Regulatory Review of Adult Day Services: Final Report

SECTION 1. OVERVIEW OF ADULT DAY SERVICES REGULATIONS

August 26, 2005

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SECTION 1, TABLE OF CONTENTS

LICENSING, CERTIFICATION, AND OTHER REQUIREMENTS
Licensure
Certification
Both Licensure and Certification
Other Required Types of Provider Agreements
DEFINITIONS OF ADULT DAY SERVICES
PARAMETERS FOR WHO CAN BE SERVED
REQUIRED AND OPTIONAL SERVICES
PROVISIONS REGARDING MEDICATIONS
STAFFING REQUIREMENTS
TRAINING REQUIREMENTS
MONITORING
RELEVANT MEDICAID CONTRACTING REQUIREMENTS
LIST OF EXHIBITS
EXHIBIT 1. Approach to Regulation by States
EXHIBIT 2. Staffing Ratios by State
EXHIBIT 3. Special Provisions for People with Dementia by State
EXHIBIT 4. Additional Medicaid Waiver and/or State Plan Adult Day Services Provider Requirements by State
ENDNOTES


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


LICENSING, CERTIFICATION, AND OTHER REQUIREMENTS

The majority of states approach ADS regulation by requiring licensure or certification in accordance with state standards. 25 states require licensure, ten states require certification; and four states require both licensure and certification (in these states, Medicaid and non-Medicaid providers have different requirements.) Thirteen states require ADS providers to seek approval from or enter into some type of agreement with a state agency. Exhibit 1 indicates whether a state requires licensure, certification, both, and/or some other arrangement.

Licensure

States vary in their approach to licensure, primarily licensing providers of specific ADS programs or operators of specific types of facilities or centers. Some states license a single program; others cover two or more program types under a single licensing category; some have separate licenses for specific types of programs in addition to basic licensure.

For example, Maine licenses two types of programs--adult day health services and social ADS programs--as Adult Day Services. Either program may operate a night program that provides services to persons with dementia. However, the ADS provider must have a separate license to operate a night program and must keep record keeping distinct.

States do not generally license by levels of care. Louisiana is an exception. The state licenses both adult day care and adult day health care and has a unique system of licensing with six distinct types of licensed services settings related to the capacities of the clients with developmental disabilities whom they serve. Louisiana is the only state that defines adult day care as a service only for persons with developmental disabilities rather than for "older persons with disabilities" or "adults with disabilities."

EXHIBIT 1. Approach to Regulation by States
Licensure and Certification Requirementsa
State Licensure Only Certifiction Only Both Required Other
Alabama       X
Alaska   X    
Arizona X      
Arkansas X      
California     X  
Colorado   X    
Connecticut   X    
Delaware X      
District of Columbia   X   X
Florida X      
Georgia       X
Hawaii X      
Idaho       X
Illinois       X
Indiana   X    
Iowa   X    
Kansas X      
Kentucky     X  
Louisiana X      
Maine X      
Maryland     X  
Massachusetts       X
Michigan       X
Minnesota X      
Mississippi       X
Missouri X      
Montana X      
Nebraska X      
Nevada     X  
New Hampshire X      
New Jersey X      
New Mexico X      
New York       X
North Carolina   X    
North Dakota       X
Ohio   X    
Oklahoma X      
Oregon       X
Pennsylvania X      
Rhode Island X      
South Carolina X      
South Dakota       X
Tennessee X      
Texas X      
Utah X      
Vermont   X    
Virginia X      
Washington       X
West Virginia X      
Wisconsin   X    
Wyoming X      
TOTAL 25 10 4 13
  1. For more detailed information, please consult the individual state profiles in Section 2. For example, Kentucky requires licensure or certification depending on the type of services offered; adult day health care is licensed and adult day care is certified.

