Regulatory Review of Adult Day Services: Final Report - Section 2

Regulatory Review of Adult Day Services: Final Report

SECTION 2. STATE REGULATORY PROFILES

The following profiles summarize states' approaches to regulating adult day services. While state regulations cover a multitude of areas, a primary purpose of this study is to understand the role that ADS plays in the health care and long-term care systems. Therefore, in addition to identifying each state's general approach to regulating adult day services, we focused primarily on those provisions related to the target population and services.

Consequently, our regulatory review does not include a summary of all regulatory provisions. The following are not included in the state profiles:

• Advisory board and governing body requirements.
• Enrollment procedures.
• Facility, equipment, and physical plant requirements.
• General health and safety requirements, such as infection control, fire safety, and emergency operations.
• Program activities requirements.
• Record keeping requirements.
• Participants' rights.
• Personnel policies not related to staffing and training, such as conducting criminal background checks.
• Meal and food requirements related to food handling, preparation, and storage.
• Medication storage policies.

All of these areas, while important, are not directly related to the provisions of health and long-term care services.

The regulatory profiles have several sections:

Overview. The overview contains a brief description of the state's general approach to regulating ADS providers, indicating whether the state uses licensure, certification, or some other approach. The overview also indicates whether the state's Medicaid program has additional requirements for ADS providers who serve Medicaid beneficiaries. Because the focus of this review is on services for elderly persons, the profiles do not include regulatory or Medicaid information for ADS providers who exclusively serve individuals with mental retardation or other developmental disabilities.

Licensing, Certification, or Other Requirements. This section specifies whether a state requires licensure, certification, both, or neither or uses some other regulatory approach such as contracts with public funders of adult day services.

Definitions of Adult Day Services. This section provides the regulatory definitions for each type of adult day service that the state regulates (i.e., adult day care and adult day health care).

Parameters for Who Can Be Served. This section includes provisions that specify the health and functional needs of the population that may be served. These provisions are generally not specifically stated in regulation. The information in this section was obtained from a combination of sources: discharge criteria, definitions of adult day services, lists of required services, and Medicaid eligibility criteria for ADS services.

Inspection and Monitoring. This section contains basic information about the type and frequency of oversight activities.

Required and Optional Services. This section lists required and optional services in a table format. Although states may specify a service as optional, some also specify that providers are required to cover any services specified in a participant's care plan.

Provisions Regarding Medications. This section contains information pertaining to self-administration of medications and the administration of medications to ADS participants, including what types of staff (e.g., licensed personnel) may administer medications to ADS participants.

Provisions for Groups with Special Needs. This section indicates whether a state has regulatory provisions for serving populations with special needs such as dementia. While states may not have a section of their regulations addressing the needs of groups with special needs (e.g., dementia), many have specific provisions for dementia participants in the regulatory sections dealing with staffing and training.

Staffing Requirements. This section includes information about the type of staff required in addition to required staff-to-participant ratios.

Training Requirements. This section includes information about staff training requirements, including orientation training and annual training.

Relevant Medicaid Contracting Requirements. This section includes additional contracting requirements for ADS providers serving Medicaid beneficiaries in waiver programs or under the State Plan.

Each profile ends with citations for information sources and the URL addresses for on-line information sources when available.

The profiles are intended to provide basic information for how states regulate providers of ADS for elderly persons. They do not include information about specific programs or sources of public funding other than Medicaid (e.g., Older Americans Act and Veterans Administration funding).

Alabama

Overview

Alabama provides adult day care (ADC) as a function of Adult Protective Services, under the Department of Human Resources, under Adult Day Care Requirements from the Office of Social Service Contracts.

Alabama provides adult day health care (ADHC) as a service of the Elderly and Disabled Waiver. The State Medicaid Agency requires waiver service providers to have specific approval to offer adult day health care under the waiver, with staffing qualifications and required services outlined in the Elderly and Disabled 1915(c) Waiver document and the regularly updated Provider Manual.

The profile contains requirements for both adult day care and adult day health care.

Alabama also provides adult day health care as a respite service through the Department of Senior Services Caregiver Support Program, Alabama CARES (Caregiver Assistance with Resources, Education, and Support). This Older American Act-funded service is implemented by Area Agencies on Aging through contracts with waiver providers who agree to the additional Medicaid specifications noted in this profile. These services are monitored by the Alabama Department of Senior Services.

There is no state agency that regulates facilities other than those served by these programs.

Licensure and Certification Requirements

Definitions

Adult day care. The purpose of the adult day care program is to protect an individual, 18 years of age or older at risk of abuse, neglect, or exploitation; to provide services to such an individual at risk of institutionalization; and to provide services to such an individual who is in need of supervision or assistance with activities of daily living outside the home for a portion of a day.

Adult day health care (two types). (1) Adult day health (ADH) is a service that provides waiver clients 18 years of age or older with a variety of health, social, recreational, and support activities in a supervised group for 4 or more hours per day on a regular basis. ADH is based on the needs of the individual client. (2) Adult day health care under the Medicaid Elderly and Disabled waiver provides social and health care for a minimum of 4 hours per day in a community facility approved to provide such care and includes health education, self-care training, therapeutic activities, and health screening. Services are provided Monday through Friday except for regularly scheduled holidays.

Parameters for Who Can Be Served

The eligibility criteria for the publicly funded programs set the parameters for who can be served.

Adult day care. Adults who are 18 years of age or older who are certified as eligible by the appropriate County Department of Human Resources.

Adult day health care. All individuals 18 years of age or older who needs can be met in an outpatient setting, encompassing both health and social services needed to ensure optimal functioning.

Inspection and Monitoring

Adult day care. An annual monitoring is conducted to ensure that providers are in compliance.

Adult day health care. None identified.

Required and Optional Services

Provisions Regarding Medications

Adult day care. Program staff will not administer medications.

Adult day health care. Services include supervising medication and observing for possible reaction and assisting, supervising, or administering medication. Unlicensed staff may not administer medications but can only assist or supervise clients with taking their medications, including reminding a client to take medication. A registered nurse (RN) or licensed practical nurse (LPN) licensed by the Alabama Board of Nursing may administer medications from a container filled by a licensed pharmacist with a pharmacy label indicating physician instructions.

Provisions for Groups with Special Needs

Staffing Requirements

Adult Day Care

Type of staff. The director and at least one other staff person must be certified in cardiopulmonary resuscitation (CPR) and first aid. An LPN or RN must be available to provide clients a monthly health screening.

Staffing ratios. At a minimum the provider will maintain one staff member for 1-10 clients, two for 11-25 clients, three for 26-35 clients, four for 36-43 clients, and an additional staff member for each additional eight clients. At least two staff will be in the center when clients are present, and at least one of these must be certified in CPR and first aid. Staff whose primary responsibilities do not require direct involvement with clients will not be counted unless their job descriptions specify time periods when they have responsibility only for working with clients. Volunteers may be counted in the staff ration if they meet the same qualifications as paid staff and are scheduled for the entire period that a paid worker would have worked.

Adult Day Health Care

Type of staff. There shall be a designated person to serve as the center administrator who does not have to be full-time, and a registered or licensed practical nurse must be available 2 hours per week or 8 hours per month for consultation.

Staffing ratios. At a minimum the provider will maintain one staff member for 1-10 clients, two for 11-25 clients, three for 26-35 clients, four for 36-43 clients, and an additional staff member for each additional eight clients. At least two staff will be at the center when clients are present. At least one staff member present must be certified in CPR and trained in first aid. Waiver ADH centers must have at least two staff members with CPR and first aid certification.

