staff must receive orientation to the general operation of the home and training in fire prevention, operation of safety equipment, emergency planning and evacuation procedures, within 30 days of employment or volunteer services. A sufficient number of staff shall be trained, certified and recertified in CPR, and first aid and trained in the Heimlich maneuver so that at least one staff person so trained, certified and recertified is present in the PCH at all times.

Staff receive training within six months in accordance with a written schedule in the following areas: medication procedures, medical terminology and personal hygiene; nutrition, food handling and sanitation; recreation; mental illness; gerontology; and staff supervision, if applicable.

Background

Not specified.

Rhode Island

Citation

Residential care and assisted living facilities R23-17.4 SCF

General Approach

The state's regulations use the term "residential care and assisted living facilities." Legislation was passed in 1997 authorizing the RI Housing and Mortgage Finance Agency (HMFA), working in collaboration with the Department of Human Services and the Department of Elderly Affairs, to serve up to 200 low and moderate income chronically impaired or disabled adults who are eligible for or at risk of entering a nursing home in facilities certified and financed by the HMFA.

Fifty four facilities are licensed and nine nursing homes have converted to assisted living.

Definition

"A publicly or privately operated residence that provides directly or indirectly by means of contracts or arrangements personal assistance, lodging, and meals to two (2) or more adults. ... Residential care and assisted living facilities include sheltered care homes, and board and care residences, or any other entity by any other name providing the above services which meet the definition of residential care and assisted living facility." There are four levels of licensure for residential care and assisted living facilities. A residence may have areas within the facility that are licensed separately. The levels are:

Level F1: licensure for residents who are not capable of self preservation; and/or
Level F2: licensure for residents who are capable of self preservation; or
Level M1: licensure for residents who require that the facility centrally store and administer medications; or
Level M2: licensure for residents who require assistance (as elaborated in section 19.3.1) with self-administration of medications; or a
Combination per area of facility.

The state's Medicaid waiver defines assisted living as "personal care and services, homemaker, chore, attendant care, companion services, medication oversight (to the extent permitted under state law), therapeutic social and recreational programming, provided in a home-like environment in a licensed community care facility. This service includes 24-hour on-site response staff to meet unscheduled or unpredictable needs in a way that promotes maximum dignity and independence, and to provide supervision, safety and security."

Unit Requirements

Resident rooms may have no more than two beds. Single rooms must have at least 100 square feet in area, and double bedrooms must be at least 160 square feet in area. There must be at least one bath per 10 beds and one toilet per eight beds or fraction thereof on each floor where residents' rooms are located and not otherwise serviced by bathing facilities within the resident's room. There must be an area within the resident's bedroom and/or facility to be under lock for the safe keeping of personal possessions.

The Medicaid waiver allows sharing of units only by the consent of the residents

The demonstration legislation defines a unit as "an apartment, condominium, bed or other dwelling quarters in an assisted living facility as defined by this statute."

Tenant Policy

Residents must be adults, not requiring medical or nursing care as provided in a health care facility, but who may require the administration of medication. A resident must be capable of self-preservation in emergency situations, unless the facility meets a more stringent life safety code; or residents must be reasonably oriented and not require care beyond that permitted by the level of service for which the facility is licensed.

Services

Twenty-four hour adult staffing; personal services; assistance with self-administration of medication or administration of medications by appropriately licensed staff; assistance with arranging for supportive services that may be reasonably required; monitoring health, safety, and well-being; and reasonable recreational, social and personal services. Nurse review is necessary under all levels of medication licensure. A registered nurse must visit the facility at least once every 30 days to monitor the medication regimen for all residents; evaluate the health states of residents; make necessary recommendations to the administrator; follow up on previous recommendations; and provide signed, written reports to the facility documenting the visit.

Facilities offering care in special care units such as Alzheimer's Special Care Units must disclose information to the licensing agency and any person seeking placement in such a unit that explains the additional care that is provided by the unit including information on: the philosophy of care; pre-admission, admission, and discharge process; assessment, care planning and implementation; staffing patterns and training ratios; physical environment; resident activities; family role in care; and program costs.

The demonstration project authorizes personal care, homemaker, chore, attendant care, companion services, medication oversight, therapeutic social and recreational programming, transportation, twenty four hour on site response staff to meet scheduled or unpredictable needs and nursing and skilled therapy services which are incidental to the provision of supportive services.

Financing

The Medicaid HCBS waiver covers assisted living and a new pilot program was authorized by the legislature in 1997. The HCBS waiver serves a maximum of 630 people per year of which 30 slots are set aside for beneficiaries leaving nursing homes. Nineteen facilities currently contract with Medicaid and serve 20 beneficiaries. Facilities receive a prospective Medicaid payment based on their customary rate not to exceed $1400 a month, including room and board covered by SSI. Beneficiaries retain $100 a month as a personal needs allowance.

Medication

RNs must administer medications and monitor health conditions. Unlicensed staff may only remind residents to take their medications and observe. Staff must have four hours of training by an RN regarding policies and procedures and have passed an exam based on the training.

Staffing

Facilities must have a responsible adult on the premises at all times, who is in charge of the operation of the facility and who is physically and mentally capable of communication with emergency personnel. All facilities must provide staffing which is sufficient to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psycho-social well being of the resident, according to the appropriate level of licensing.

Training

Administrators must be at least 21 years old and obtain certification as a residential care/assisted living facility administrator or equivalent training. Certification requirements include at least 40 classroom hours of course work covering topics referenced in the regulations. The course work must take place in a college, vocational training, state or national certification program which is approved by the Director of Health. Licensed nursing home administrators are considered certified. Administrators must complete at least 16 hours of continuing education annually.

Staff shall have training as appropriate for maintaining the above conditions within the facility, specifically in the areas of: fire safety procedures; medical emergency procedures; emergencies; resident rights; and first aid.

Orientation and training appropriate for job specifications shall be provided in the areas of: assistance with medications; assistance with personal care; supervision; record keeping; housekeeping/sanitation; food service; and infection control.

The Medicaid waiver requires a minimum 1 hour orientation and 12 hours annual in-service training for staff.

Background

All employees are subject to a nationwide criminal records check through state or local police.

Monitoring

The licensing agency may inspect and investigate facilities as it deems necessary. Representatives of the licensing agency have the right to enter facilities any time without prior notice to inspect the premises and services. Every facility is given notice by the licensing agency of all deficiencies reported as a result of an inspection or investigation.

South Carolina

Citation

Community Residential Care Facilities R61-84

General Approach

In 1996, Governor David Beasley issued a long term care plan for the state that created a framework for developing assisted living. The plan seeks to provide a local and accessible continuum of care and recommends the exploration of long term care housing alternatives to expand the current array of choices and recognizes that nursing facilities and community residential care facilities will not continue to meet the diverse needs of aging and disabled citizens. "Assisted living has the potential to expand the current array of choices in the long term care service delivery system. Still in its early stages, assisted living may provide cost effective and appropriate services for frail elders and disabled adults. It offers developers, owners and management agencies prospects for expansion."

The task force included representatives from the Department of Health and Human Services, Aging, Consumer Affairs and the Housing Finance and Development Authority. In addition, representatives from the residential care facilities association, two nursing home associations and others also participate. The task force recommended a definition of assisted living and adult foster care and public funding to the extent possible.

Legislation passed in 1996 requires facilities advertized as special care facilities serving residents with Alzheimer's disease to disclose the form of care and treatment that distinguishes it as being suitable for people with Alzheimer's disease, the admission/transfer and discharge criteria, care planning process, staffing and training, physical environment, activities the role of family members and the cost of care.

In 1998 there were 490 licensed facilities with 11,668 beds.

Definition

"Community residential care facility is a facility which offers room and board and which provides a degree of personal assistance for a period of time in excess of twenty four consecutive hours for two or more persons, eighteen years old or older, unrelated to the operator within the third degree of consanguinity." The definition includes facilities which serve people with mental illness and alcohol or drug abuse needs.

Task force recommendation Assisted living is a special combination of housing, supportive services and health care designed to respond to the individual needs of those who need help with ADLs and IADLs. Supportive services are available 24-hours a day to meet scheduled and unscheduled needs, in a way that promotes maximum dignity and independence for each resident and involves the resident's family, neighbors and friends.

Unit Requirements

Bedrooms must offer 80 square feet for single rooms and 60 square feet per resident in multiple occupancy rooms. No more than four residents may share a room. One toilet is required for every eight residents and one tub/shower for every 10 residents. Pets are allowed.

Tenant Policy

Facilities may not admit anyone suffering from acute mental illness, anyone needing hospital or nursing home care, anyone needing daily attention of a licensed nurse.

Services

Facilities must provide personal assistance, protection and recreation. Personal assistance includes assistance with ADLS, assistance with making appointments and arranging transportation to receive supportive services required in the care plan. Continuous supervision must be provided for anyone whose mental condition is such that their safety requires it.

Medications

Facilities may administer medications and are responsible for ascertaining that medications are taken by residents in accordance with physician's orders.

Staffing

At least one staff member shall be available for every 10 residents during the day and one per 44 residents at night. Facilities with more than 10 residents must have one staff member awake and dressed at night.

Training

Administrators must be licensed by the SC Department of Labor, Licensing and Regulation and be no less than 21 years of age, possess mature judgement and have sufficient education (high school or equivalent) to read, understand and comply with the regulations. They must have three reference letters attesting to their character, be unimpaired by drugs or alcohol, demonstrate adequate knowledge of licensing requirements and have other attributes.

Staff In-service training programs shall be planned and provided for all personnel and shall include at least: basic first aid; fire protection; medication administration and management; care of persons who may have contagious, communicable or sexually transmitted diseases and licensing regulations. Training shall be provided on a continuous basis and not less than annually.

Background Check

Not specified.

South Dakota

Citation

Assisted living centers Article 44:04 et seq.

General Approach

There were 65 facilities with about 1,200 beds in 1996 and 100 facilities with a total capacity of 2,000 beds in 1998. About 30 more facilities are expected to be licensed in 1998.

Definition

An assisted living center is defined as "any institution, rest home, boarding home, place, building, or agency which is maintained an operated to provide personal care and services which meet some need beyond basic provision of food, shelter, and laundry to five or more persons in a free standing, physically separated facility."

Unit Requirements

In newly constructed or renovated facilities, there must not be more than two residents per room. In single bed rooms, there must be a minimum area of 120 square feet and in two-bed rooms there must be at least 200 square feet. Each resident room must have a toilet room and lavatory.

Tenant Policy

Prior to admission, residents must submit written evidence from their physician of a physical examination certifying that they are in reasonable good health and free from communicable disease, chronic illness, or disability which requires any services beyond supervision, cuing, or limited hands-on physical assistance to carry out normal activities of daily living and instrumental activities of daily living.

Assisted living centers may not admit or retain residents who require ongoing nursing care. Facilities that admit or retain residents who require administration of medications must employ or contract with a licensed nurse who reviews resident care and conditions at least weekly and a registered nurse or pharmacist who provides medication administration training to unlicensed assistive personnel who administer medications.

Facilities that admit or retain residents with cognitive impairments must have the resident's physician determine and document if services offered by the facility continue to enhance the functions in ADLs and identify if other disabilities and illnesses are impacting on the resident's cognitive and mental functioning. All staff members must attend an annual in-service training in the care of the cognitively impaired and those with unique needs. Such facilities must have exit alarms.