Several states address licensure in the context of co-location of an adult day care facility within an already licensed acute or LTC setting. For example, Florida does not require licensed assisted living facilities, licensed hospitals, and licensed nursing homes that provide adult day care services to adults who are not residents to be licensed as adult day care centers (ADCCs), providing they do not represent themselves to the public as ADCCs. However, the state must monitor the facility during the regular inspection and at least biennially to ensure adequate space and sufficient staff. Other examples include:

States generally do not license dementia-specific facilities or programs separately from adult day service programs. Few states have separate licensing requirements for providers who serve persons with dementia or other special needs. However, many states have special requirements in their standard ADS licensing requirements for providers who serve individuals with dementia. These requirements generally relate to staffing and training--requiring lower staff-to-participant ratios and dementia-specific training.

Certification

Ten states require certification in place of licensure. Of these, Alaska, Colorado, Ohio, Indiana, and Wisconsin require only Medicaid providers to be certified according to ADS certification standards; non-Medicaid providers do not have be certified. Adult day certification is voluntary for non-Medicaid providers in Wisconsin. The District of Columbia requires Medicaid providers to be certified; non-Medicaid providers must follow Office on Aging contracting requirements.

Like states that license providers, states that require certification distinguish between different types of ADS programs. For example:

A few states certify Alzheimer's programs separately from other ADS programs. For example, Iowa certifies ADS programs as dementia-specific ADS programs. North Carolina does not have a separate certification, but allows certified adult day care centers to provide special care services by promoting programming, activities, or care specifically designed for persons with Alzheimer's disease or other dementias, mental health disabilities, or other special needs, diseases, or conditions. To provide special care services, providers must follow specific requirements in the certification standards.

Colorado is one state that does have specialized requirements for dementia-specific facilities. The state certifies specialized ADS centers (SADS) to provide intensive health supportive services for participants with a primary diagnosis of Alzheimer's or other dementias, Multiple Sclerosis, brain injury, chronic mental illness, or developmental disability or post-stroke participants who require extensive rehabilitative therapies. The state has staffing and service requirements specifically for SADS centers that differ from those for ADS centers.

One state has certification standards specific to co-location of an adult day care facility within an already licensed acute or LTC setting. Wisconsin's certification standards address adult day care programs operating in a multi-use facility that is not located in or connected to a nursing home (e.g., a residential care facility or hospital) and adult day care programs that are located in or connected to nursing homes. For the former, the standards addressed include staffing of the program from other parts of the multiuse facility to meet staff-to-participant ratios; planning of joint activities; space requirements (e.g., program must be separate from living areas); and facility requirements (e.g., program must have a separate door). For the latter, the standards list criteria related to external setting (e.g., name and location connote a community-based setting rather than a health care facility); interior setting (e.g., décor must reflect non-institutional settings); and integrity of the program that must be adopted (e.g., activities are unique and not part of nursing facility activity calendar).

Both Licensure and Certification

Only four states both license and certify providers. Kentucky licenses Medicaid providers of adult day health care but certifies facilities for the Adult Day Care and Alzheimer's Respite program. Nevada requires all facilities offering adult day or adult day health care to be licensed (including Medicaid waiver and State Plan providers) and requires Medicaid State Plan providers to meet adult day health care certification standards. Maryland licenses two types of adult day services--Day Care and Medical Day Care--but also offers a small social adult day care program called Senior Center Plus. Senior Center Plus providers do not have to be licensed but must meet Maryland Department of Aging certification requirements. California licenses two types of facilities: adult day programs and adult day health care centers. Adult day health care centers must also be certified. In addition, each local area Agency on Aging designates at least one Alzheimer's day care resource center (ADCRC) in its Planning and Service Area to provide specialized Alzheimer's care and community outreach and education. Until recently, the law permitted ADCRCs to function without a facility license, although the majority of ADCRCs are located in licensed ADPs or ADHC centers.