Training Requirements

Adult day care. Training will assure that day care staff have sufficient knowledge of the adult process (mental, emotional, and physical) to enable them to meet individual client needs. The program shall provide staff who have no previous experience or training in adult day care an on-site orientation and a designated period of supervised training.

All staff shall regularly (at least quarterly) participate in in-service training or other available training related to adult day care. This shall include training on how to deal with clients with physical, mental, or emotional impairments.

Adult day health care.

1. The provider will assure that the staff have sufficient knowledge of the adult process (mental, emotional, and physical) to enable them to meet individual client needs. The training program must be approved by the Operating Agency and the Alabama Medicaid Agency.
2. The provider will assure that staff who have had no previous experience or training working with adults who are elderly and disabled have on-site orientation with a designated period of supervised training. The minimum training requirement must be completed prior to initiation of service with a client. The ADHC center is responsible for providing and/or conducting training.
3. The provider will assure that all ADH staff have at least 6 hours in-service training annually in the following areas: behavior intervention, acceptance, and accommodation; providing care and supervision including safety and nonmedical care; first aid; documenting client participation; fire and safety measures; confidentiality; client rights; needs of the elderly and disabled population; basic infection control/universal standards; communication skills; and other areas of training as appropriate or as mandated by Medicaid and the operating agencies. Documentation of CEU training required by the Alabama Board of Nursing may be accepted as in-service training for licensed nurses.

Relevant Medicaid Contracting Requirements for Adult Day Services Providers

Alabama has one 1915(c) Medicaid waiver, the Elderly and Disabled Waiver, which provides adult day health care. Specific regulations for providers of adult day health care under the waiver are described in this profile under the Adult Day Health Care heading.

Location of Licensing, Certification, or Other Requirements

1. http://www.medicaid.state.al.us/MANUALS/April%202005/provman.pdf.
2. http://www.medicaid.state.al.us/ABOUT/AdultDayHlthStds.pdf.
3. http://www.medicaid.state.al.us/ABOUT/E&DwaiverRequest.pdf.
4. Provided by the State of Alabama Department of Human Resources; on file at RTI.

Citations

1. Provider Manual, Alabama Medicaid Management Information System. [April 2005]
2. Alabama Medicaid Adult Day Health Standards Program Narrative. [9/18/03]
3. Section 1915(c) Waiver Format, Application to CMS for a 1915(c) Elderly and Disabled Waiver. [October, 2002]
4. Adult Day Care Requirement. Office of Social Service Contracts, Department of Human Resources. [Revised 11/2001]

Alaska

Overview

There are no licensure requirements in the State of Alaska for adult day services. There is no oversight for adult day service programs that serve only private pay clients.

All provider agencies that provide adult day services using Division of Senior and Disabilities Services (DSDS) grant funds or under a Medicaid Waiver must be certified as a Medicaid provider and meet the minimum standards as stated in Adult Day Services Standards, which the Alaska Commission on Aging adopted on February 20, 2003. Provider requirements and program standards are in the Home and Community-Based Waiver Services Certification Application Packet and in the chapter on Medical Assistance in the Alaska Administrative Code.

Adult day services are provided under a number of Medicaid Home and Community-Based Services (HCBS) Waivers, including Adults with Physical Disabilities and Older Alaskans.

Licensure and Certification Requirements

Definitions

Adult day services are defined as the provision of an organized program of services during the day in a community group setting for the purpose of supporting an adult's personal independence and promoting his or her social, physical, and emotional well-being. Adult day services provide a variety of program activities designed to meet the individual needs and interests of the participants, and referral to and assistance in using appropriate community resources. Adult day services help clients remain in their communities and allows families and other caregivers to continue caring for them at home. The program must operate for a minimum of 5 hours each day.

Parameters for Who Can Be Served

Individuals may not be served whose medical conditions are beyond the professional expertise of the staff, who are bedfast or too weak to attend on a regular basis, who are actively infected with a communicable disease, who have emotional or behavioral disorders that include a pattern of disruptive behaviors that pose a danger to others, who make abusive use of alcohol and/or drugs, or who are too independent to benefit from adult day activities. Eligibility varies by funding source, and depending on the program, providers may serve individuals age 55 or older or age 60 or older, or persons of any age who have Alzheimer's disease or other dementia. Each adult day center must define the target population(s) it intends to serve.

Inspection and Monitoring

The rules specify only internal monitoring. Each adult day care program shall conduct an internal evaluation, at least annually, of its operation and services. The evaluation shall include: (1) the involvement of the governing body (if incorporated), advisory board, program director, staff, consumers, families/caregivers, and other relevant agencies, organizations, or businesses; (2) review of the extent to which the program assisted participants and their families and caregivers; (3) measurement of the achievement of goals and objectives; (4) outcome measures as designed by the agency (may include client satisfaction and/or caregiver surveys); (5) assessment of the cost-effectiveness of the program; (6) assessment of the relationship of the program to the rest of the community service network; and (7) recommendations for improvement, corrective action of problem areas, and future program directions.

Site visit inspections are required for programs receiving state grant funds (personal communication from state reviewer).

Required and Optional Services

Provisions Regarding Medications

The program shall have a policy on medications, specifying that participants who are able to keep their medicines shall keep them safely and that the program will keep medicines of participants who are unable to be responsible for their own. Under no circumstances shall staff administer a participant's medications, unless the staff person is a licensed or certified professional whose scope of practice includes the ability to administer medications, such as an registered nurse (RN).

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

Provisions for Groups with Special Needs

Staffing Requirements

Type of staff. The program director has full authority and responsibility to plan, staff, direct, and implement the program and manage the center's day-to-day operations. In the absence of the director, a staff member shall be designated to supervise the program.

The program shall have as a staffing goal to have a registered nurse or a licensed practical nurse on staff or as a consultant. Person(s) responsible for the client assessment, development of a care plan, client monitoring, reassessment, and discharge plan must be a nurse, social worker, mental health professional, a certified care coordinator, or someone with similar or relevant experience.

Substitute or volunteer staff may be used to provide care in the absence of regular staff. The required staff to participant ratio shall be maintained. Two staff, one of which may be a volunteer, must be present at all times during operation of the program. Cardiopulmonary resuscitation (CPR)/first aid certification shall be required of at least one staff on duty at all time.

Staffing ratios. Adult day services providers shall meet a staff-to-participant ratio of a minimum of one-to-eight. Volunteers may be used and included in the staff-to-participant ratio only when they conform to the same standards as paid staff. Programs that serve a higher percentage of participants with dementia shall have a higher ratio of staff to participants of approximately one-to-four. Only staff involved in direct service to participants can be used in determining the adequate staff-to-participant ratio.

Training Requirements

The ADS agency shall provide an orientation to employees that transmit the agency values, philosophy, and mission and shall inform staff of all laws, policies, procedures, and individual reporting responsibilities regarding client abuse, neglect, and mistreatment, prior to actual service delivery. All paid and volunteer staff shall be provided general orientation to the facility (location, staff, activities, etc.), information on fire and safety measures/codes, an overview of participants and activities, and information on other staff training opportunities. All staff and volunteers who have contact with and responsibility for special populations should receive specific training in serving that population. The agency shall periodically assess the need for specific staff training programs and shall comply with all mandatory personnel licensure and training schedules.

Relevant Medicaid Contracting Requirements for Adult Day Services Providers

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

Admission. Adults over 18 years of age with disabilities and service needs similar to older Alaskans who are at risk of institutional placement, but who do not experience a developmental disability. Such persons must have service needs that are compatible with current adult day service participants so that the provision of care is of benefit to other participants and does not diminish services to the primary groups of persons being served.

Staff. Includes an activity coordinator. All employees who provide direct services must maintain current CPR and first aid qualifications.