Services

Centers must provide supportive services, activities, services to meet the spiritual needs of residents. Outside services utilized by residents must comply with and complement facility care policies. Assisted living centers must provide for the availability of physician services. All residents must be seen by a physician at least once a year.

Financing

The SSI payment for room and board assisted living facilities is $910 per month less a personal needs allowance of $30. If the Department of Social Services determines that a Medicaid eligible individual also needs medication administration, the facility receives $150 per month through the Medicaid HCBS waiver for a total of $1,030 per month. Thirty five facilities contract with Medicaid and serve 65 people.

Staffing

For facilities with 10 or fewer beds, one staff person is permitted during sleeping hours. This staff person may sleep if the facility fire alarm is adequate to alert staff, a staff call system is available, the staff bedroom has an egress window, and the residents are capable of prompt evacuation. For facilities with 11 to 16 beds, one staff person who is awake is required during sleeping hours.

Training

Administrator The administrator must have a high school diploma or equivalent and, if hired after July 1, 1995, complete a 75 hour training program and competency evaluation. The areas covered include: communication and interpersonal skills; infection control; safety/emergency procedures; promoting resident's independence; and respecting resident rights. Additional topics cover: basic nursing skills; personal care skills; mental health and social services; care of cognitively impaired residents; basic restorative services and resident rights.

Staff The facility must have a formal orientation program and an ongoing education program for all personnel. These programs must include the following subjects:

Fire prevention. The facility must hold at least one fire drill for each shift each quarter;
Emergency procedures;
Infection control and prevention;
Accident prevention and safety procedures;
Proper use and documentation of restraints;
Patient and resident rights;
Confidentiality of patient information;
Incidents and diseases subject to mandatory reporting and the facility's reporting mechanism; and
Care of the cognitively impaired and of those patients or residents with unique needs.

Background Check

A facility may not knowingly employ any person with a conviction for abusing another person.

Monitoring

The governing body of the facility must provide for an ongoing evaluation of the quality of services provided to residents. Quality assurance evaluations must include the establishment of facility standards; interdisciplinary review of resident services to identify deviations from the standards and plans of correction; resident satisfaction surveys, utilization of services provided; and documentation of the evaluation.

Tennessee

Citation

Assisted Care Living Facilities: Rules of the Department of Health Chapter 1200-8-9 et seq.

Homes for the Aged: Chapter 1200-8-11

General Approach

Rules implementing a bill signed in 1996 were effective in April 1998 creating an assisted care living facility category. Regulations were developed by the Health Care Facilities Board through a 13 member task force consisting of six members of the Board, three Department of Health representatives and four associations (Tennessee Health Care Association, Association of Homes for the Aging, Home Care Association and the Assisted Living Association). The new rules allow a higher level of care and require new facilities to meet the 1997 edition of the standard building code. Existing Homes for the Aged are grandfathered from meeting the higher building code if they choose to convert their license.

There were 244 residential homes for the aged with 5,200 beds and 30 institutional homes for the aged and 1,963 beds in 1998.

Definition

Assisted care living facility means a building, establishment, complex or distinct part thereof which accepts primarily aged persons for domiciliary care and which provides on site to its residents, room, board, non medical living assistance services appropriate to the residents' respective needs, and medical services as prescribed by each resident's treating physician, limited to the extent not covered by a physician's order to a home care organization and not actually provided by a home care organization. An ACLF may directly provide such medical services as medication procedures, topicals, suppositories and injections (excluding intravenous) pursuant to a physician's order, and emergency response. All other skilled nursing services (part time or intermittent nursing care, physical occupation and speech therapy, medical social services, medical supplies other than drugs and biologicals, and durable medical equipment) that a home care organization is licensed to provide may be provided in the facility only by a licensed home care organization, except for home health aide services.

Home for the aged: a home which accepts aged persons for relatively permanent, domiciliary care. It provides room, board and personal services to one or more non-related persons. A home for the aged may be any building, section or a building, or distinct part of a building, a residence, a private home a boarding home for the aged or other place, either for profit or not, which provides, for a period exceeding 24-hours, housing, food services and one or more personal services for one or more aged persons who are not related to the owner or administrator by blood or marriage. Homes for the aged must have agreements with a physician who is available to render care or who will come to the home to visit residents when necessary and with a nursing home that will accept its residents who must be discharged.

Unit Requirements

Assisted care living facility A minimum of 80 square feet of bedroom space must be provided for each resident. No more than two residents may share a bedroom. No more than six residents may share a toilet, lavatory, bath or shower.

Home for the aged Each resident must have at least 80 square feet of bedroom space. Bedrooms may not have more than two beds, and privacy screens or curtains must be provided and used when requested by the resident. Beds with full side rails, potty chairs, bedpans, or urinals shall not be used routinely in residents' rooms. Residents' rooms must always be capable of being unlocked by the resident.

Tenant Policy

Assisted care living facilities may not admit or retain anyone who: is in the later stages of Alzheimer's disease, requires physical or chemical restraints, poses a serious threat to self or others, requires nasopharyngeal and tracheotomy aspiration, requires initial phases of a regiment involving administration of medical gasses, requires a Levin (or nasogastric) tube, requires arterial blood gas monitoring or is unable to communicate his or her needs.

Residents in all but the latter stages of Alzheimer's disease may be admitted only after determination by an interdisciplinary team that care can be safely and appropriately provided. This determination must be reviewed quarterly.

Facilities may not admit, but may retain for 21 days, any resident requiring intravenous or daily intramuscular injections or intravenous feedings; gastronomy feedings; insertion, sterile irrigation and replacement of catheters, except for routine maintenance of Foley catheters; treatment of extensive stage 3 or 4 decubitus ulcer; exfoliative dermatitis; or requires sterile wound care.

Residents with these conditions may be retained longer than 21 days if the Health Department is notified and does not object. However, residents may not be retained after 21 days if they require four or more skilled nursing visits per week for any other condition.

Home for the aged Residents who need continual professional medical/nursing observation and/or care cannot be admitted or retained. Residents who require more technical nursing care or medical care than the personnel and the facility can lawfully provide shall be transferred to a hospital or nursing home. Homes for the aged cannot admit a person whose primary diagnosis is a mental health condition which clearly endangers himself or others and/or who is receiving active treatment from a mental health facility for a condition which clearly endangers himself and others. Homes for the aged may serve people with mental health conditions, but these residents may not make up more than 50% of the home's residents. Persons in the early stages of Alzheimer's disease and related disorders may be admitted if an interdisciplinary team made up of a physician who is experienced in the treatment of Alzheimer's disease, a social worker, registered nurse, and a family member (or patient care advocate) determines that care can appropriately and safely be given in the home for the aged. Such residents must be reviewed at least quarterly as to the appropriateness of placement in the home.

Services

Assisted care living facility Non-medical living assistance and some medical services may be provided. Medical services include part time or intermittent nursing, physical, occupational and speech therapy, medical social services, medical supplies, durable medical equipment may be provided but only by a licensed home care agency. Home health aide services may not be provided by a licensed home care agency because they would duplicate services provided by the facility.

Home for the aged Assistance and supervision with medications is allowed and medications may be administered by a licensed nurse. Homes for the aged may not care for residents who require restraint, and so must not use restraints. Homes may provide personal care such as bathing, dressing, and grooming of hair, fingernails and toenails. Laundry and linen services, food service and recreational activities are also provided.

Financing

Assisted care living facilities The law does not authorize Medicaid coverage for medically necessary home care services provided in an assisted care living facility. Legislation providing funding for home care services including Assisted Care Living Facilities and Homes for the Aged is pending before the legislature.

Home for the aged Personal care is not funded by Medicaid either as a state plan service or as a waiver service. There is an SSI pilot program paying up to $9/day/quarter per resident, with an overall spending cap of $525,100.

Medications

Assisted care living facility staff may assist with self-administration of medications. A licensed professional may administer medications within the scope of their license.

Staffing

Assisted care living facilities Must be sufficient to meet the needs, including medical services of residents. Facilities must have a licensed nurse available.

Training

Administrators

Assisted care living facilities Administrators must be certified biannually. Certification requires 24 hours of classroom hours of continuing education courses approved by the board that includes instruction in the following: state rules and regulations for homes for the aged/ACLFs; health care management; nutrition and food service; financial management; and healthy lifestyles.

Homes for aged The licensee of a home for the aged must be at least 18 years old. The chief administrator of the home must be certified by the Board as a residential home administrator, unless the administrator is currently licensed in Tennessee as a nursing home administrator. The licensee must have a high school diploma or equivalent; persons serving as a chief administrator of a licensed home for a continuous period of at least nine months prior to January, 1990 are exempt from this requirement. Licensees must have at least 24 hours of continuing education each year. Personal care attendants must be at least 18 years old. Facilities with five or more residents whose level of evacuation capability is classified as "slow" must have a responsible attendant on duty and awake at all times.

Training

Staff

Assisted care living facilities No continuing education is required for direct care staff.

Homes for aged staff must attend any training program which may be required by the Department when such programs are offered without charge, in each of the three regions of the state, and no more frequently than annually.

Background Check

The administrator must not have been convicted of a criminal offense involving abuse or intentional neglect of an elderly or vulnerable individual. Facilities may not employ any peson listed on the Department's abuse registry.

Monitoring

Inspections are conducted each year. Deficiencies must be addressed by plans of correction. Homes must comply with local fire safety authority regulations.

Fees

Fees for assisted care living facilities vary with the number of beds: < 50: $400; 50-74: $500; 7599: $600; 100-124: $700; 125-149: $800; 150-174: $900 and 175-199: $1000. Facilities over 200 are charged $1000 plus $60 for every 25 beds or fraction thereof.

Texas

Citation

Personal care homes. Texas Rev. Health and Safety Stat. Ann. § 247.001 et. Seq.; Texas Administrative Code Title 25, §146.321 et seq.

General Approach

New personal care home rules were effective in June 1998. Further amendments to the training and staffing sections are being developed. Legislation was passed in 1996 that sets new standards for personal care homes providing specialized care for people with Alzheimer's Disease and regulations implementing this law have been proposed. These rules set standards for administrators, staff, activities and a secure environment.

Assisted living/residential care services are provided through the state's Medicaid Home and Community Based Services waiver program in licensed personal care homes. Settings must be licensed as personal care homes and may contract with Medicaid under three models: assisted living apartments, residential care apartments and residential care non-apartments.

The Texas Medicaid program contracts with 169 facilities to provide assisted living/residential care services. About 565 beneficiaries are being served.

Definition

Personal care facility is "an establishment, including a board and care home, that furnishes food and shelter, in one or more facilities, to four or more persons who are unrelated to the owner of the establishment; and provides personal care services; and in addition, provides minor treatment under the direction and supervision of a physician ... or services which meet some need beyond basic provision of food, shelter and laundry."

Four types of Personal Care Homes are licensed.

Type A home residents are capable of evacuating the facility unassisted, do not require routine attendance during night time hours and are capable of following directions under emergency conditions.
Type B facility residents may require staff assistance to evacuate, may not be able to follow directions, require attendance during the night and while not permanently bedfast, may require assistance in transferring to and from a wheelchair.
Type C facilities offer up to four beds and are considered adult foster care but after the effective date of the regulations, will be required to obtain a personal care license.
Type D facilities are operated by the Department of Mental Health and Mental Retardation.