Other Required Types of Provider Agreements

States that neither license nor certify generally require publicly funded ADS providers to enter into official, most often contractual, agreements with a state agency, specifying that they will comply with mandated requirements. These states do not have any requirements for providers who serve only private-pay clients. For example:

Two states have operating standards for providers:

One state specifically developed provider standards to follow the Commission on Accreditation of Rehabilitation Facilities adult day services standards. The Idaho Commission on Aging requires adult day care programs to operate under guidelines it established, which are in accordance with the standards developed by the Commission on Accreditation of Rehabilitation Facilities.

One state has a separate type of arrangement/agreement specific to co-location of an adult day care facility within another acute or LTC setting. Adult day care services providers who want to operate in a licensed basic care or skilled nursing facility must obtain approval from the North Dakota Department of Health. There are no other requirements for adult day care providers operating in stand-alone or other types of facilities. Medicaid Aged and Disabled waiver adult day care providers must follow a separate set of administrative rules.

One state has an agreement that separately addresses services to persons with special needs. Michigan's operating standards recognize two types of adult day community services: adult day care and dementia adult day care. Some standards are the same for both types and some differ.


DEFINITIONS OF ADULT DAY SERVICES

States vary considerably in the terms they use for ADS. For example, Arizona and Pennsylvania license adult day health care facilities, Delaware and New Mexico license adult day care facilities, and Oklahoma licenses adult day care centers. West Virginia licenses medical adult day care centers as a special type of ambulatory health care center. Nonetheless, the majority of state regulations define only one or two types of adult day services.

In those states with two types, the most frequent distinction between the two hinges on the provision of health and nursing services. For example, in Washington, adult day care is defined as a supervised daytime program providing core services appropriate for adults with medical or disabling conditions that do not require the intervention or services of a registered nurse or licensed rehabilitative therapist acting under the supervision of the client's physician. Adult day health care is defined as a supervised daytime program providing skilled nursing and rehabilitative therapy services in addition to core services provided in adult day care. However, in some states that define just one type of adult day services, which is not specified as day health services, these programs are allowed to provide a high level of care that would be considered an intermediate level of nursing home care in many states.

A few states define several delivery models within their basic definition, generally based on the level of need or the specialized needs of participants. For example, Ohio distinguishes between two level of adult day services--enhanced and intensive--and defines them as follows:

Colorado defines a specialized adult day services center as one that provides intensive health supportive services for participants with a primary diagnosis of Alzheimer's or other dementias, Multiple Sclerosis, brain injury, chronic mental illness, or developmental disabilities or for post-stroke participants who require extensive rehabilitative therapies. However, as noted above, very few states have a specific licensing category for ADS providers serving individuals with specific conditions.

Definitions of adult day services generally incorporate a statement about their purpose, thresholds for the number of people who can be served, limits on the number of hours a person may be served, and parameters for who may or may not be served. Definitions range from general to specific. Examples of states' definitions follow:

Participant thresholds and hourly limits. States do not vary much with regard to the maximum number of participants that providers may serve before licensure or certification is required. The maximum is generally between three and five individuals who are unrelated to the provider. Tennessee is an exception, setting the threshold at ten individuals.

States vary more with regard to specifying the maximum hours of services that ADS providers may furnish. For example, in Idaho participants may be served during any part of the day but only for less than 14 hours. Iowa's maximum is 16 hours in a 24-hour period. Some states, such as Kansas, do not specify minimums or maximums but only that facilities must operate fewer than 24 hours a day. On the other hand, Tennessee defines adult day care services as those that are provided for more than 3 hours per day but less than 24 hours per day, implying that providers who furnish services fewer than 3 hours a day do not have to be licensed.


PARAMETERS FOR WHO CAN BE SERVED

The regulation of a service targeted to frail elders and individuals with disabilities needs to assure that providers can meet the needs of their clients. One option for assuring this is through explicit admission/retention/discharge criteria that set the parameters for who can be served.