Location of Licensing, Certification, or Other Requirements

1. http://www.legis.state.ak.us/cgi-bin/folioisa.dll/aac/query=[group+!277…{@1}/hits_only.
2. http://hss.state.ak.us/dsds/dd/pdfs/combinedcertificationpacket2-12-04.pdf.
3. http://www.hss.state.ak.us/dsds/hcbsforms/AdultDayStandards2003.pdf.

Citations

1. Adult Day Services (Title 7 Health and Social Services--Part 3 Public Assistance and Medical Assistance, Chapter 43 Medical Assistance, Article 28 Home and Community-Based Waiver Services Program, Rule 43.1043). Alaska Administrative Code. [Effective 5/15/05]
2. Home and Community-Based Waiver Services Certification Application Packet, Division of Senior and Disabilities Services. [Effective 2/12/04]
3. Adult Day Services Standards, Division of Senior and Disabilities Services. [Effective 7/1/03]

Arizona

Overview

The Department of Health Services licenses adult day health care facilities. The Arizona Administrative Code R9-10-501 to 514 serves as the basis for the licensing requirements. Tribal providers need approval from the tribal government or the Bureau of Indian Affairs to operate an adult day care/adult day health care facility. Medicaid providers of adult day health care must also be licensed and must meet a few additional Medicaid requirements.

Licensure and Certification Requirements

Definitions

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

Parameters for Who Can Be Served

Providers may not admit or retain participants whose behavior is dangerous to self or interferes with the physical or psychological well-being of other residents, or whose service requirements exceed those services for which the facility is licensed to provide.

Inspection and Monitoring

A licensee applying to renew a health care institution (an adult day care facility is defined as health care institution class or subclass) license shall submit an application packet to the Department at least 60 days but not more than 120 days before the expiration date of the current license. All initial licenses are issued for 1 year. The Department shall issue a renewal license for:

1. 1 year, if a licensee is in substantial compliance with the applicable statutes and this Chapter, and the licensee agrees to implement a plan acceptable to the Department to eliminate any deficiencies; or
2. 2 years, if a licensee has no deficiencies at the time of the Department's licensure inspection (if a facility has been issued a 2-year license, the department will conduct a renewal survey at the end of that licensing period).

Required and Optional Services

Provisions Regarding Medications

The administrator shall ensure that medications are ordered, administered, stored, and destroyed as follows:

1. The participant's medical provider shall order, in writing, all medications and treatments. The orders shall include the name of the medication or treatment, method of administration, dosage, and frequency.
2. A licensed nurse, medical provider, or an individual as provided by law shall administer medications that cannot be self-administered.
3. A licensed nurse, family member, or an individual as provided by law may prepare patient medication organizers up to 1 month in advance for self-administration by participants.
4. Staff may remind and supervise a participant who is functionally capable in the self-administration of medication according to the order of the medical provider and instruction of the pharmacist as indicated on the label of the individual container of medication. Supervision may include: (1) opening a bottle cap for a participant, (2) reading the medication label to the participant, (3) checking the self-administration dosage against the label of the container and reassuring the participant that the dosage is correct, and (4) observing the participant while the medication is taken.

Provisions for Groups with Special Needs

Staffing Requirements

Type of staff. An administrator shall have the authority and responsibility to operate the facility and manage adult day health services.

All personnel must be 18 years of age or older. An administrator must be 21 years of age.

A registered nurse shall supervise the health care needs of participants. A licensed nurse shall be on duty daily to perform the following functions: (1) administer medications and treatments, (2) monitor participant's health status, and (3) conduct initial health assessments. Each facility that is operated by a nursing care institution shall not share staff with the nursing care institution during the course of a day.

Staffing ratios. The administrator shall ensure that two staff members are on duty at all times when two or more participants are in the facility. One staff member, certified in cardiopulmonary resuscitation and trained in first aid, shall be on duty at all times.

Training Requirements

Within the first week of employment, all personnel must attend orientation that includes: (1) policies and procedures, including personnel procedures; (2) participant rights and facility rules; (3) protection of participant privacy and confidentiality; (4) basic infection control techniques, including hand washing and prevention of communicable diseases; and (5) fire, safety, and emergency procedures. All personnel must also attend 10 hours of in-service training per year, which may include time spent in orientation.

Personnel providing direct care to participants shall attend 4 or more hours of orientation, in addition to training listed above, before providing care to participants. The orientation shall include: (1) communication skills, (2) assistance with the activities of daily living, (3) personal living skills training, and (4) special needs of the elderly and functionally impaired.

Relevant Medicaid Contracting Requirements for Adult Day Services Providers

The state's entire Medicaid program--Arizona Long Term Care System (ALTCS)--operates under an 1115 waiver and covers services provided by licensed adult day health care facilities. If ALTCS members who reside in an adult foster care home, assisted living home, or assisted living center are to receive adult day health care services, special justification is required by the member's case manager and approval by the Contractor or Arizona Health Care Cost Containment System (AHCCCS) Administration. Members residing in a Level II or Level III behavioral health facility are not eligible to receive adult day health care services.

Admission. Services are available for members who are elderly and/or have physical disabilities who need supervision, assistance in taking medication, recreation and socialization, or personal living skills training.

Required services. Health monitoring and/or other health-related services such as preventive, therapeutic, and restorative health care services.

Location of Licensing, Certification, or Other Requirements

1. http://www.azsos.gov/public_services/Title_09/9-10.pdf.
2. http://www.ahcccs.state.az.us/Regulations/OSPpolicy/chap1200/Policy1240….

Citations

1. Department of Health Services--Health Care Institutions: Licensing-General and Adult Day Health Care Facilities (Title 9, Chapter 10, Articles 1 and 5 (R9-10-501 through 514)). Arizona Administrative Code. Article 5 adopted, effective April 4, 1994.
2. Adult Day Health Care Services, Policy 1240--Home and Community Based Services, Chapter 1200--ALTCS Services/Settings for the Elderly and/or Disabled--AHCCCS Medical Policy Manual. Arizona Health Care Cost Containment System.
3. Contracting requirements for Non-Medical Home and Community-Based Care Providers--Adult Day Care/Adult Day Health Care (Section 7.3). Aging and Adult Administration, Department of Economic Security. [Hard copy only]

Arkansas

Overview

The Arkansas Office of Long Term Care in the Department of Human Services licenses adult day care (ADC) and adult day health care (ADHC) under separate rules and regulations. Arkansas provides ADC and ADHC under the ElderChoices Medicaid waiver and requires providers to be licensed.

Licensure and Certification Requirements

Definitions

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

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

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

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

Parameters for Who Can Be Served

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

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

Inspection and Monitoring

Adult day care. The Office of Long Term Care shall review each application and investigate each applicant and ADC program to determine that they comply with the ADC licensure law and these regulations and to ensure that the health and safety of the participants are protected. Reviews shall be conducted as often as necessary and at least annually.

Adult day health care. The Office of Long Term Care shall conduct routine inspections of facilities to ensure that rules and regulations are met, complaint inspections to determine the validity of complaints against an operator, and follow-up inspections of facilities that are out of compliance with rules and regulations. Providers will afford any authorized agents of the Department of Health Services, or their designee, full access at any time during normal business hours to participants, grounds, buildings, and files.

Required and Optional Services

Provisions Regarding Medications

Adult day care. Participants must be able to self-administer their own medication. There shall be a written and approved system of handling and storing participants' medications.

Adult day health care. Participants who are able to do so may keep and administer their own medicines while attending the ADHC program. They shall be supervised as necessary in administering their medications. If it is determined that a participant is unable to be responsible for self-medication, the medicines must be kept for him/her during attendance at the facility and administered by the registered nurse (RN)/licensed practical nurse (LPN) health care coordinator at the prescribed time and dosage. The provider shall provide for injection of insulin or other intramuscular or subcutaneous injections by licensed personnel for individual participants as ordered by the participant's physician.