Medicaid Assisted living/residential care services provide a 24-hour living arrangement for persons who, because of a physical or mental limitation, are unable to continue independent functioning in their homes. Services are provided in personal care facilities licensed by the Texas Department of Human Services (DHS). In effect the rules recognize three types of units provided in licensed personal care facilities. Nursing facility waiver participants are responsible for their room and board costs and, if applicable, a copayment for assisted living/residential care services.

Unit Requirements

Personal care facility rules require 80 square feet for single bedrooms and 60 square feet per bed for multiple occupancy rooms in Type A facilities and 100 square feet and 80 square feet respectively in Type B facilities. A maximum of four people may share a room. Units with separate living/dining and bedroom space may include 10% of the required bedroom space as living area. Not more than 50% of the beds may be in rooms of three or more. Bathrooms, including bathing units, are required for every six residents.

The Medicaid program guidelines distinguish among assisted living apartments, residential care apartments and residential care non-apartments. Assisted living apartments must provide each participant a separate living unit to guarantee their privacy, dignity and independence. Units must include individual living and sleeping areas, a kitchen, bathroom and adequate storage. Units must provide 220 square feet, excluding bath, but units in remodeled buildings may provide 160 square feet. Double occupancy units may be provided if requested.

Residential care apartments must be double occupancy with a connected bedroom, kitchen, and bathroom area providing a minimum of 350 square per client. Indoor common space used by residents may be counted in the square footage requirement. Kitchens must be equipped with a sink, refrigerator, cooking appliance (stove, microwave, built-in surface unit) that can be removed or disconnected and space for food preparation.

Residential care non-apartments means a licensed personal care facility which does not meet either of the above definitions. These units may be double occupancy units in free standing buildings that have 16 or fewer beds.

Tenant Policy

Personal care facility rules allow facilities to serve residents who have mental or emotional disturbance but are not a danger, need assistance with movement, bathing, dressing, and grooming, routine skin care (such as application of lotions, treatment of minor cuts and burns), need reminders to encourage toileting, require temporary services by professional personnel, need assistance with medications, supervision of self-medication or administration of medications, have hearing or speech impairments, are incontinent but without pressure sores, require established therapeutic diets, require self-help devises, or need assistance with meals.

Facilities may not admit or retain residents whose needs cannot be met by the facility or residents requiring services from the facility's RN on a daily or regular basis (exceptions are made for residents with terminal conditions or for short term needs).

Licensed staff may provide supervision or oversight of the physical and mental well-being of residents.

Services

An assessment must be completed within 14 days of admission. Personal care facility rules allow licensed staff to administer medications and provide occasional treatment which enables residents to maintain independence. Residents may contract to have home health services provided. The rules broaden the definition of personal care to include the administration or assistance with or supervision of medication to implement changes that allow nurse delegation under the nurse practice act.

Services that can be provided through the waiver include 24-hour supervision, personal care, administration of medications, congregate meals and social and recreational activities. Nursing services must be provided through contracts with certified home health agencies.

Special care facilities must have activities that encourage socialization, cognitive awareness (crafts, arts, story telling, reading, music, discussion, reminiscences and others), self-expression and physical activity in a planned and structured program.

Financing

The Medicaid waiver provides $35.06 a day for services in single occupancy assisted living apartments, $27.64 a day for double occupancy residential care apartments and $22.63 a day for residential care non-apartments. The SSI payment for room and board is $409 a month and the personal needs allowance is $85. The combined room and board and service rates are $1,460.80 a month for assisted living apartments, $1,238.20 for residential care apartments and $1,087.90 for residential care non-apartments. The rates are being reviewed and increases were expected to be approved in August 1998. The waiver includes a cap that limits community based alternatives services to no more than 95% of rate paid to nursing homes.

Medications

Licensed staff may administer medication. The waiver rules allow the direct administration of all medications or assistance with or supervision of medication.

The proposed changes in personal care home rules allow unlicensed staff to administer medications as well as to assist with or supervise medications through nurse delegation provisions.

Staffing

Required staff ratios are 1 to 16 for day shifts; 1 to 20 for evening shifts and 1 to 40 for night shifts. Night staff must be immediately available in facilities with less than 40 residents and available and awake in facilities with 40 or more residents. Night staff must be available and awake in Type B facilities regardless of size.

Special care facilities (16 or less residents) must designate an activities staff; facilities of 17 or more must have an activity director at least 20 hours a week.

Training

Administrators Managers must have a high school diploma or equivalency and 12 hours of annual continuing education in at least one of the following areas: resident and provider rights and responsibilities; abuse/neglect, and confidentiality; basic principles of supervision; skills for working with residents, families and other professional service providers; resident characteristics and needs; community resources; accounting and budgeting; basic emergency first aide; and relevant federal laws. Administrators in special care facilities must have a college degree (psychology, social work, counseling, gerontology, nursing or related field) with documented course work in dementia; or one year experience with persons with dementia and complete six hours of continuing education in dementia care.

Staff Facilities must document that attendants are competent to provide personal care and have the following knowledge: needs of residents and the tasks to be provided, health conditions and how they affect the provision of tasks and conditions about which the attendant should notify the manager. Annual in-service training must cover communication techniques and skills providing geriatric care (communicating with hearing impaired, visually impaired and cognitively impaired); assessment and nursing interventions related to common physical and psychological changes of aging for each body system; geriatric pharmacology; common emergencies of geriatric residents; common mental disorders with related nursing implications; ethical and legal issues regarding advance directives, abuse and neglect, guardianship and confidentiality.

Staff in special care facilities must receive:

Four hours of dementia specific orientation on basic information about the causes, progression and management of dementia;
16 hours of on the job supervision with 16 hours of orientation providing assistance with ADLs, emergency and evacuation procedures and managing dysfunctional behavior; and
12 hours of annual in-service training regarding Alzheimer's disease covering assessing resident capabilities and developing and implementing service plans; promoting dignity, independence, and privacy; planning and facilitating activities; communicating with families; resident rights and principles of self-determination; care of persons with physical, cognitive, behavioral and social disabilities; medical and social needs of residents; common psycho-tropic drugs and side effects and local community resources.

Monitoring

Unlicensed facilities are subject to restraining orders and civil penalties between $1,000 and $10,000 a day.

Fees

Fees for Type A and B facilities are $100 plus $3 for each bed with a maximum of $400. Type C licenses are $50.

Utah

Citation

Assisted living facilities R432-270

General Approach

The state's regulations were effective July 1995 and establish assisted living as a place of residence where elderly and disabled persons can receive 24-hour individualized personal and health related services to help maintain maximum independence, choice, dignity, privacy and individuality in a home-like environment. The rules provide for three levels of license: large facilities, 17 or more residents; small facilities, 6-16 residents; and limited capacity facilities, up to five residents.

In 1998 there were 8 licensed facilities and 260 units. One nursing home has converted to assisted living. There were also 109 licensed residential health care facilities with 1,956 beds. Five nursing homes with 173 beds converted to this level of licensure.

Definition

Assisted living HB 201, which was passed during the 1994 legislative session, defines assisted living as "a residential facility with a home-like setting that provides an array of coordinated supportive personal and health care services, available 24-hours per day, to residents who have been assessed under division rule to need any of these services. Each resident shall have a service plan based on the assessment, which may include: specified services of intermittent nursing care, administration of medication, and supportive services promoting residents' independence and self-sufficiency."

Residential health care facility means a facility providing assistance with activities of daily living and social care to two or more residents who require protected living arrangements.

Unit Requirements

A residential living unit means a one or two bedroom unit which may also include a bathroom and additional living space. A maximum of two residents may occupy a resident living unit and only by the consent of the residents. Additional living space means a living room, dining space and kitchen facilities, or a combination of these facilities, in a resident living unit. Units must have lockable doors and tenants must have a key.

Facilities providing only bedrooms must provide a toilet and lavatory for every four residents and a bathtub or shower for every 10 residents. Occupancy units without additional living space must be a minimum of 120 square feet for single occupancy units and 200 square feet for double occupancy units. Bedrooms in units that do provide additional living space must be at least 100 square feet for single units and 160 square feet for double units.

Tenant Policy

Facilities may not serve anyone who requires inpatient hospital care or 24-hour continual nursing care that will last more than 15 calendar days or people who cannot evacuate without the physical assistance of one person. Written acceptance, retention and transfer policies are required of each facility. Facilities may not accept anyone who is suicidal, assaultive or a danger to self or others, has active tuberculosis or other communicable disease that cannot be adequately treated at the facility or on an outpatient basis or may be transmitted to other residents through general daily living.

A physician's statement is required that documents the resident's ability to function in the facility and describes the following information: whether the resident's health condition is stable, free from communicable disease, allergies, diets, current prescribed medications with dose, route, time of administration and assistance required, physical or mental limitations and activity restrictions.

The rules allow pets to be kept if permitted by local ordinances.

Services

Facilities must provide personal care, food service, housekeeping, laundry, maintenance, activity programs, medication administration and assistance with self-administration and arrange for necessary medical and dental care.

Financing

The state had anticipated amending its HCBS waiver to add assisted living as a covered service, however, officials have had difficulty developing rates that current licensed providers would accept. Further work is being done. In addition, a task force developing a capitated long term care demonstration program plans to include assisted living as a service covered by the capitation payment.

Medications

Facilities are allowed to provide medication administration by licensed staff and assistance with self-medication by unlicensed staff (opening containers, reading instructions, checking dosage against the label, reassuring the resident that the correct dosage was taken and reminding residents that a prescription needs to be refilled.

Staffing

Direct care staff are required on-site 24-hours a day to meet resident needs as determined by assessments and service plans. Staff providing personal care must be CNAs or complete a CNA training program within four months.

Training

Administrators must complete a national certification program and meet one of the following criteria: experience, licensing or college degree.

Staff Orientation shall include job descriptions; ethics, confidentiality, and resident rights; fire and disaster plan; policy and procedures; and reporting responsibility for abuse, neglect and exploitation. In-service shall be tailored to include all the following subjects that are relevant to the person's job:

Principles of good nutrition, menu planning, food preparation and storage;
Principles of good housekeeping and sanitation;
Principles of providing personal care and social care;
Proper procedures in assisting residents with medications;
Recognizing early signs of illness and determining when there is a need for professional help;
Accident prevention, including safe bath and shower water temperatures; and
Communication skills which enhance resident dignity.

Background Check

Administrators must be of good moral character with no felony convictions.

Board and Care

Residential health care facilities are not allowed to provide nursing services and therapies although residents may contract on their own with a community home health agency to receive these services. RHC residents must be ambulatory and able to evacuate in an emergency. Assisted living residents may be semi-independent or require assistance from one person to transfer or ambulate.

Vermont

Citation

Residential care homes (Level III, IV) Regulations effective 10/7/93.

Assisted living (draft)

General Approach

Assisted living rules have been submitted to a legislative committee for a hearing and final adoption. The rules will be effective in 1998. Medicaid waiver coverage will be added to cover services in assisted living.

The Department of Aging and Disabilities established a task force in 1996 to develop an assisted living model. Both Medicaid and state funded homemaker and/or attendant care programs are being considered for financing services for low income residents. The purpose and philosophy of assisted living is described in the beginning of the rules. The draft rules are designed to support dignity, independence, individuality, privacy, choice and decision making of individual residents.