Many states lack specific provisions regarding the types or level of functional or health needs that should trigger discharge. Most states do have provisions related to involuntary discharge, which generally give providers some discretion to determine whether or not they can meet an individual's needs. For example, Vermont's rules limit involuntary discharges to the following situations: (1) the participant's care needs exceed those an adult day center is certified to provide, (2) an adult day center is unable to meet the participant's assessed needs, or (3) the participant presents a threat to himself or herself or to other participants or staff. Similarly, Alabama requires that providers discharge participants when the program of care can no longer meet their needs or when their condition presents an immediate and serious risk to the health, safety, or welfare of the participants or others.

In most states, parameters for who can be served are set (although indirectly) through provisions regarding mandatory and optional services that indicate a participant's level of need. For example, Virginia requires adult day health care centers (ADHC) to meet the needs of each participant, but specifies that a minimum range of services must be available to every Medicaid ADHC recipient, including nursing services and rehabilitation services. Virginia further specifies that centers can admit recipients who have skilled needs only if there is professional nursing staff immediately available on site to provide the specialized nursing care these recipients require. Provisions such as these indicate that persons with a high level of nursing or medical needs can be served in these centers. Additional examples follow:

Generally, states permit medical models of ADS to serve individuals with a high level of nursing and medical needs. This level of care is assumed in states that cover ADS in their waiver programs because individuals must meet the state's nursing home level-of-care criteria to be eligible for waiver services. However, because these criteria vary considerably among states, individuals who are considered nursing home eligible in one state may have greater or lesser needs than those considered nursing home eligible in another state.


REQUIRED AND OPTIONAL SERVICES

All states identify a range of required and optional ADS in their licensing or certification requirements or other types of agreements. States list required and optional services for each type of ADS that they license, certify, or otherwise regulate (e.g., for adult day care and adult day health care).

The services we included in our review are:

  • ADL assistance;
  • health education;
  • health monitoring;
  • medication administration;
  • nursing services;
  • physical, occupational, and speech therapy;
  • skilled nursing services;
  • social services; and
  • transportation.

We limited our review to these services because the purpose of this study is to better understand the role of ADS in addressing elderly persons' health and functional needs. We did not include services such as emergency services and nutritional services, because they are provided to all residents regardless of residents' functional or health status. See Section 2 for individual state information about which services are required and optional.

States generally require adult day care providers to furnish ADL assistance and health monitoring. Health education; physical, occupational, and speech therapy; and skilled nursing services are less likely to be cited as either required or optional.

States generally require adult day health care or medical adult day care providers to furnish more services than adult day care providers. In addition to ADL assistance, social services, and health monitoring, adult day health care providers are generally required to furnish medication administration; nursing services; physical, occupational, and speech therapy; and skilled nursing services.


PROVISIONS REGARDING MEDICATIONS

Most states do not specify medication administration as a required service, except for adult day health care providers. The majority of states require licensed personnel to administer medications. States that permit unlicensed staff to administer medications generally required that they do so under nurse delegation provisions, though a few require only consultation with a physician or pharmacist or specific training. Examples include the following:

Most states require providers to have written policies for medication management and administration. For example, Georgia requires adult day care programs to have a written policy for medication management designating specific staff to be authorized and trained to assist with the administration of medications and designating the program's role in the supervision of self-administered medications and/or staff-administered medications.

Many states also specify requirements related to self-administration of medications. For example, Texas requires individuals who self-administer their medications to be counseled at least once a month by licensed nursing staff to ascertain if they continue to be capable of self-administering their medications.