Provisions for Groups with Special Needs

Staffing Requirements

Adult Day Care

Type of staff. The ADC program shall have a director. Either the director or his/her designee shall be present and in charge during all hours that participants are on the premises.

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

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

Trained volunteers at least 18 years of age may be counted in the direct care staff-to-participant ratio provided a volunteer program description, including the training to be provided and the system for assuring the presence of volunteer help as scheduled, is in writing and on file in the facility.

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

Adult Day Health Care

Type of staff. ADHC facilities licensed for more than ten participants must have a full-time director. The program director shall have the authority and responsibility for the management of activities and direction of staff and shall insure that activities and services are appropriate and in accordance with established policies.

An ADHC program must have a full-time health care coordinator to supervise the delivery of health care services. This is an RN or LPN under the supervision of an RN. Physical therapists, occupational therapists, or other health care professionals shall be employed on a contract basis to fulfill the needs and care plans of the participants.

Facilities licensed for ten or fewer participants may have a full-time program director who also serves as the health care coordinator, provided that this individual meets all of the qualification of both positions, and the requirements for the staffing pattern are met.

No staff member or volunteer providing direct nursing or personal care shall be permitted to combine housekeeping or kitchen duties with nursing/personal care due to the danger of cross infection to the participants.

Staffing ratios. The staffing pattern shall depend on the enrollment criteria and the particular needs of the participants who are to be served. The ADHC program shall have sufficient staff responsible for personal care to comply with these regulations and the care requirements of the participants.

The ratio of paid staff to participants shall be adequate to meet the goals and objectives of the program. The minimum ratios shall be as follows: one paid full-time equivalent staff position with responsibility for direct care for each five participants; or, when there are four or more participants with a diagnosis of Alzheimer's disease, a minimum of one paid full-time equivalent staff position with responsibility for direct care for each four participants.

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

Trained volunteers may also be counted in the direct care staff-to-participant ratio.

Training Requirements

Adult day care. Direct care paid staff and volunteer staff shall be trained and oriented to perform the duties required by the written job description.

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

A minimum of 8 hours in-service training shall be provided at least quarterly to staff, as appropriate to their job function and participant care needs. Documentation shall be maintained for review by the Office of Long Term Care personnel.

Adult day health care. There shall be a program of orientation for new employees and volunteers and a program of ongoing staff development and in-service training.

In-service training sessions for direct care staff and volunteers are required at a minimum of every 6 months. In-service training sessions must total a minimum of 4 hours per training. In-service training subjects shall be appropriate to direct-care staff job functions, and shall include, but are not limited to, sessions on communication with the elderly, normal signs of aging, health problems of the elderly, procedures for emergency situations, procedures for assisting ADL/instrumental ADL, record keeping, and correct procedures for lifting.

Relevant Medicaid Contracting Requirements for Adult Day Services Providers

Arkansas provides adult day care and adult day health care under the ElderChoices Medicaid waiver. Medicaid providers must be licensed and certified by the Division of Aging and Adult Services.

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

Location of Licensing, Certification, or Other Requirements

1. http://www.medicaid.state.ar.us/general/units/oltc/regs/adc.pdf.
2. http://www.medicaid.state.ar.us/general/units/oltc/regs/adhc.pdf.
3. http://www.medicaid.state.ar.us/provider/amprcd/searcharea/manuals/elde… elder_ii.pdf.

Citations

1. Rules and Regulations Pertaining to Long Term Adult Day Care Facilities. Department of Human Services, Division of Medical Services, Office of Long Term Care. [1/1/87]
2. Rules and Regulations for Adult Day Health Care Providers in Arkansas. Arkansas Department of Human Services. [Undated]
3. ElderChoices Provider Manual, Section II--Program Coverage. Department of Human Services, Division of Medical Services. [10/13/03]

California

Overview

In California, adult day care services are provided in two types of licensed facilities: adult day programs (ADP) and adult day health care (ADHC) centers. 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.

Adult day program providers are licensed by the State Department of Social Services (DSS) Community Care Licensing Division as community care facilities. The term "adult day program" replaced two earlier program names in legislation (SB 1982, Statutes of 2002): adult day care facility (ADCF) and adult day support center (ADSC). These two programs were licensed by DSS under separate regulations in the California Code of Regulations (CCR) Title 22, based on California Health and Safety Code. Because the regulations have not yet been combined, whenever they differ, they are presented separately in this profile under the heading Adult Day Program. ADP services are not available under the Medicaid State Plan.

Adult day health care providers are licensed by the Department of Health Services (DHS) Licensing and Certification Division as health facilities. The California Department of Aging (CDA) administers the program and certifies each center for Medi-Cal (California's Medicaid State Plan) reimbursement. Licenses are not issued or renewed for an ADHC center that is not certified as a Medi-Cal provider of ADHC services. ADHC providers must meet, at a minimum, the licensing requirements specified in Health and Safety Code, Chapter 3.3; the certification requirements specified in Welfare and Institutions Code, Chapter 8.7; and additional requirements specified in the CCR, Title 22. If an ADHC center licensee also provides adult day care or ADSC services, the ADHC license shall be the only license required to provide these additional services.

ADP and ADHC services are also available to clients of the Multipurpose Senior Service Program (MSSP), a case management program targeted to frail elderly clients who are eligible for nursing facility placement. MSSP operates under a Home and Community-Based Services (HCBS) waiver and contracts with appropriately licensed and certified providers for services.

In August 2004, a 1-year moratorium on new ADHC centers enrolling in the Medi-Cal program was instituted and will most likely be extended until the state transitions the ADHC program from the Medicaid State Plan to an HCBS waiver program. During the time of the moratorium, ADHC applicants may be licensed to provide services to persons who pay privately or have insurance coverage for the services. ADHC centers may be certified for the Medi-Cal program only if they meet the exemptions to the moratorium as specified in SB 1103.

ADCRCs are specialized day care centers that target services to persons with Alzheimer's disease and other dementias. Until recently, the law permitted ADCRCs to function without a facility license, although the majority of ADCRCs are located in licensed ADP or ADHC centers. Legislation (AB 2127, Statutes of 2004) amended Welfare and Institutions Code 9542 as follows: an Alzheimer's day care resource center that was not licensed as an adult day program or adult day health care center prior to January 1, 2005, shall be required to be so licensed by January 1, 2008. A direct services program that qualifies to operate as an Alzheimer's day care resource center after January 1, 2005, shall be required to be licensed as an adult day program or adult day health care center. The ADCRC program is currently authorized by statutes, and specific requirements are specified in a program manual, not in regulation. Regulations that were being developed for the ADCRC program were suspended, effective November 1, 2003. All ADCRCs are funded by grants from CDA. Services are reimbursed by Medi-Cal for eligible participants if the program is housed in an ADHC center.

Licensure and Certification Requirements

Definitions

Adult Day Program

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

Adult day care facility means any facility of any capacity that provides nonmedical care and supervision to adults on less than a 24-hour per day basis.

Adult day support center means a community-based group program designed to meet the needs of functionally impaired adults through an individual plan of care in a structured comprehensive program that provides a variety of social and related support services in a protective setting on less than a 24-hour basis.

Adult day support center services means those nonmedical services provided in an ADSC to adults with physical, emotional, or mental impairments and who require assistance and supervision.

Adult Day Health Care

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

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

Parameters for Who Can Be Served

Adult Day Program

Adult day care facility. Providers determine the parameters for who can be served insofar as they are required to determine whether they can meet prospective clients' service needs prior to admission. They may serve clients with "obvious symptoms of illness" only if these clients are "separated from other clients."