In 1995, the Vermont legislature approved funding for a pilot project to provide residential services to Medicaid recipients in licensed Level III residential care homes. The Department of Aging and Disabilities received approval from HCFA on March 1, 1996 for a Medicaid Home and Community Based Services Waiver to offer "enhanced residential care" to residents in Level III Residential Care Homes. The project established four outcome measures: participants are satisfied with Enhanced Residential Care Services; participants continue to reside in his/her residence of choice; participants receive all services which are necessary to live as independently as possible; and services provided are comprehensive and individualized.

There were 129 licensed residential care homes caring for 2,279 residents in 1998.

Definition

Assisted living residence means a program which combines housing, health and supportive services for the support of resident independence and aging place. Within a homelike setting, assisted living units offer, at a minimum, a private bedroom, private bath, living space, kitchen capacity and a lockable door. Assisted living promotes resident self-direction and active participation in decision-making while emphasizing individuality, privacy and dignity. A facility with a license under another section of 7102 is not an assisted living residence.

Residential care home is a place, however named, excluding a licensed foster home, which provides for profit or otherwise, room, board and personal care to three or more residents unrelated to the licensee. Level III means a residential care home licensed to provide room, board, personal care, general supervision, medication management and nursing overview. Level IV homes do not provide nursing overview. The Medicaid waiver for this program includes standards covering negotiated risk which is defined as "allowing residents choices in accepting certain risks. These choices are negotiated between the resident, case manager, provider, and family members with the intent of fostering independence, safety and self-determination."

Unit Requirements

Assisted living residences Residential living space must be a minimum of 225 square feet per unit, excluding bathroom and closets. Each unit must provide accessible or adaptable sleeping, living and eating areas. Units must include a private bathroom, bedroom, living space and kitchenette, adequate storage and a lockable door. Units may be shared only by choice. Kitchenettes must include food preparation and storage area, refrigerator, cabinets, counter space, sink and source of water, a cook top or microwave that can be removed or disconnected and outlets.

An 18 month grandfathering period is allowed for pre-existing structures being converted or remodeled. These residences must have a minimum of 160 square feet not including the bathroom or storage space. Kitchen capacity is not required but a community kitchen must be available.

Residential care homes The regulations indicate that every effort must be made to provide a home-like environment. Each private bedroom must have at least 100 square feet of usable floor space and multi-bed rooms must have 80 square feet per bed. After October 1993, all new homes may offer only single or double occupancy rooms. One bath, toilet and sink is required for every eight residents.

Tenant Policy

Assisted living residences Residents may be moved if they pose an immediate threat to others or have needs that cannot be met by the residence. Residents may be retained who have the following conditions:

Require 24-hour, seven day a week on-site nursing care;
Bedridden more than 14 days;
Consistently and totally impaired in four or more ADLs;
Cognitive decline severe enough to prevent making simple decisions;
Stage 3 or 4 pressure sores or multiple stage 2 sores; or
Medically unstable conditions and/or has special health problems and a regimen of therapy that cannot be implemented appropriately in the setting.

The facility must notify the licensing agency and describe how it will meet the person's needs. The licensing agency determines whether the plan is appropriate.

Residential care homes Facilities must provide a written agreement which describes the daily, weekly, or monthly rate to be charged, a description of the services covered in the rate and the policy concerning discharge or transfer when a resident's financial status changes from private pay to SSI.

Residential care homes may retain people who need nursing services if the following conditions are met:

The services are received less than three times a week; are provided seven days a week for no more than 60 days and the resident's condition is improving;
The home has an RN on staff or a contract with a home health agency;
The home is able to meet the resident's needs without detracting from services to other residents;
There is a written agreement concerning which nursing services the home provides or arranges which is explained to the resident before admission or at the time of admission, how services are paid for and the circumstances under which a resident will be required to move; and
Residents are fully informed of their options and agree to such care in the residential home.

RCHs cannot admit or retain anyone needing full time nursing care, the level of care provided in a nursing facility, or who has care needs which exceed the facility's capacity to safely and appropriately provide. Residents who have a serious, acute illness requiring medical, surgical or nursing care cannot be admitted or retained.

Services

Assisted living residences provide three meals a day appropriate to the needs and preferences of residents, 24-hour staff supervision to meet emergency, scheduled and unscheduled needs, personal and other laundry services, individual and group socialization, personal care, assistance with IADLs, intervention for residents who have dementia, weekly housekeeping, medication management, administration and assistance, medical and social transportation and maintenance of a personal fund account showing deposits and withdrawals. Residences may also provide nursing assessment, health monitoring, routine nursing tasks and intermittent skilled nursing services, including that which may be delegated to unlicensed staff.

RCHs provide personal care, medication management, laundry, meals, toiletries, transportation and nursing overview. Nursing overview means a process in which a nurse assures that the health and psychosocial needs of the resident are met. The process includes: observation, assessment, goal setting, education of staff and the development, implementation and evaluation of a written individualized treatment plan to maintain the resident's well being.

Intravenous therapy, ventilators or respirators, daily catheter irrigation, feeding tubes, care of stage III or IV decubitus, suctioning and sterile dressings may not be provided to any resident unless a variance is approved by the state licensing agency.

Medication

Assisted living residences provide assistance with self-administration of medications and administer medications under the supervision of and delegation by registered nurses. Each residence must have a policy on the procedures for delegation of administration, how medications will be obtained including choice of pharmacies and documentation procedures.

RCH staff are able to assist resident to self-administer medications and administer medication under the supervision of and delegation by registered nurses.

Reimbursement

An HCBS waiver will be submitted to cover assisted living residences. The Department of Aging and Disability has designed a unique three tiered system that was developed using MDS 2.0 and assessment data. Residents receive a score in five areas: ADLs, bladder and bowel control, cognitive and behavior status, medication administration and special programs (behavior management, skin treatment or rehabilitation/restorative care). Residents are assigned to a level (1 or 2) based on the extent of ADL impairments. Scores of 6-18 are assigned to level 1 and scores between 19-29 are assigned to level 2. The four remaining areas are rated and additional points are assigned. The payment tier is determined by combining the ADL level and the additional points. Payment rates have not been devised. The Department has piloted the classification system and will be developing rates for each tier.

PAYMENT AREAS AND SCORING SYSTEM
Area	Maximum Points	Factors
ADLs	29	Eating, toileting, mobility, bathing, dressing
Continence	13	Bladder and bowel
Cognitive/behavior status	65	Sleep pattern, wandering, danger to self/others
Medication administration	5	Administration
Special programs	49	Mood, behavior, cognitive loss. Skin: Turning/repositioning, nutrition or hydration, dressings, ulcer care, surgical wound care. Rehab: range of motion, skin brace assistance, transfer, walking, dressing/grooming, eating/swallowing, prosthesis care, communication.

VERMONT RATING SYSTEM (proposed)
Tier 1		Tier 2		Tier 3
Level	Point	Level	Point	Level	Point
1	0-30	1	31-59	1	60+
		2	0-35	0	36+

Residential care homes provide two levels of SSI reimbursement based on the provision of nursing oversight. A Medicaid waiver covers nursing overview (assessment, oversight, monitoring and routine tasks), personal care services, case management, medication assistance, recreational and social activities, support for individuals with cognitive impairments and 24-hour on-site supervision. The waiver allows up to 200 participants although funding is available for 70 participants a month and 98 unduplicated participants during the first year. Services must be provided in non-institutional, home-like settings. Participants must meet the nursing home eligibility criteria. While not required, preference is given to providers that offer single occupancy units.

Staffing

Assisted living residences must employ sufficient staff to meet the needs of each resident. At least one personal care assistant must be on duty at all times. A registered nurse shall be employed to oversee implementation of service plans, conduct nursing assessments, and provide health services. The RN shall be on-site to the degree necessary to achieve the outcomes as specified in the individual service plans.

RCHs must have a sufficient number of qualified staff to meet resident needs.

Training

Administrators

Residential care homes Managers must complete a state approved certification course.

Assisted living residences The director must be at least 21 and have demonstrated experience in gerontology and supervisory and management skills. Directors shall have evidence of 20 hours of training per year regarding assisted living and its principles and the care of elderly and disabled individuals.

Staff

Residential care homes Staff must receive 20 hours of training each year that includes at least procedures in case of fire, resident rights and mandatory reporting of abuse, neglect and exploitation. Training in direct care skills may be provided by a nurse.

Assisted living residences All staff must be trained in the principles of assisted living including assisted living principles, resident rights, laws relating to abuse and neglect and exploitation, dementia care, infection control policies and emergency response procedures. The residence shall employ or contract with personal care assistants trained in the provision of personal care services. Staff shall receive documented training from the residence or provide evidence of similar required training. At the time of employment, all staff shall be provided with and/or provide evidence of an initial orientation to the principles of assisted living and shall receive training on an annual basis regarding the provision of services in accordance with the resident-driven values of assisted living. RNs must receive 16 hours of training in assisted living principles and the care of elderly and disabled individuals annually. Staff providing personal care must receive training within four months of employment covering:

Personal care activities (earing, bathing, dressing, transferring, mobility, ambulation, toileting and personal hygiene),
Communication skills relating to residents with Alzheimer's disease and other dementias;
Infection control;
Transfers;
Documentation;
Alzheimer's disease and other dementias; and
Behavioral management.

Staff providing personal care shall also receive 16 hours of training annually in the above areas.

Background

A criminal records and adult abuse registry check is required for directors and all staff. Staff with substantiated charges of abuse, neglect or exploitation, or those convicted of an offense relation to bodily injury, theft or misuse of funds or property or other crimes inimical to the public welfare may not be employed or retained.

Monitoring

Residential care homes Monitoring is conducted by the licensing agency and the ombudsman program.

Assisted living residences Monitoring includes services plans, written outcome measures for residents based on service plans. No frequency of visits is described. Exist conferences must be held with the director.

Fees

RCHs Fees are $5 plus $1 per bed.

Virginia

Citation

Adult care residence 22 VAC 40-71-10 et seq.

General Approach

The state legislature has created a two-tier licensing structure for adult care residences, residential living and assisted living. Regulations were effective February 1, 1996. A Medicaid HCBS waiver was effective August 1, 1996. The regulations contain a statement of philosophy and guiding principles. The regulations are intended to maximize independence and promote the principles of individuality, personal dignity, freedom of choice, and fairness for all individuals residing in adult care residences. The principles state that:

Residents are entitled to appropriate, safe and quality care;
Each resident shall be viewed as an individual and empowered to make decisions regarding his care;
Each residence should identify the types and extent of services offered and those services should reflect the needs of the population served;
The resident should be entitled to remain in care as long as the facility is able to adequately care for the resident within the limitations established by law so that social ties and relationships may be preserved to the fullest extent possible; and
Standards are consistent with the provision of cost effective services.

Definition

Adult care residence (ACR) means any place, establishment, or institution, public or private, operated or maintained for the maintenance or care of four or more adults who are aged, infirm or disabled and who are cared for in a primarily residential setting, except a facility or portion of a facility licensed by the State Board of Health or the Department of Mental Health, Mental Retardation and Substance Abuse Services (and other exceptions).