STAFFING REQUIREMENTS

States vary with regard to the number of staff required. Most states specify minimum staff-to-participant ratios. As shown in Exhibit 2, mandatory ratios range between one to four and one to ten. Some states require different ratios for different types of ADS, and some states specify both a required ratio and a recommended ratio. Some states require lower ratios when serving participants with greater needs, but allow providers to determine what level of need requires the lower ratio. For example:

Several states do not have minimum staff-to-participant ratios and allow providers to determine the number of staff, requiring only that they have "sufficient" staff to meet participants' needs. For example, Idaho states that staff must be adequate in numbers and skill to provide essential services but does not define essential services. The state further specifies that the number of staff per participant must increase appropriately if the number of participants in day care increases or if the degree of severity of participants' functional or cognitive impairment increases. However, we identified no state guidance to providers for what constitutes an "appropriate" increase.

Idaho's Medicaid provisions, on the other hand, have more specific requirements. Medicaid providers are required to have a minimum of one staff for every six participants, and a ratio of one-to-four when serving a high percentage of participants who are severely impaired.

EXHIBIT 2. Staffing Ratios by Statea
  1:4 1:5 1:6 1:7 1:8 1:9 1:10
Alabama             X
Alaska X       X    
Arizona              
Arkansas X X     X    
California X       X    
Colorado         X    
Connecticut       X      
Delaware X       X    
District of Columbia              
Florida     X        
Georgia X       X    
Hawaii     X        
Idaho              
Illinois              
Indiana X   X   X    
Iowa              
Kansas              
Kentucky   X          
Louisiana           X  
Maine     X        
Maryland     X        
Massachusetts X   X   X    
Michigan             X
Minnesota   X     X    
Mississippi              
Missouri              
Montana              
Nebraska              
Nevada              
New Hampshire         X    
New Jersey           X  
New Mexico   X          
New York       X      
North Carolina   X X   X    
North Dakota              
Ohio     X        
Oklahoma         X    
Oregon X   X        
Pennsylvania       X      
Rhode Island           X  
South Carolina         X    
South Dakota X   X        
Tennessee         X    
Texas         X    
Utah     X   X    
Vermont       X      
Virginia     X        
Washington     X        
West Virginia     X        
Wisconsin     X   X    
Wyoming     X        
TOTAL 9 5 16 4 17 3 2
  1. For more detailed information, please consult the individual state profiles in Section 2. For example, in Indiana, for Basic (Level 1) care, the minimum staff-to-client ratio is 1:8. For Enhanced (Level 2) care, the minimum staff-to-client ratio is 1:6. For Intensive (Level 3) care, the minimum staff-to-client ratio is 1:4.

Staffing for persons with dementia. Exhibit 3 lists the states that have special provisions for serving individuals with dementia, most of which relate to staffing and training requirements.

Required staffing ratios for persons with dementia are generally one staff to four participants, though Michigan requires Dementia Adult Day Care programs to have a minimum staff/volunteer/student-to-participant ratio of one-to-three. Some states specify lower ratios for people with cognitive impairment who may not have a diagnosis of dementia. For example, Minnesota states that when an adult day care/services center serves both participants who are capable of taking appropriate action for self-preservation under emergency conditions and participants who are not, it is required to maintain a staff-to-participant ratio of one-to-five for participants who are not capable of self-preservation and one-to-eight for participants who are capable of self-preservation.

EXHIBIT 3. Special Provisions for People with Dementia by State
State Special Provisions for
Persons with Dementia
  State Special Provisions for
Persons with Dementia
Alabama     Montana  
Alaska X   Nebraska  
Arizona     Nevadac X
Arkansas X   New Hampshire  
Californiac X   New Jersey X
Colorado X   New Mexico  
Connecticut X   New York X
Delaware     North Carolina X
District of Columbia     North Dakota  
Florida X   Ohio  
Georgia X   Oklahoma  
Hawaii     Oregon X
Idaho     Pennsylvania X
Illinois     Rhode Island  
Indiana     South Carolina  
Iowa X   South Dakota X
Kansas X   Tennessee X
Kentucky X   Texas  
Louisianab X   Utah X
Maine X   Vermont  
Maryland     Virginia  
Massachusetts X   Washington  
Michigan X   West Virginia  
Minnesota X   Wisconsin  
Mississippi     Wyoming  
Missouri X   TOTAL 25
  1. Only for Adult Day Health Care.
  2. Only for Adult Day Health Care.
  3. Only in the State Plan Adult Day Health Care program.