Adult day support center. Adults with physical, emotional, or mental impairments with nonmedical needs who require assistance and supervision may be served. Such persons include, but are not limited to, the following:

• Persons who require assistance with ADL (e.g., bathing, dressing, grooming) and instrumental activities of daily living (IADL) (e.g., laundry, shopping, paying bills). These persons may live independently, at home with a care provider, in a community care facility, or in a health facility, but do not require a medical level of care during the day.
• Persons who require assistance and supervision in overcoming the isolation associated with functional limitations or disabilities.
• Persons who, without program intervention, are assessed to be at risk of physical deterioration or premature institutionalization due to their psychological condition.

Providers determine in part the parameters for who can be served insofar as they are required to determine whether they can meet prospective clients' service needs prior to admission and can discharge those whose needs they can no longer meet or who pose a danger to themselves or others. The regulations also state that participants cannot have specific restricted health conditions as specified in CCR, Title 22, Division 3, Subdivision 1, Chapter 5. (The list of these conditions is too extensive to include here.)

Adult Day Health Care

ADHC facilities may serve persons 55 years of age or older and other adults who are chronically ill or impaired and would benefit from ADHC. Providers may not admit individuals for whom, in their clinical judgment, they cannot appropriately care. They may serve persons with dementia and other special needs populations, such as persons with developmental disabilities or persons with mental disabilities. Providers may discharge participants if they are unable or unwilling to use the prescribed services and ADHC staff have made every effort to remove possible obstacles.

Medicaid provisions for enrollment in ADHC specify that providers may serve individuals: (1) with medical conditions that require treatment or rehabilitative services prescribed by a physician, (2) with mental or physical impairments that handicap ADL but which are not of such a serious nature as to require 24-hour institutional care, and (3) who are at risk for deterioration and probable institutionalization if ADHC services were not available.

Inspection and Monitoring

Adult day program. Within 90 days after the date of issuance of a license or special permit, the department shall conduct an inspection of the facility for which the license or special permit was issued. Any duly authorized officer, employee, or agent of the State Department of Social Services may enter and inspect any place providing personal care, supervision, and services at any time, with or without advance notice, to secure compliance with, or to prevent a violation of, any provision of the General Licensing Requirements, Health and Safety Code.

Every licensed community care facility shall be subject to unannounced visits by the department. The department shall visit these facilities as often as necessary to ensure the quality of care provided. The department will conduct random annual unannounced visits to no less than 10 percent of facilities. Under no circumstances shall the department visit a community care facility less often than once every 5 years.

Adult day health care. If an ADHC center or an applicant for a license has not been previously licensed, the department may only issue a provisional license to the center. A provisional license to operate an ADHC center shall expire 1 year from the date of issuance, or at an earlier time as determined by the department at the time of issuance. Within 30 days prior to the expiration of a provisional license, the department shall give the ADHC center a full and complete inspection, and, if the ADHC center meets all applicable requirements for licensure, a regular license shall be issued. Annual licenses are required; however, the director has discretion to approve applications for relicensure for a period of up to 24 months.

Required and Optional Services

Provisions Regarding Medications

Adult day program. Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. In ADCFs and ADSCs, staff may be trained by the client's family or primary caregiver if the licensee obtains written documentation from the client's family or primary caregiver outlining the procedures and the names of facility staff whom they have trained in those procedures, and the licensee ensures that the client's family or primary caregiver reviews staff performance as necessary, but at least annually.

All staff training shall be documented in the facility personnel files. Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee shall be authorized to assist clients with self-administration of injections as needed. For every prescription and nonprescription PRN medication for which the licensee provides assistance, there shall be a signed and dated written order from a physician on a prescription blank maintained in the client's file and a label on the medication.

Adult day health care. Each participant's health record shall include a drug history that lists all medications currently being taken by the participant and any medications to which the participant is allergic. Medications stored in the center or administered by center personnel shall be labeled in conformance with state and federal laws and regulations. Medications shall be administered only by licensed medical or licensed nursing personnel. Self-administration of medications shall be permitted only under the following conditions: (1) the center shall have approved policies permitting self-administration of medications when approved by the multidisciplinary team; (2) training in self-administration of medications shall be provided to all participants based on the recommendation of the multidisciplinary team; and (3) the health record of each participant who is capable of self-medication shall name all drugs that are to be self-administered.

Provisions for Groups with Special Needs

Staffing Requirements

Adult Day Program

Adult Day Care Facility

Type of staff. All ADCFs shall have an administrator. A licensee who is responsible for two or more ADCFs shall be permitted to serve as an administrator of one or more of the facilities. The administrator shall be on the premises the number of hours necessary to manage and administer the facility in compliance with applicable law and regulation. When the administrator is absent from the facility, there shall be coverage by a substitute designated by the licensee who shall be capable of and responsible and accountable for management and administration of the facility in compliance with applicable law and regulation.

Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall at all times be employed in numbers necessary to meet such needs. The licensee shall provide for an overlap of staff at each shift change to ensure continuity of care. Care staff shall not be assigned to any of the support staff duties, such as housekeeping, cooking, or office work, unless the care and supervision needs of clients have been met.

Staffing ratios. There shall be an overall ratio of not less than one staff member providing care and supervision for each 15 clients present. Whenever a client who relies upon others to perform all ADL is present, the following minimum staffing requirements shall be met:

• For Regional Center clients, staffing shall be maintained as specified by the Regional Center.
• For all other clients, there shall be a staff-client ratio of no less than one direct care staff to four such clients.

Adult Day Support Center

Type of staff. All ADSCs shall have an administrator. If an administrator is responsible for two or more ADSCs, there shall be at each site an employee who is responsible for the day-to-day operation of the center and who meets the following qualifications: (1) a baccalaureate degree in psychology, social work, or a related human services field or (2) a minimum of 1 year of experience in a supervisory or management position in the human services delivery system. An administrator shall not be responsible for more than five centers. When the administrator or the employee specified above is absent from the center, there shall be coverage by a substitute designated by the licensee who is on site and who shall be capable of, and responsible and accountable for, the management and administration of the center in compliance with applicable laws and regulations.

Support staff and direct care staff are required. Direct care staff provide care and supervision to participants at least 70 percent of the hours of program operation per month.

There shall be at least two persons on duty, at least one of whom is a direct care staff member, at all times when there are two or more participants in the center. The licensee shall provide for an overlap of staff at each shift change to ensure continuity of care. The center shall have at least one full-time staff member who has a current certificate in first aid and cardiopulmonary resuscitation present in the facility during operating hours.

Staffing ratios. There shall be an overall ratio of not less than one direct care staff member providing care and supervision for each group of eight participants, or fraction thereof, present. For each group of 25 participants, or fraction thereof, there shall be at least one direct care staff person who has a baccalaureate degree in a health, social, or human service field, or 1 year documented full-time experience providing direct services to frail or physically, cognitively, or emotionally impaired adults. Whenever a participant who relies upon others to perform all ADL is present, the following minimum staffing requirements shall be met:

• For Regional Center participants, staffing shall be maintained as specified by the Regional Center.
• For all other participants, there shall be a staff-participant ratio of no less than one direct care staff to four such participants. Volunteers may be included in the staff-to-participant ratio if the volunteer meets the requirements for direct care staff.

Adult Day Health Care

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

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

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

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

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

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

Support employees shall include maintenance, food service, and clerical employees sufficient in number to perform the necessary duties. Volunteers may be used in centers but shall not be used to replace required employees. Each volunteer shall receive orientation, training, and supervision.