Residential living means a level of service provided by an adult care residence for adults who may have physical or mental impairments and require only minimal assistance with activities of daily living. Minimal assistance means dependency in only one ADL or one or more IADLs or medication administration.

Assisted living means a level of service provided by an adult care residence for adults who may have physical or mental impairments and require at least moderate assistance with activities of daily living. Moderate assistance means dependency in two or more ADLs. This level also includes individuals who are dependent in behavior pattern (abusive, aggressive, disruptive). Within assisted living, there are two payment levels for recipients of an Auxiliary Grant: regular assisted living and intensive assisted living as defined by the Department of Medical Assistance Services. Intensive assisted living services are for individuals who meet the criteria for home and community based waiver services (at risk of nursing home placement).

Unit Requirements

ACRs may offer single rooms (minimum 100 square feet for newer buildings) or multiple occupancy rooms (80 square feet per occupant). A maximum of four people may occupy a room. Facilities must provide one toilet and wash basin for every seven people and one bath tub for every 10 people.

Tenant Policy

ACRs cannot admit or retain residents with the following conditions or needs:

Ventilator dependent;
Dermal ulcers (III or IV) unless a stage III ulcer is healing;
*Intravenous therapy or injections directly into the vein;
Airborne infectious disease in a communicable state;
Psychotropic medications without an appropriate diagnosis and treatment plan;
Nasogastric tubes;
*Gastric tubes except when an individual is capable of independently feeding himself and caring for the tube or by exception;
Individuals who present a danger to themselves or others;
Individuals requiring continuous nursing care (around the clock observation, assessment, monitoring, supervision, or provision of medical treatment by a licensed nurse);
Individuals whose physician certifies that placement is no longer appropriate;
Unless the individual's physician determines otherwise, individuals who require maximum physical assistance as documented by an assessment and meet Medicaid nursing facility level of care criteria; or
Individuals whose health care needs cannot be met in the specific ACR as determined by the residence.

* Exceptions are allowed when requested by resident and care is provided by a physician, a licensed nurse or a licensed home care organization except for Auxiliary Grant residents.

Public pay residents must have an assessment completed by a case manager or other qualified assessor. Assessments for private pay residents may be completed by a case manager or other qualified assessor, an independent physician, or an employee of the facility who has documented training in the completion of the uniform assessment instrument. Assessments completed by facility staff must be signed by the administrator or designated representative.

Services

The regulations offer ACRs the flexibility to develop a program that meets the following criteria:

Meet physical, mental, emotional and psycho-social needs,
Provide protection, guidance and supervision;
Promote a sense of security and self worth; and
Meet the objectives of the service plan.

Each facility develops a written program description for prospective residents that describes the population to be served and the program components and services available. Facilities are permitted but are not required to offer all services as long as they have services that are appropriate for the needs of residents. ACRs must also provide 24-hour capacity to meet scheduled and unscheduled service needs. Skilled nursing services provided by a licensed home care organization for less than 30 days may be delivered. Eleven hours of activities per week for residential living and fourteen hours for assisted living must be scheduled. The Medicaid payment for intensive assisted living services covers personal care, homemaker, attendant care, companion services, medication oversight and therapeutic social and recreational programming.

An assessment using the approved Uniform Assessment Instrument must be performed on all residents prior to admission, every 12 months, and whenever a change in the resident's condition warrants a level of care change. An individualized service plan or plan of care is developed from the assessment in conjunction with the resident, family, case worker, case manager and health care providers. The service plan shall reflect the philosophy and values described above.

Financing

Two payment levels for the provision of personal care services in ACRs with an assisted living license have been developed to supplement the ACR's Auxiliary Grant rate which covers room, board, basic supportive services and supervision. The Auxiliary Grant program is a state and locally funded assistance program to supplement the income of a recipients of the federal Supplemental Security Income (SSI) program and certain other aged, blind and disabled individuals residing in an ACR. The maximum Auxiliary Grant payment is $737 or $848 depending upon the area of the state. DMAS provides an additional per diem payment above the current auxiliary grant rate for regular assisted living services, which are reimbursed by General Funds rather than Medicaid, at a rate of $3 a day to a maximum of $90 a month; and the rate for intensive assisted living services, which is a combination of general funds and federal waiver funds, is $6 a day and a maximum of $180 a month. Nursing care would not be covered in the rate.

Medications

Residents may self-administer medications, although assistance with self-administration is not described in the regulations. Medication administration is permitted when licensed staff are available or a medication training program approved by the Board of Nursing has been completed.

Staffing

Staffing patterns must be appropriate to deliver the services required by the residents as described in the plans of care.

Training

Administrators must be 21, a high school graduate with one year of post graduate study or experience and attend at least 20 hours of training related to management or operation of a residential facility for adults or client specific training needs within each 12 month period. When adults with mental impairments reside in the facility, at least five of the required 20 hours of training shall focus on the resident who is mentally impaired.

Administrators of assisted living facilities must complete at least two years of post secondary education or one year of courses in human services or group care administration from an accredited college or a department curriculum specific to the administration of an adult care residence.

Staff All employees shall be made aware of: the purpose of the facility; the service provided; the daily routines; and required compliance with regulations for adult care residences as it is related to their duties and responsibilities.

All personnel shall be trained in the relevant laws, regulations and the residence's policies and procedures sufficiently to implement the following:

Emergency and disaster plans for the facility;
Techniques of complying with emergency and disaster plans including evacuating residents where applicable;
Use of first aid kit and knowledge of its location;
Observance of rights and responsibilities of residents;
Procedures for detecting and reporting abuse, neglect or exploitation of residents to the appropriate local department of social services;
Techniques for assisting residents to overcome transfer trauma;
Confidential treatment of personal information; and
Specific duties and requirements of their positions.

Within the first 30 days of employment, all direct care staff shall have been trained to have a general knowledge in the care of aged, infirm or disabled adults with due consideration for their individual capabilities and their needs. On an annual basis, all direct care staff shall attend at least eight hours of training. The training shall be relevant to the population in care and shall be provided through in-service training programs or institutes, workshops, classes or conferences. When adults with mental impairments reside in the facility, at least two of the eight required hours of training shall focus on the resident who is mentally impaired. Documentation of this training shall be kept by the facility in a manner that allows for identification by individual employee.

Staff in assisted living residences must also be trained to deal with residents who have a history of aggressive behavior or of dangerously agitated states covering information, demonstration and practical experience in self-protection and prevention and de-escalation of aggressive behavior. Training to serve residents who are restrained is also required which covers proper techniques for applying and monitoring restraints, skin care, and active assisted range of motion exercises, assessment of blood circulation, turning and positioning, provision of sufficient bed clothing and covering to maintain body temperature and provision of additional attention to meet the physical, mental, emotional and social needs of restrained residents.

Assisted living staff must attend at least 12 hours of training annually which focuses on the needs of residents who are mentally or physically impaired as appropriate to the populations served.

Background Check

The statute (§63.1-173.2) does not allow persons convicted of specific types of crimes to be employed. Staff must submit a sworn statement disclosing criminal convictions or pending charges. False statements are a Class 1 misdemeanor. An original criminal records check must be obtained by the facility from the Central Criminal Records Exchange.

Monitoring

Public pay residents receive annual reassessments by assigned case managers. Residents who require coordination of multiple services, are not able and do not have support available to assist in coordinating activities and need a level of coordination that is beyond what the ACR is able to provide, receive Medicaid funded, targeted case management from a case manager.

Private pay residents also receive annual reassessment to assure continued appropriate placement and services.

The Department of Social Services conducts regular licensing inspections of ACRs. DMAS conducts on-site visits to monitor the quality and appropriateness of assisted living services provided to public pay residents of ACRs.

Washington

Citation

Boarding homes Chapter 246-316 WAC

Assisted living (Medicaid) Chapter 388-110 WAC

General Approach

The state initiated its assisted living program as a pilot program under Medicaid in one site in 1989. Effective June 8, 1996, the Aging and Adult Services Administration issued regulations for licensed boarding homes who contract with Medicaid for residential care services that covered assisted living, enhanced adult residential care and adult residential care. Enhanced residential care facilities provide limited nursing services and personal care while adult residential care facilities provide only personal care. Boarding homes are licensed by the Health Department.

The number of facilities contracting with Medicaid has risen from 14 in 1995, to 77 in September 1996 and 104 in 1998. The number of units occupied by Medicaid clients has increased from 847 in July 1996 to 1,500 in 1998. Medicaid contracts with 243 facilities providing residential care and enhanced residential care to 1,366 beneficiaries.

Definition

Boarding home means any home or other institution, however, named, which is advertised, announced or maintained for the express or implied purpose of providing board and domiciliary care to three or more aged persons not related by blood or marriage to the operator.

Medicaid "Assisted living services is a package of services, including personal care and limited nursing services, that the department contracts with a licensed boarding home to provide in accordance with Parts I and II of this chapter. Assisted living services include housing for the residents in a private apartment-like unit."

The contract previously defined assisted living as "a coordinated array of personal care, health services and other supportive services available 24-hours per day to residents who have been assessed to need these services. Assisted living promotes resident self-direction and participation in decisions that emphasize independence, individuality, privacy, dignity, choice and residential surroundings."

Unit Requirements

Boarding home Rooms must offer 80 square feet for single occupancy and 70 square feet per person in multiple occupancy rooms. No more than four residents may occupy a room. One toilet and sink is required for every eight residents and one bathing fixture is required for every twelve residents.

Medicaid To contract with Medicaid, facilities must provide individual units with 220 square feet including counters, closets and built-ins, and excluding the bathroom. Existing facilities may have a minimum of 180 square feet. The kitchen area must have a refrigerator, microwave or stove top and a counter or table for food preparation. New facilities must also have a sink and counter area and storage area. Units must have lockable entry doors and a living area wired for telephone and television service, where available. The physical environment is supposed to enhance autonomy in ways which reflect the personal and social values of dignity, privacy, independence, individuality, choice and decision-making of residents. Facilities must provide a home-like environment enhancing the dignity, independence, individuality, privacy, choice and decision-making ability of residents.

Two people may occupy a unit but only by choice. Facilities are prohibited from offering a shared unit at a lower cost per month. Medicaid will reimburse facilities a separate full rate for a qualified second occupant.

Tenant Policy

Boarding home Generally, homes may not provide respiratory ventilation, intravenous procedures, suctioning, feeding tube insertion or site maintenance and care of residents who are bed bound more than 14 consecutive days as a result of a medical condition. However, residents may arrange for these services if they reside in lockable quarters with a private toilet, sink, bathing fixture and emergency power if necessary for life support equipment.

Medicaid Residents may be required to move when their needs exceed the services provided through the contract with the state agency; the residents places themselves or others at an unreasonable risk; the residents have failed to make proper payments for services; or the residents require a level of nursing care that exceeds what is allowed by the boarding home license. Case managers must approve all discharges from facilities.

Services

Boarding homes provide basic domiciliary care, general health supervision and assistance with self-administration of medications, following prescribed diets and activity regimes, making and keeping appointments for health care services, maintain personal hygiene, obtaining and maintaining functional aids, arranging for social, recreational and religious activities, resident mobility and incontinence care. Homes may apply for a limited nursing license and employ or contract with an RN or physician to provide or supervise limited nursing services (not continuous nursing care) such as insertion of catheters, routine ostomy care, enemas, uncomplicated routine colostomy and urethral care, care of superficial wounds, and assistance with glucomoter testing.