Types of staff. In addition to staffing ratios, virtually all states require specific types of staff for ADS programs. The major difference in requirements between adult day care and adult day health care is that states require the latter to have licensed nurses available in some capacity (e.g., as full time or part time employees or as consultants). Because most states require staffing consistent with participants' needs, licensed nurses are required if adult day health care service centers need skilled nursing services.

The following are examples of requirements regarding types of staff and nurse staffing:

In some states, the Medicaid program has specific requirements for nurse staffing to assure that the needs of waiver clients are met. For example:


TRAINING REQUIREMENTS

Virtually all states have both orientation and initial and ongoing training requirements, but they are minimal. Some requirements are quite general, while others are specific regarding the type of training and the number of hours required. Most states require at least one staff trained in first aid and CPR on duty at all times. Examples of the wide range of requirements follow:

As noted in Exhibit 3, many states have specific requirements for ADS providers who serve persons with dementia, most relating to staffing and training. Examples follow:


MONITORING

The majority of states require inspections--most of them annual inspections that coincide with an initial license application and annual license renewal. Several states also stipulate that unannounced visits by state personnel can occur at any time. Only one state does not have external monitoring. Alaska does not license or monitor ADS. The state's rules require only that an adult day care program conducts an internal evaluation, at least annually, of its operation and services. However, site visit inspections are required for programs receiving state grant funds.1

States vary in the extent of their monitoring of ADS providers. For example:

A few states specify provisions for addressing complaints. For example, the Arkansas Office of Long Term Care conducts complaint inspections in adult day health care facilities to determine their validity, and in Missouri the state makes unannounced visits for investigative purposes when complaints have been filed regarding a program.


RELEVANT MEDICAID CONTRACTING REQUIREMENTS

Relevant Medicaid Contracting Requirements All states fund ADS for elderly persons through either their Medicaid State Plan or waiver program. State primarily use 1915(c) waivers; Tennessee is an exception using an 1115 waiver. Providers of Medicaid-funded ADS must meet all applicable regulatory requirements whether they include licensure, certification, or some other arrangement. Over one-third of the states require ADS providers to meet additional Medicaid provisions. Exhibit 4 indicates the states that have additional Medicaid requirements.

Additional Medicaid requirements are generally for ADS providers who furnish adult day health care services to waiver participants. Many of the states with additional Medicaid requirements license or certify adult day care only, while the Medicaid requirements are for adult day health care. These requirements, often health services, are in addition to those required for licensure and include additional staffing (type and number) and training. Some examples follow:

EXHIBIT 4. Additional Medicaid Waiver and/or State Plan Adult Day Services Provider Requirements by State
State Additional
Requirements
  State Additional
Requirements
Alabama     Montana  
Alaska X   Nebraska X
Arizona X   Nevadac X
Arkansas     New Hampshire X
Californiac X   New Jersey X
Colorado     New Mexico X
Connecticut     New York  
Delaware X   North Carolina  
District of Columbia X   North Dakota X
Florida X   Ohio X
Georgia X   Oklahoma X
Hawaii     Oregon  
Idaho X   Pennsylvania  
Illinois     Rhode Island  
Indiana     South Carolina X
Iowa     South Dakota  
Kansas X   Tennessee  
Kentucky     Texas X
Louisianab     Utah  
Maine X   Vermont X
Maryland X   Virginia X
Massachusetts     Washington  
Michigan     West Virginia  
Minnesota X   Wisconsin  
Mississippi X   Wyoming  
Missouri X   TOTAL 26


ENDNOTES

  1. We did not identify this requirement in the rules; a state staff person who reviewed the profile provided this information.

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