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

Training Requirements

Adult Day Program

Adult day care facility. All personnel shall be given on-the-job training or shall have related experience that provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance: (1) principles of nutrition, food preparation and storage, and menu planning; (2) housekeeping and sanitation principles; (3) provision of client care and supervision, including communication; (4) assistance with prescribed medications that are self-administered; (5) recognition of early signs of illness and the need for professional assistance; (6) availability of community services and resources; and (7) Universal Precautions as defined in Title 22, Section 8001(u)(1). Training in Universal Precautions may be provided in the facility, or staff may attend training provided by a local health facility, county health department, or other local training resources.

Adult day support center. The licensee shall develop, maintain, and implement a written plan for the orientation, continuing education, on-the-job training and development, supervision, and evaluation of all direct care staff. (1) The plan shall require direct care staff to receive and document a minimum of 20 hours of continuing education during the first 18 months of employment or within 18 months after the effective date of these regulations and during each 3-year period thereafter. (2) The administrator shall receive and document a minimum of 30 hours of continuing education every 24 months of employment. (3) Continuing education shall include completion of courses related to the principles and practices of care of the functionally impaired adult including, but not limited to, workshops, seminars, and academic classes. The center shall train program staff and participants in emergency procedures.

Adult Day Health Care

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

Relevant Medicaid Contracting Requirements for Adult Day Services Providers

To obtain certification as a provider of ADHC under the state's Medicaid program (Medi-Cal), a provider must meet all the requirements of licensure as an ADHC center pursuant to Chapter 3.3 (commencing with Section 1570) of Division 2 of the Health and Safety Code, and Chapter 10, Division 5, Title 22 of CCR. Medi-Cal has additional requirements for providers of ADHC services guided by the Adult Day Health Medi-Cal Law pursuant to Chapter 8.7 of the Welfare and Institutions Code, and Chapter 5, Division 3, Subdivision 1, Title 22 of CCR. CDA may implement a 1-year moratorium on the certification and enrollment into the Medi-Cal program of new ADHC centers.

Purpose. The Medi-Cal benefit is intended to establish and continue a community-based system of quality day health services that will: (1) ensure that elderly persons not be institutionalized prematurely and inappropriately; (2) provide appropriate health and social services designed to maintain elderly persons in their own homes; (3) establish adult day health centers in locations easily accessible to the economically disadvantaged elderly person; and (4) encourage the establishment of rural alternative ADHC centers, which are designed to make ADHC accessible to impaired Californians living in rural areas.

Discharge. An adult day health center shall not terminate the provision of adult day health services to any participant unless approved by the state department.

Optional services. (1) Podiatric services, (2) optometric screening and advice for low-vision cases, (3) dental screening for the purpose of appraising the participant of the necessity of regular or emergency dental care, and (4) such other services within the concept and objectives of ADHC as may be approved by the department.

Inspection. Initial Medi-Cal certification for ADHC providers shall expire 12 months from the date of issuance. The director shall specify any date he or she determines is reasonably necessary, but not more than 24 months from the date of issuance, when renewal of the certification shall expire. The certification may be extended for periods of not more than 60 days if the Department determines it to be necessary. Every ADHC center shall be periodically inspected and evaluated for quality of care by a representative or representatives designated by the director, unless otherwise specified in the interagency agreement entered into pursuant to Section 1572 of the Health and Safety Code. Inspections shall be conducted prior to the expiration of certification, but at least every 2 years, and as often as necessary to ensure the quality of care being provided. As resources permit, an inspection may be conducted prior to, as well as within, the first 90 days of operation.

Staffing. A provider shall employ appropriately licensed personnel for furnishing required services. A provider serving a substantial number of participants of a particular racial or ethnic group, or participants whose primary language is not English, shall employ staff who can meet the cultural and linguistic needs of the participant population.

Training. An in-service training plan for each center staff member shall commence within the first 6 months of employment. The training plan shall address, at a minimum, the specific medical, social, and other needs of each participant population the center proposes to serve.

Location of Licensing, Certification, or Other Requirements

1. http://www.dss.cahwnet.gov/getinfo/pdf/adcfman.PDF.
2. http://www.dss.cahwnet.gov/getinfo/pdf/adscman.PDF.
3. http://www.dss.cahwnet.gov/getinfo/pdf/genman1.PDF.
4. http://www.leginfo.ca.gov/cgi-bin/calawquery?codesection=hsc&codebody=&hits=20.
5. http://www.leginfo.ca.gov/cgi-bin/calawquery?codesection=wic&codebody=&hits=20.
6. http://files.medi-cal.ca.gov/pubsdoco/Pubsframe.asp?hURL=/pubsdoco/io_s….
7. http://ccr.oal.ca.gov/cgi-bin/om_isapi.dll?clientID=138589&infobase=ccr… Browse_Frame_Pg42.

Citations

1. Adult Day Care Facilities--Community Care Licensing Division--Manual of Policies and Procedures (CCR, Title 22, Division 6, Chapter 3). Department of Social Services. [Updated 9/30/02]
2. Adult Day Support Center--Community Care Licensing Division--Manual of Policies and Procedures (Title 22, Division 6, Chapter 3.5). Department of Social Services. [Updated 3/08/00]
3. General Licensing Requirements. (CCR, Title 22, Division 6, Chapter 1, Article 1) Department of Social Services. [Updated 12/17/04]
4. California Adult Day Health Care Act--California Health and Safety Code (Chapter 3.3, Section 1570-1596.5). [Effective 1978]
5. Adult Day Health Care Program, California Welfare and Institutions Code (Chapter 8.7, Section 14520-14588). [Effective 1978]
6. Adult Day Health Care Centers, Medi-Cal Inpatient/Outpatient Provider Manual, Department of Health Services. [Effective August 2000]
7. Adult Day Health Care, California Medical Assistance Program, Health Care Services (CCR, Title 22, Division 3, Subdivision 1, Chapter 5) and Adult Day Health Centers, Licensing and Certification of Health Facilities, Home Health Agencies, Clinics, and Referral Agencies, (CCR, Title 22, Division 5, Chapter 10). [Effective date unknown]

Additional Information

A licensed and certified ADHC center may establish one or more satellites. A satellite may be in the county of the parent or a rural service area. The parent center's license and certification shall cover ADHC services at one or more satellites.

A rural alternative ADHC center shall operate its programs a minimum of 3 days weekly unless the program can justify, to the satisfaction of the department, fewer days of operation due to space, staff, financial, or participant reasons.

In December 2003, the Centers for Medicare & Medicaid Services (CMS) notified DHS that the ADHC program should not have been approved as an optional Medi-Cal benefit and directed the state to transition the program into an HCBS waiver. DHS and CDA are currently working on the waiver application, and the administration has introduced legislation that authorizes the state to obtain a waiver to continue ADHC services.

Colorado

Overview

Colorado recognizes two types of centers: adult day services (ADS) centers and specialized adult day services (SADS) centers. Adult day services centers in Colorado have to conform to state-established certification standards in the Medical Services Board Medical Assistance Staff Manual in order to receive Medicaid reimbursement. These standards are part of state rules for the Home and Community-Based Services for the Elderly, Blind, and Disabled (HCBS-EBD) program. This profile presents the certification standards as they apply to Medicaid providers. Colorado does not require ADS centers that do not participate in Medicaid to meet certification standards; however, state informants are not aware of any such centers in operation.

Licensure and Certification Requirements

Definitions

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

Basic adult day services center means a community-based entity that conforms to all state-established requirements as described by provider participation requirements and services provided by ADS centers.

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

Parameters for Who Can Be Served

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

Inspection and Monitoring

The Department of Health Care Policy and Financing or its designee conducts an annual on-site survey of ADS centers and SADS centers.