Medicaid Facilities contracting with Medicaid must obtain a limited nursing license. The negotiated service plan format has been changed. A specified form is no longer required. A formal written negotiated plan, which involves the resident, appropriate staff, AASA case manager and family or others if chosen by the residents, must be completed within 30 days of move-in. The services must meet a range of needs and preferences of residents and facilitate aging in place by being flexible. Services must support managed risk and allow the resident to take responsibility for risks associated with decision-making. A negotiated plan to reduce the probability of a poor outcome when the resident's decision or preference creates risk must be developed.

The service plan should decrease the probability of a poor outcome when a resident's decision or preference places the resident or others at risk, leads to adverse consequences, or conflicts with other residents' rights or preferences. This negotiated services planning process is now required for boarding homes and adult family care programs.

Facilities must provide personal care services based on the resident's negotiated service agreement and provide the range of services required to meet the increasing or changing needs of residents as they age-in-place to the maximum extent permitted by boarding home regulations. Contractors have to provide or arrange for limited nursing services at no additional cost.

Facilities must also assist the resident to arrange, obtain and coordinate services such as transportation to medical appointments and recreational activities, ancillary services related to medical care (physician, pharmacist, mental health, physical or occupational therapy, hospice, home health care, podiatry), barber/beauty services and others necessary to support and assist the resident in maintaining independence.

In 1995, amendments to the state's nurse practice act were passed which allow RNs to delegate tasks to nursing assistants in licensed boarding homes, assisted living facilities and adult family homes. Nursing assistants must complete a core training program. Nurses may delegate the following tasks: oral and topical medications and ointments; nose, ear, eye drops and ointments; dressing changes and catheterization; suppositories, enemas and ostomy care; blood glucose monitoring and gastronomy feeding in established and healed condition. Delegation is at the discretion of the nurse and only for people whose conditions are stable and predictable.

Financing

The reimbursement methodology and rate for Medicaid recipients who meet the nursing home level of care criteria has been revised. AASA developed three rate levels and three geographic areas. The rates are based on components for nursing staff, operations and capital costs. Residents without any other income apply $14.82 per day from their SSI check to the room and board costs. Services costs are reimbursed by Medicaid. (See narrative for a discussion of the rate structure.)

WASHINGTON RATE STRUCTURE
	Level 1	Level 2	Level 3
MSA Counties	$51.36	$57.05	$63.29
Non-MSA counties	$49.93	$55.39	$61.05
King County	$55.74	$66.32	$69.41

A capital add-on is available for newly constructed facilities whose capital costs exceed the allowance. The add-on ranges from $4.08 to $4.49.

Medications

Medication administration is covered under the boarding homes rules. The boarding home rules allow for reminders, assistance with self-administration and administration of medications by licensed staff. Changes in the nurse practice act to allow nurse delegation is pending in the legislature.

Staffing

Boarding home Staff must be sufficient to furnish services and care needed by residents, maintain the home free of safety hazards and implement fire and disaster plans.

Medicaid RNs or LPNs are required to be available on-site five hours a day, seven days a week and on call 24-hours a day to provide services listed in the negotiated service agreements. Other staff must be sufficient to deliver services identified in service agreements. New staff must receive five hours of training and monthly in-service sessions on assisted living values and principles.

Training

Administrators

Boarding home Administrators must be 21 and have a high school degree and two years experience or an advanced degree, or certification.

Medicaid Administrators must complete 40 hours of training regarding assisted living services, resident rights and the social model of services within the first six months of employment. All administrators shall have 10 hours of continuing education credits per calendar year.

Staff

Boarding homes must provide staff orientation and appropriate training for expected duties, including: organization of the boarding home; physical boarding home layout; specific duties and responsibilities; and policies, procedures and equipment necessary to perform duties. Other sections require training in CPR, first aid, infection control, and HIV/AIDs.

Medicaid Caregivers must complete the department designated fundamentals of caregiving training. Contractors who meet the prescribed criteria may be approved to provide this training. Caregivers who are RNs, LPNs, nursing assistants, or who have successfully completed personal care training from an area agency on aging are exempt.

Caregivers must complete 10 hours of in-service training a year. Topics include but are not limited to: resident rights; personal care; dementia; mental illness; developmental disabilities; depression; medication assistance; communication skills; alternatives to restraints; and activities for residents.

Contractors must provide a minimum of five hours of training for all staff regarding assisted living services, resident rights, the social model of services and service planning for residents.

Background Checks

Boarding home The licensee and administrator must file a disclosure statement as defined in RCW 43.43.824-hour. The licensee must obtain a Washington state patrol criminal history (RCW 43.43.842(1) for all staff having direct contact with residents. Staff may not be hired who have a conviction of a crime against individuals, financial exploitation or abuse.

Monitoring

The licensing agency makes periodic inspection and survey visits. Case managers are a primary source of monitoring for quality assurance for Medicaid beneficiaries. During regular visits, the case manager checks to see if the client is satisfied, the negotiated service plan is being carried out and that the plan is appropriate for the resident.

Fee

Facilities are charged $54 per licensed bed. An additional $150 is payable for facilities receiving a third site visit because of failure to respond adequately to deficiencies or a complete on-site review resulting from a complaint.

West Virginia

Citation

Personal care homes 64 CSR 14 et seq.

Residential care homes 64 CSR 65 et seq.

Residential care communities §16-5N-1 et seq.

General Approach

A new category of residential care communities was created by legislation in 1997. Rules implementing the law were to be proposed by July 1998.

Definition

Personal care homes "Any institution, residence or place or any part or unit thereof, however named, in this state which is advertised, offered, maintained or operated by the ownership or management, whether for a consideration or not, for the express or implied purpose of providing accommodations and personal assistance and supervision, for a period of more than twenty-four hours, to four or more persons who are dependent upon the services of others by reason of physical or mental impairment who may require limited and intermittent nursing care, including those individuals who qualify for and are receiving services coordinated by a licensed hospice."

Board and care homes "Any residence or any part or unit thereof, however named, in this state which is advertised, offered, maintained or operated by the ownership or management, whether for a consideration or not, for the express or implied purpose of providing accommodations and personal assistance and supervision, for a period of more than twenty-four hours, to four to 10 persons who are not related to the owner or managed by blood or marriage with in the degree of consanguinity of second cousin and are dependent upon the services of others by reason of physical or mental impairment or who may require limited and intermittent nursing care but are capable of self-preservation and are not bedfast, including those individuals who qualify for and are receiving services coordinated by a licensed hospice."

Residential care communities is a new category created by Chapter 163 (1997). A residential care community means any group of seventeen or more residential apartments, however named, which are part of a larger independent living community and which are advertised, offered, maintained or operated by an owner or manager, regardless of consideration or the absence thereof, for the express or implied purpose of providing residential accommodations, personal assistance and supervision on a monthly basis to seventeen or more persons who are or may be dependent upon the services of others by reason of physical or mental impairment or who may require limited and intermittent nursing care but who are capable of self-preservation and not bedfast.

There are 65 licensed personal care homes with 2,414 beds and 76 residential board and care homes with 641 beds.

Unit Requirements

Personal care homes Rooms must have 80 square feet for single occupancy and 60 square feet for multiple occupancy rooms. A maximum of two residents may share a room in newly constructed homes. Toilets are required for every five residents and bath/showers for every 10 residents.

Residential board and care homes Single rooms must have at least 80 square feet of floor space, and rooms with multiple beds must have at least 60 square feet per resident. There may not be more than three residents per bedroom. There must be at least one toilet and washroom per six people, including staff. There must be at least one bathing facility per 10 individuals residing in the home, and at least one per floor on which the resident rooms are located.

Residential care communities must offer apartment units with at least 300 square feet, with lockable doors, at least one bedroom, a kitchenette with a sink and refrigerator, and one full bathroom.

Tenant Policy

Personal care homes may not admit residents needing extensive or ongoing nursing care, or residents for whom the facility does not have appropriate staff to provide care.

Residential board and care homes Residents must be capable of self-preservation on admission and may need personal assistance in activities of daily living, supervision because of mental or physical impairment, or have limited and intermittent nursing care needs. Individuals with identified mental or developmental disabilities may be admitted if the home can provide evidence of continued professional follow-up to address the individual's mental health needs or the individual is a client of licensed behavioral health agency.

Facilities may not admit those who require the use of routine physical or chemical restraints, require ongoing or extensive nursing services, or require a level of service of which the home is not licensed or does not provide. Individuals who become bedfast subsequent to admission may remain in the home for 90 days during a temporary illness or recovery from surgery if the resident's care does not require nursing care in excess of limited and intermittent nursing care.

Services

Personal care homes provide limited and intermittent nursing services (direct hands-on care for no more than two hours a day for not more than 90 consecutive days per episode), personal assistance, assistance with self-administration of medications, transportation for medical and social services, supervision, meals, dietary and general household services (housekeeping), making appointments for appropriate medical, dental, nursing or mental health services, and 11 hours of activities a week. Homes must have arrangements for a registered nurse to manage and oversee personal care and nursing services. Homes may administer medications according to physician orders.

Residential board and care homes provide treatment and care in accordance with the functional needs assessment and service plan to assist each resident to maintain the highest level of functioning possible. Services include making appointments for appropriate medical, dental, nursing or mental health services as needed by the resident; arranging for transportation, personal assistance, assistance with medication administration, and supervision.

Financing

The state does not currently reimburse residential care but is exploring a method to do so.

Staffing

Personal care homes Administrators must be 21, have a high school diploma or GED. Awake staff are optional in homes of 10 beds or less if all residents are certified by a licensed health care professional not to need sleep time supervision and do need limited and intermittent nursing services. Larger facilities must have one awake staff per floor in multi-story buildings unless residents meet the requirements for smaller homes and there is an emergency call system.

Residential board and care homes The administrator must be at least 21 years old and have a high school diploma or GED. There must be awake staff during normal resident sleeping hours when residents require supervision during sleeping hours or are in need of limited and intermittent nursing services.

Training

Personal care homes and residential board and care homes
Administrators must receive at least 10 hours of training related to the operation and administration of personal care homes each year.

Staff Employee orientation and training. Training shall be provided to new employees and new admissions within the first twenty four hours of association with the home in emergency procedures, evacuation of the home, procedures to report a missing resident, medical emergencies, accidents, fire, natural disasters or other emergencies.

The home shall maintain a written plan of orientation and training for employees. Such training will be provided within the first fifteen days of employment inclusive of the following:

Policies and procedures of the home;
The rights and responsibilities of residents including protection of resident privacy and confidentiality;
Complaint procedures of the home;
Procedures and agencies available in instances of abuse, neglect, and mistreatment ...;
The care of aged, infirm or disabled adults with consideration for individual capabilities and needs;
Personal assistance procedures as needed for resident care, including at a minimum, personal grooming care, personal hygiene care, nutritional services, and signs and symptoms of alteration of skin integrity;
Specific duties and responsibilities of the residential staff for assisting current residents of the home (i.e. a review of individualized service plans, the activities program and/or professionally-designed intervention strategies to help a resident with behavioral health needs to manage his or her behavior);
Cardiopulmonary resuscitation (CPR), as applicable, and first aid; and
Infection control.