Required and Optional Services

Provisions Regarding Medications

Nurses shall supervise the administration of medications. Medication administration shall be included in an ADS center's written operation policies.

Provisions for Groups with Special Needs

Staffing Requirements

Type of staff. All ADS centers shall provide nursing services for regular monitoring of the ongoing medical needs of participants and the supervision of medications. These services must be available a minimum of 2 hours daily and must be provided by a registered nurse (RN) or licensed practical nurse (LPN). Certified nursing assistants (CNAs) may provide these services under the direction of an RN or an LPN. Supervision of CNAs must include consultation and oversight on a weekly basis or more according to the participant's needs.

SADS centers providing a restorative model of care shall have sufficient staff to provide the following: (1) nursing services during all hours of operation provided by a licensed RN or LPN or by a CNA under the supervision of an RN or LPN, and (2) therapies to meet the restorative needs of the client participant.

Staffing ratios. All ADS centers must maintain a staff-to-participant ratio of one-to-eight or lower to provide for the needs of the population served.

Training Requirements

ADS centers providing medication administration as a service must have qualified persons on their staff who have been trained in accordance with state law regarding qualified medication administration staff members. All staff must be trained in the use of universal precautions (infection control). The operator and staff must have training specific to the needs of the populations served (e.g., elderly, blind, and disabled). All staff and volunteers must be trained in the handling of emergencies, including written procedures to meet medical crises.

Relevant Medicaid Contracting Requirements for Adult Day Services Providers

Providers participating in the HCBS-EBD program must be certified according to the standards outlined in this profile.

Location of Licensing, Certification, or Other Requirements

1. http://www.chcpf.state.co.us/HCPF/Pdf_Bin/491ads.pdf.

Citations

1. Medical Services Board Staff Manual Volume 8--Medical Assistance (State Rules). Home and Community-Based Services for the Elderly, Blind, and Disabled--Adult Day Services (Section 8.491). Department of Health Care Policy and Financing. [Adopted 12/13/96 and effective 2/01/97]

Connecticut

Overview

The state has two models of adult day care (ADC): the social model and the medical model. The social model is designed for individuals who need supervision and activities but not extensive personal care and medical monitoring.

There are no licensing requirements for ADC in Connecticut. However, ADC programs must be certified by the Connecticut Association of Adult Day Centers, Inc. to be reimbursed for services provided to persons eligible for the Connecticut Home Care Program for Elders (CHCPE), the Adult Services Program, or any other program funded or administered by the State Department of Social Services (DSS) or any other state agency. The Association, in collaboration with DSS, sets standards and interpretive guidelines that must be approved by DSS, which are source of the information contained in this profile.

Licensure and Certification Requirements

Definitions

Adult day care (or adult day health services as it is called in the CHCPE) is provided through a community-based program designed to meet the needs of cognitively and physically impaired adults through a structured, comprehensive program that provides a variety of health, social, and related support services, including but not limited to socialization, supervision and monitoring, personal care, and nutrition in a protective setting during any part of a day.

Parameters for Who Can Be Served

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

Individual centers may serve special needs groups through their case-mix policy.

Inspection and Monitoring

There is an annual inspection by the Fire Marshall. ADC providers are required to have a written plan for an annual evaluation of its operation and services.

State-contracted entities are responsible for the monitoring of clients under the CHCPE, including those in ADC.

Required and Optional Services

Provisions Regarding Medications

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

Provisions for Groups with Special Needs

Staffing Requirements

Type of staff. Providers are required to have staff to meet the needs of their client base. An administrator shall be responsible for the daily operation of the center. In the absence of the director (sic), an on-site staff member shall be designated to supervise program and staff.

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

The activity director shall develop planned individual and group activities suited to the needs and abilities of the participants as determined in the individual plans of care.

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

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

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

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

Staffing ratios. The direct care staff-participant ratio shall be a minimum of one-to-seven. Volunteers can be included in the ratio only when they conform to the same standards and requirements as paid staff. Staffing shall meet the needs of the client base.

Training Requirements

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

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

Relevant Medicaid Contracting Requirements for Adult Day Services Providers

The Medicaid program has no additional contracting requirements.

Location of Licensing, Certification, or Other Requirements

1. http://www.ctmedicalprogram.com/prmanuals/ch7chc.pdf.

Citations

1. Requirements for Payment of Connecticut Home Care Program for Elders (Section 17b-342-2(b) Adult Day Health Services). Department of Social Services. [Amended 4/17/1998]
2. Standards for Adult Day Care Centers in Connecticut, Connecticut Association of Adult Day Centers, Inc. [Revised 4/19/05]

Delaware

Overview

The Department of Health and Social Services (DHSS) establishes standards for regulation in the operation of adult day care facilities and grants licenses for the operation of such facilities to persons, associations, or organizations that have been approved in accordance with the State of Delaware Regulations for Adult Day Care Facilities and which pay the appropriate fee. The state covers medical and social day care in its Elderly and Disabled waiver program. The waiver program requires providers to agree to all terms and conditions listed in the Delaware Medical Assistance Program (DMAP) contract and the policies and procedures listed in the Elderly and Disabled Waiver Provider Specific Policy Manual.

Licensure and Certification Requirements

Definitions

Adult day care facility refers to any program that provides health, social, and related support services for four or more functionally impaired adults who reside in the community and are in need of these services as determined by a preadmission assessment. These services are provided to adults for a period of less than 12 hours during the day and are provided in a setting other than a participant's home or the residence of the facility operator.

Parameters for Who Can Be Served

The adult day care facility shall admit only those individuals whose need can be met by the facility. No participant shall be discharged from an adult day care facility except for the following: the participant's needs can no longer be met by the program of care, medical reasons, nonparticipation in the plan of care or noncompliance with the written admission agreement, or the participant's own welfare or the welfare of the other participants.

Inspection and Monitoring

Every adult day care facility for which a license has been issued shall be periodically inspected by a representative of DHSS. Regular inspections shall occur at least once every 3 years.

Required and Optional Services

Provisions Regarding Medications

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

Provisions for Groups with Special Needs

Staffing Requirements

Type of staff. There shall be an activities coordinator who will plan group activities for all participants and personalized options for individuals with varying interests and needs. The director/administrator or designee responsible for the management of the adult day care program shall be present and in charge during all hours that participants are on the premises. There shall be at least one registered nurse (RN) or licensed practical nurse (LPN) on the premises at all times when participants are present for those facilities serving participants requiring nursing services. There shall be at least one employee on the premises at all times when participants are present who is certified in cardiovascular pulmonary resuscitation (CPR).

Staffing ratios. There shall be at least two adult day care facility staff on duty at all times when participants are present. If separate sections are established within each facility, each separate section shall independently comply with the staffing requirements of this section. The minimum staffing requirements shall not include volunteers or employees who have not yet completed the required orientation program.

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

Programs serving mainly participants with severe cognitive or physical disabilities shall have a staff-to-participant ratio of at least one-to-four for all severely disabled participants.

Training Requirements

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

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

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

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

Relevant Medicaid Contracting Requirements for Adult Day Services Providers

The Elderly and Disabled waiver program covers medical and social day care that are provided during the day in a day care center near to where an individual lives. The staff there provide meals and snacks, services, supervision and recreational and/or medical therapy.

The waiver program requires providers to agree to all terms and conditions listed in the DMAP contract and the policies and procedures listed in the Elderly and Disabled Waiver Provider Specific Policy Manual. We were not able to identify medical and social day care definitions in the manual. The manual states that DMAP will not have control or supervision of the details of the tasks to be performed, but will have authority to exercise general direction.