Personal care homes and residential board and care homes shall provide ongoing in-service training annually in the areas of: resident rights and confidentiality; abuse, neglect, mistreatment and procedures to prevent the occurrence of such incidents; emergency care of residents (first aid and as applicable CPR), emergency plans for the home, including fire safety and evacuation plans; the responsibilities of the residential staff for assisting residents (i.e. individualized service plans, activity programs, etc.); and infection control.

Background Check

Residential board and care homes Administrators must be free of evidence of fraud, abuse or substantial and repeated violations of applicable laws and conviction of crimes relevant for the provision of care to a dependent population.

Personal care homes Personnel records must contain documentation of a criminal record investigation covering convictions for abuse, mistreatment or neglect, and theft of property from the populations served.

Monitoring

The licensing agency makes on-site unannounced inspections are made as needed and investigates complaints.

Wisconsin

Citation

Residential care apartment complexes (formerly Assisted Living) Chapter HFS 89. WS Act 13, 1997.

Community based residential care facilities Chapter HFS 83

General Approach

Two categories of facilities are available -- residential care apartment complexes (RCACs) and community based residential care facilities (CBRFs). Regulations providing for registration and certification of assisted living facilities were effective in March 1997. Legislation changing the category from assisted living facilities to RCACs was passed in September 1997. Certified facilities submit an application and may be visited by the department staff to determine compliance. Tenants must be notified that the department does not regularly visit or inspect registered facilities. Facilities who seek to receive Medicaid reimbursement must be certified. On-site review of all certified applications is conducted. Facilities must submit documents showing compliance with all applicable federal, state and local licensing, building, zoning and related requirements.

There are 28 registered residential care apartment complexes with a total of 823 units and 15 certified units with a capacity of 516.

Several levels of CBRFs are licensed based on size (small: 5-8; medium: 9-20; and large: 21 or more) and the six classes of care based on whether residents are ambulatory (walk without difficulty), semi-ambulatory (able to walk with difficulty or only with assistance of an aid such as crutches, a cane or walker) and non-ambulatory (not able to walk at all but able to be mobile with the help of a wheelchair).

Definition

Residential care apartment complex "a place where five or more adults reside that consists of independent apartments, each of which has an individual lockable entrance and exit, a separate kitchen, including a stove, and individual bathroom, sleeping and living areas, and that provides, to a person who resides in the place, not more than 28 hours per week of services that are supportive, personal and nursing services. Residential care apartment complex does not include a nursing home or a community-based residential facility, but may be physically part of a structure that is a nursing home or community based residential facility."

Facilities that are part of a nursing facility must be physically separate and distinct although they may share a common lobby and entrance. They may also share common dining and activity areas as long as they are not scheduled for concurrent use.

Community based residential facility is a place where five or more unrelated adults reside in which care, treatment or services above the level of room and board are provided to residents as a primary function of the facility.

Unit Requirements

Residential care apartment complex The rules require units with a minimum of 250 square feet for sleeping and living areas, excluding closets and cabinetry. The kitchen must be a visually and functionally distinct area of the unit. The sleeping and living area also has to be visually and functionally distinct but not a separate room. Variances may be granted for facilities converting to assisted living to allow up to a 10% reduction in square footage requirements.

Community based residential facilities Private rooms must offer 100 square feet and double rooms 80 square feet per person. No more than two residents may share a room. Small and medium facilities must offer one bathroom and shower facilities for every eight residents. Large facilities must have one toilet, bath and shower for every eight male residents and every eight female residents.

Tenant Policy

Residential care apartment complex The rules require the development of a mutually agreed upon service agreement and signing of a negotiated risk agreement. The risk agreement identifies situations or conditions known by the facility to arise from the tenant's preferences which are contrary to the facility's advice, how they will be accommodated, alternatives offered to reduce the risk, the agreed upon course of action and the tenant's understanding and acceptance of responsibility.

Facilities may retain tenants whose needs can be met by the facility or met by services available from another provider. Facilities may not admit anyone who has a court determination of incompetence, anyone who has an activated power of attorney for health care, anyone found by a physician or psychologist to be incapable of recognizing danger, summoning assistance, expressing need or making care decisions -- unless they share a unit with a competent person. Facilities may also retain a tenant who becomes incompetent as long as there is adequate oversight and the service and risk agreements are signed by the guardian or agent with power of attorney.

Facilities may terminate agreements with tenants whose needs cannot be met by the facility if service needs exceed 28 hours a week (unless additional services are secured by the tenant from other providers), tenants require 24-hours a day nurse availability, the tenant is a danger to self or others or fees have not been paid.

Community based residential facilities may not admit or retain anyone who is confined to bed by illness or infirmity (unless it is temporary); who is destructive; has physical, mental, psychiatric or social needs that are not compatible with the CBRFs client group; needs more than three hours of nursing care per week except for a temporary condition lasting no more than 90 days; requires 24-hour supervision by an RN or LPN; has chronic personal care needs that cannot be met by the facility or a community agency; or who requires restraints. A waiver may be granted for residents needing more than three hours of skilled care a week if condition is stable and the services needed are available in the facility.

Services

Residential care apartment complex Facilities must provide or contract for services which are sufficient and qualified to meet the care needs identified in the tenant service agreement. The minimum service package includes supportive services (meals, housekeeping, laundry, arranging access to medical services and transportation to medical services); personal services (daily assistance with ADLs); and nursing services (health monitoring, medication administration, and medication monitoring). Services above these minimums may be provided during acute episodes, release from a hospital or at other times when the tenant may experience temporary need.

A comprehensive assessment must be done and used as the basis of a service plan and risk agreement. The assessment covers: physical health, physical and functional limitations and capacities, medication and ability to self-administer, nutritional status and needs, mental and emotional health, behavior patterns, social and leisure needs and preferences, strengths, abilities and capacity for self-care, situations or conditions which could put the tenant at risk, and the type, amount and timing of services desired by the tenant.

The legislation and regulations limit supportive, personal and nursing services to 28 hours a week. The threshold was devised to prevent facilities from discharging residents prematurely. The threshold was developed based on an analysis of the amount of care required by participants in the state's Community Options (Medicaid Waiver) program and the Community Integration Program and reflects a higher level of care than the average community client.

The hours of service include staff time attributable to providing or arranging supportive, personal and nursing services including nursing assessment, documentation and consultation, and standby assistance. Services that are not included are meals, laundry, social and recreational activities. Tenants have the right to contract for or arrange for additional services outside the service agreement.

Community based residential facilities Residents receive an assessment upon admission, a plan of care and an individualized service plan. Facilities provide general services, medication administration and assistance and client group specific services. General services include supervision, information and referral, leisure time activities, community activities, family contacts, transportation, and health monitoring. Client group specific services include personal care, independent living skills, communication skills, socialization, activity programming for persons with dementia, transitional services, and nursing care (up to three hours a week).

Financing

Residential care apartment complex State funding is provided to Medicaid recipients who meet the nursing home level of care criteria through the Medicaid Community Options Program Waiver (COP-W) and the Community Integration Program II (CIP II). CIP II funding is only available when nursing home beds are closed and funding is transferred to provide community care to replace the closed capacity.

The legislation limits state reimbursement to 85% of the average statewide Medicaid nursing home rate excluding room and board. Rates are negotiated between facilities and the county. The maximum spending for the resident's total service plan is $52.32 per day which includes assisted living services provided by the facility, and other waiver costs such as county care management, transportation and therapies not covered by the Medicaid state plan. Room and board is not included in this ceiling.

Fifteen facilities currently contract with counties with a total capacity of 504 apartments. About 25 of the units are occupied by waiver participants.

Medications

Residential care apartment complex Facilities can offer medication administration and medication management (storage, preparation or organization or reminder system, assessment of effectiveness of medications, monitoring of side effects, negative reactions and drug interaction and delegation and supervision of administration).

Staffing

Residential care apartment complex The number, assignment and responsibilities of all staff shall be adequate to provide all services identified in the tenants' service agreements including assisting tenants with unscheduled care needs.

Training

Residential care apartment complex administrators Each RCAC must have a service manager responsible for the day to day operation of the facility, including ensuring that the services provided are sufficient to meet tenant needs and are provided by qualified persons; that staff are appropriately trained and supervised; that facility policies and procedures are followed; and that the health, safety and autonomy of the tenants are protected. The service manager shall be capable of managing a multi-disciplinary staff to provide services specified in the service agreements.

Community based residential facilities administrators must be 21, have a high school diploma or GED and have administrative experience or one post high school course in business management and one year experience or a post high school course related to the needs of the client group.

Staff

Residential care apartment complex Services shall be provided by staff who are trained in the services that they provide and are capable of doing their assigned work. Personal and supportive services shall be provided by staff who have documented training or experience in needs and techniques for assistance with tenant care and activities of daily living such as bathing, grooming, skin care, transfer, ambulation, exercise, meal preparation, and eating assistance, dressing and use of adaptive aids and equipment. All facility staff shall have training in safety procedures, including fire safety, first aid, universal precautions and the facility's emergency plan and facility policies and procedures relating to tenant's rights. Staff providing assisted living services must have documented training in the following areas:

Physical, functional and psychological characteristics associated with aging or likely to be present in the tenant population and their implications for service needs;
The purpose and philosophy of assisted living, including respect for tenant privacy, autonomy and independence; or
Assigned duties and responsibilities, including the needs and abilities of individual tenants.

Community based residential facilities Administrators and staff must have 45 hours of initial training covering: resident rights; recognizing and responding to challenging behaviors; client group specific training; needs assessment of prospective residents and individualized service plans; universal precautions; and fire safety, first aid and procedures to alleviate choking. Administrators and appropriate staff must receive three hours training in dietary needs, menu planning, food preparation and sanitation. The administrator and appropriate staff who are not under the supervision of a registered nurse or pharmacist must receive eight hours training in management and administration of medications. Exemptions from training are allowed for employees with specified licenses or credentials.

Administrators and staff must receive 12 hours of continuing education beginning the second year of employment that is relevant to their job responsibilities.

Background

Residential care apartment complex Facilities must conduct a criminal record check with the Wisconsin Department of Justice and with the registry for nurses aides, home health aides and hospice aides for managers, service providers and others.

Community based residential care facilities The department conducts a criminal records check of the applicant or licensee during the licensing process. Criminal checks are conducted for administrators and staff, using form DJ-LE-250 or 250A, from the Department of Justice. The state's registry for nurses assistants, home health aides and hospice aides are also checked.

Monitoring

Residential care apartment complex The Department conducts periodic inspections to determine compliance.

Fees are charged for plan review of new construction or additions for CBRFs based on the estimated value of the project.

Wyoming

Citation

Assisted living Chapter 4

General Approach

In 1992, the Director of the Department of Health formed a task force to determine how board and care homes can be established as low cost options in the continuum of care for the elderly. The task force reviewed who qualifies, current and future needs, existing and potential resources and cost reimbursement options. The task force included state agencies including the housing agency, ombudsman, consumer advocacy (AARP), home health agencies, not-for-profit nursing homes, board and care homes, and domiciliary care homes. The group's report was issued in October, 1992. In 1993, the legislature passed a definition of assisted living that allowed limited nursing care to be provided. Regulations were effective in October 1994 that re-name and modify the board and care licensure category. Board and care facilities can also be licensed as an assisted living facility in order to provide limited skilled nursing services and medication administration.

Definition

Assisted living means "a dwelling or rooming house operated by any person, firm or corporation engaged in providing limited nursing care, personal care and boarding home care, but not habilitative care, for persons not related to the owner of the facility."

Boarding home care means "a dwelling or rooming house operated by any person, firm or corporation engaged in the business of operating a home for the purpose of letting rooms for rent and providing meals and personal daily living care, but not habilitative or nursing care, or personal not related to the owner."

Unit Requirements

Rooms must provide 120 square feet for single occupancy and 80 square per person for double occupancy. No more than two people may share a bedroom. Bedrooms include toilets and sinks. One tub and shower room is required for every 10 residents.

Tenant Policy

The regulations allow residents who need limited nursing to be served. Previously, residents needing skilled nursing had to transfer to a nursing facility. However, residents who need continuous assistance with transfer and mobility, are unable to feed themselves, need total assistance with bathing and dressing, require catheter care, continuous oxygen and monitoring, have significant physical deterioration requiring more than seven days bed rest, wander excessively, need wound care requiring sterile dressings, stage II skin care and beyond, exhibit inappropriate social behavior and demonstrate chemical abuse that puts residents at risk may not be served.

Services

The facility must describe the services provided and the charges for services. Facilities must provide meals, housekeeping, personal and other laundry services, assistance with transportation, assistance obtaining medical, dental and optometric care and social services, partial assistance with personal care, limited assistance with dressing, minor non-sterile dressing changes, stage I skin care, infrequent assistance with mobility, cuing for ADLs with visually impaired residents and intermittently confused and/or agitated residents requiring occasional reminders to time, place and person, care for residents who care for their own catheter/ostomy without assistance, care for residents who are incontinent but care for themselves, RN assessments and medication review, and 24-hour supervision.

Services that may not be provided in assisted living include continuous assistance with transfer and mobility, care for residents who cannot feed themselves independently, total assistance with bathing or dressing, provision of catheter or ostomy care, care of residents who are on continuous oxygen if monitoring is required, residents whose medical condition requires more than 7 days bedrest, residents who wander, need stage II skin care and beyond, wound care and incontinence care.

Medications

The regulations allow assistance with self-administration which includes but is not limited to reminders, removing from containers, assistance with removing caps, and observing the resident take the medication.

Financing

The task force report recommended that the Wyoming Department of Commerce be authorized to make loans to finance the development, remodeling and construction of board and care and/or assisted living facilities in underserved communities. No subsidies are available for low income residents.

Staffing

Staff shall be sufficient to meet the needs of residents. An RN, LPN or CNA must be on every shift. At least one awake staff is required for all facilities serving 10 more residents.

Training

Administrators Managers shall be a certified nursing assistant or the equivalent, or otherwise be capable of making informed decisions regarding quality of care.

Staff Management shall provide to new employees an orientation, education regarding resident rights, evacuation and emergency procedures and training and competent supervision designed to improve resident care. All facilities must have an active quality assurance program to ensure effective utilization and delivery of resident care services.

Background Check

Not required.

Monitoring

Facilities are surveyed no less than annually.

Section IV

STATE LICENSING AGENCY CONTACT LIST

Mia Sadler, Department of Public Health, P.O. Box 303017, Montgomery, Alabama 36130-3017

Virginia Smiley, Department of Administration, Older Alaskans Commission, Box C, Juneau, Alaska 99811-0209

Jerry Rayburn, Office of Long Term Care, Department of Human Services, P.O. Box 1437, Slott 1100 11th Floor, Little Rock, Arkansas 72201

Lisa Winn, Department of Health Services, Home & Community Based Licensure, 1647 East Morten, Phoenix, Arizona 85020

Dennyse Provolt, Department of Social Services, Community Care Licensing Division, 744 P Street, MS 19-50, Sacramento, California 95814

Terry Zamell, Department of Public Health and Environment, Health Facilities Division, 4300 Cherry Creek Drive South, Denver, Colorado 80246

Cindy Denne, Department of Public Health, 150 Washington Street, Hartford, Connecticut 06106

Jackie Rohrbaugh, Division of Public Health, Licensing and Certification, 1901 North Dupont Highway, New Castle, Delaware 19720

Meta Calder, Department of Elder Affairs, 4040 Esplanade Way, Tallahassee, Florida 323997000

Victoria Flynn, Personal Care Home Program, Department of Human Resources, 2 Peachtree Street, N.W., Suite 31-447, Atlanta, Georgia 30303-3167

Helen Yoshimi, Hawaii Department of Health, P.O. Box 3328, Honolulu, Hawaii 96801

John Hathaway, Bureau of Facility Standards, P.O. Box 83720, Boise, Idaho 83720-0036

Patricia Heidenrich, Department of Health, 525 West Jefferson, 5th Floor, Springfield, Illinois 62762

Sue Hornstein, Director, Long Term Care, Division of Regulations and Information, 2 North Meridian, Indianapolis, Indiana 46204

Beth Behnson, Department of Elder Affairs, Jewett Building, Suite 236, 914 Grand Avenue, Des Moines, Iowa 50319

Pat Maben, Department of Health, Landon State Office Building, 900 S.W. Jackson, Suite 1001, Topeka, Kansas 66612

David Crane, Cabinet for Human Resources, CHR Building, 4th Floor , Frankfort, Kentucky 40621-0001

Thalia Milliken, Bureau of Licensing, Department of Social Services, P.O. Box 3078, Baton Rouge, Louisiana 70821

Robert Steinberg, Residential Care Unit, Bureau of Licensing/Certification, 35 Anthony Avenue, State House, Station 11, Augusta, Maine 04333

Carol Benner, Licensing and Certification, 4201 Patterson Avenue, Baltimore, Maryland 212152299

Naren Dhamadoren, Executive Office of Elder Affairs, 1 Ashburton Place, Boston, Massachusetts 02108

Ron Basso, Department of Consumer and Industry Services, G Mennen Williams Building, 4th Floor, P.O. Box 30004, Lansing, Michigan 48909

Mary Cahill, Department of Health, 393 North Dunlop Street, P.O. Box 64900, St. Paul, Minnesota 55164-0900

Vanessa Philips, Department of Health, Health Facilities/Licensure Certification Division, P.O. Box 1700, Jackson, Mississippi 39215-1700

Bill Toenis, Manager of Licensure/Certification, Department of Social Services, P.O. Box 1337, Jefferson City, Missouri 65102-0088

Roy Kemp, Health Facilities Division, P.O. Box 200901, Helena, Montana 59620-0901

Claire Titus, Department of Health and Human Services, Regulation and Licensure, P.O. Box 95007, Lincoln, Nebraska 68509-0555

Joyce Herman, Division of Health, Bureau of Licensure/Certification, 1550 E. College Parkway, Suite 158, Carson City, Nevada 89706-7921

Andy Aronson, Department of Health, CN 360, Trenton, New Jersey 08625

Tina Kelley, Bureau of Health Facilities Administration, Division of Public Health, 6 Hazen Drive, Concord, New Hampshire 03301-6527

Roy Weidner, Health Facility Licensure and Certification Bureau, 1190 St. Francis Drive South 1050, Santa Fe, New Mexico 87505

Frank Rose, Department of Social Services, 39 North Pearl Street, 5th Floor, Albany, New York 12207-2785

Jim Upchurch, Department of Health and Human Services, Division of Facility Services, P.O. Box 29530, Raleigh, North Carolina 27626-0530

Fred Gladden, Division of Health Facilities, Department of Health, 600 East Boulevard Avenue, Bismarck, North Dakota 585050-0200

Madeline Dile, Special Projects Section, Department of Health, 246 N. High Street, 3rd Floor, Columbus, Ohio 43266-0588

Don Garrison, Department of Health, Residential Care Division, 1000 N.E. 10th Street, Oklahoma City, Oklahoma 73117

Kathy Labadie, Assistant Administrator, Senior and Disabled Services Division, 313 Public Service Building, Salem, Oregon 97310

Bill Yavonovich, DPW, Department of Public Welfare, Office of Social Programs, 1401 N 7th Street, P.O. Box 267, Harrisburg, Pennsylvania 17105-2675

Dalia Calabro, Department of Health, Division of Facilities Regulation, 3 Capitol Hill, Room 306, Providence, Rhode Island 02908-5097

Sandra Jones, Division of Health Licensing, Community Residential Care Program, 2600 Bull Street, Columbia, South Carolina 29201

Joan Bachman, Department of Health, Office of Health Care Facilities Licensure and Certification, 445 E. Capitol, Anderson Building, Pierre, South Dakota 57501

Bobbi Wood, Department of Health, Division of Health Care Facilities, 425 5th Avenue North, Nashville, Tennessee 37247-0508

Marc Gold, Texas Department of Human Services, P.O. Box 149030, Austin, Texas 78714-9030

Debra Wynkoop-Green, Division of Health Systems Improvement, 288 North 1460 West, P.O. Box 16990, Salt Lake City, Utah 84116-0990

Heather Johnson Lamarche, Department of Aging and Disability, 103 South Main Street, Waterbury, Vermont 05671-2301

Judy McGreal, Department of Social Services, Division of Licensing Programs, 730 East Broad Street, Richmond, Virginia 23219

Harry Sedies, Aging and Adult Services Division, P.O. Box 45600, 600 Woodland Square Loop S.E., Olympia, Washington 98504-5600

Sandra Taubman, Office of Health Facility Licensure and Certification, 1900 Kahawha Boulevard, Building 3, Room 550, Charleston, West Virginia 25305

Wendy Fearnside, Bureau of Aging, 1 West Wilson, Room 472, Madison, Wisconsin 53707

Gerald E. Broonnenberg, Office of Health Quality, Planning and Program Evaluation, 2020 Carey Avene, First Bank Building, 8th Floor, Cheyenne, Wyoming 82002-0710

Notes

These licensing categories and the number of facilities were reported by state licensing agencies. The total numbers differ from those used to create a national sample of assisted living facilities for the larger component of this project by the Research Triangle Institute which used a specific definition of assisted living and obtained data from multiple sources.
Ruth Gulyas. "The Not-for-Profit Assisted Living Industry: 1997 Profile." American Association of Homes and Services for the Aging. Washington DC. 1997. Also, "An Overview of the Assisted Living Industry: 1996." The Assisted Living Federation of America and Coopers and Lybrand. Washington, DC. 1996.
Several states with existing policy have formed a task force to review the policy and make recommendations.
States may be counted in more than one category.
New Jersey's rules require apartment settings for all new construction but allowed existing Personal Care Homes with shared rooms to convert to assisted living.
Portions of the following have been taken from HCFA's description of the waiver program which is available at its web site (http://www.hcfa.gov).
Many states have a state supplement for board-and-care facilities that may be too low to cover more intense services needs and higher capitol costs in assisted living settings.
David Liska, Brian Broen, Alina Salganicoff, Peter Lory and Bethany Kessler. "Medicaid Expenditures and Beneficiaries: National and State Profiles and Trends--1990-1995." Kaiser Commission for the Future of Medicaid. Washington, DC. November 1997.

Files

98state.pdf (pdf, 1 MB)

Topics

Long-Term Services & Supports (LTSS) | Consumer Direction | Assisted Living Facilities & Residential Care

Program

Cash and Counseling Demonstration