Location of Licensing, Certification, or Other Requirements

1. http://www.state.de.us/dhss/dph/hsp/files/adcfacregs0702.txt
2. http://www.dmap.state.de.us/downloads/manuals/elderly.disabled.waiver.provider.specific.pdf

Citations

1. State of Delaware Regulations for Adult Day Care Facilities (Title 16 Health and Safety Part I Chapter 1, Subchapter II, Section 122(3).s.1. (Sections 68.0 through 68.15)). Powers and Duties of the Department of Health and Social Services. [Effective July 2002]
2. Elderly and Disabled Waiver Provider Specific Policy Manual, Delaware Medical Assistance Program. [Revised July 2002]

District of Columbia

Overview

The District of Columbia (DC) provides adult day care, also called geriatric day care, through District of Columbia Office on Aging grants issued under the District of Columbia State Plan on Aging to providers who are governed by geriatric day care requirements issued and administered by the Office on Aging. These requirements are cited in this profile.

The District of Columbia also provides adult Medicaid day treatment through the District of Columbia Department of Health Medical Assistance Administration (MAA) Elderly Waiver, using Medicaid providers certified by the Office of Disability and Aging under MAA regulations Chapter 7,Medicaid Day Treatment Programs, of the DC Municipal Regulations for Public Welfare. Those regulations are cited in the Medicaid Contracting Requirements section of this profile.

The District of Columbia does not license or certify social model adult day care providers.

Licensure and Certification Requirements

Definitions

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

Parameters for Who Can Be Served

Provisions for the receipt of geriatric day care funded by the DC Office on Aging set the parameters for who can be served: functionally impaired individuals 60 years of age or older who may be at risk for institutionalization if they do not receive geriatric day care services, are able to maintain themselves with some assistance (i.e., are usually able to attend to toilet and feeding without assistance), are not bedfast, and represent no threat to themselves or others.

Inspection and Monitoring

None identified.

Required and Optional Services

Provisions Regarding Medications

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

Provisions for Groups with Special Needs

Staffing Requirements

Type of staff. None identified.

Staffing ratios. None identified.

Training Requirements

All staff providing service must be fully trained. The agency must maintain, follow, and continually update a training and supervision program to make sure day care staff are fully trained and familiar with agency procedures.

Relevant Medicaid Contracting Requirements for Adult Day Services Providers

The District of Columbia provides adult Medicaid day treatment through the DC Department of Health Medical Assistance Administration Elderly Waiver, using Medicaid providers certified by the Office of Disability and Aging under MAA regulations Chapter 7, Medicaid Day Treatment Programs, of the DC Municipal Regulations for Public Welfare.

Definitions. Day treatment program--a nonresidential program operated for the purpose of providing medically supervised day treatment services for elderly persons, children from birth through age three, adults with a developmental disability, and adults with mental disorders.

Discharge criteria. The participant shall be discharged from the day treatment program under one of the following conditions: if the participant demonstrates improvement sufficient to enable him or her to live more independently, if the participant requires institutional care due to illness, if the participant develops extreme behavior problems that require referral to a more appropriate environment for assistance before returning to the program, if the participant wishes to discontinue participation in the program, or if the participant's needs can be better met in another type of program. The provider will provide a discharge or referral summary with goals and recommendations for continuing care and appropriate referrals.

Inspections. None identified.

Required services. ADL assistance, health education and counseling, health monitoring, medication administration, nursing, skilled nursing, and social services.

Optional services. Physical, occupational, and speech therapy.

Services not required or optional. Transportation.

Medications. Medications shall not be administered without a written order signed by a physician. Injectable medications shall be given by a registered nurse, physician, or licensed practical nurse. The individual responsible for medicating participants who are not capable of self-medicating shall personally prepare the dosage and observe the act of swallowing oral medicines.

Groups with special needs. The program serving the population of persons with mental retardation/developmental disabilities shall also provide restorative, habilitation, or maintenance therapy services.

Staffing type. There shall be a minimum of two full-time professional staff members, one of whom shall be a social worker. The provider shall appoint one full-time professional staff member as the program director. The provider shall appoint one professional staff member as assistant program director to act in the absence of the program director. The provider shall appoint a registered nurse to be on the site daily for a minimum of 4 hours. A physician shall be available. The provider shall appoint an activities coordinator and program aides. If physical, occupational, or speech therapy services are offered, they shall be performed by or under the supervision of a licensed physical, occupational, or speech therapist. At least one staff member trained in first aid shall be on duty at all times.

Staffing ratios. There shall be a ratio of one full-time staff member involved in providing direct services to participants for each six participants. If there are 18 participants or more, the registered nurse shall be on the site daily for 8 hours. At least 25 percent of the staff of a day treatment program primarily serving mentally retarded adults shall be comprised of individuals certified as qualified mental retardation professionals.

Training. The program director shall provide for staff orientation and ongoing in-service training.

Under the Medicaid regulations, if a program is located outside the District and certified for participation in the Medicaid program of the state in which it is located, the Department may accept that state's certification as adequate for the provider's participation in the DC Medicaid Program.

Location of Licensing, Certification, or Other Requirements

1. On file at RTI, provided by the DC Office of Aging.
2. On file at RTI, provided by the DC Department of Health.

Citations

1. DC Office on Aging. Geriatric Day Care. [Revised 9/2002]
2. DC Department of Health. Chapter 7. Medicaid Day Treatment Programs. [Undated]

Florida

Overview

The Agency for Health Care Administration (the Agency), Division of Health Quality Assurance (HQA) Health Facility Regulation licenses all adult day care centers (ADCCs) as defined in The 2004 Florida Statutes. The Department of Elderly Affairs, in conjunction with the Agency, has adopted rules as defined in the Florida Administrative Code to implement the statutory provisions for ADCCs. This profile contains both statutory and regulatory language. Providers of adult day health care services under a Medicaid waiver must meet general and service-specific Medicaid provider qualifications.

Licensed assisted living facilities, licensed hospitals, and licensed nursing home facilities that provide adult day care services to adults who are not residents are exempt from licensure as an adult day care center, providing they do not hold themselves out to the public as an ADCC. However, the Agency must monitor the facility during the regular inspection and at least biennially to ensure adequate space and sufficient staff.

Licensure and Certification Requirements

Definitions

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

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

Adult day health care is not defined in licensing or requirements; however, required and optional services are outlined.

Parameters for Who Can Be Served

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

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

Any participant who is diagnosed a having a communicable disease shall be excluded from participation until deemed noninfectious. However, participants who have human immunodeficiency virus (HIV) infection may be admitted to the center, provided that they would otherwise be eligible according to the Rule.

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

Inspection and Monitoring

In addition to an initial licensure survey, a biennial license renewal survey, and a follow-up survey, the Agency shall conduct on-site surveys of ADCCs for the purpose of determining compliance with the relevant statutes and rules. The Agency may conduct an abbreviated biennial inspection of key quality-of-care standards, in lieu of a full inspection, of a center that has a record of good performance. However, the Agency must conduct a full inspection of a center that has had one or more confirmed complaints within the licensure period immediately preceding the inspection or that has a serious problem identified during the abbreviated inspection. The Agency shall develop the key quality-of-care standards, taking into consideration the comments and recommendations of the Department of Elderly Affairs and of provider groups. These standards shall be included in rules adopted by the Department of Elderly Affairs.

Required and Optional Services

Provisions Regarding Medications

No participant who requires medication during the time spent at the center and who is incapable of self-administration shall be admitted or retained unless there is a person licensed according to Florida law to administer medications. A physician, advanced registered nurse (RN) practitioner, dentist, RN, licensed practical nurse (LPN), or physician's assistant can administer medications. Supervision of self-administered medication shall not be construed to mean that a center shall provide such supervision to participants who are capable of administering their own medications.

No prescription drug shall be brought into the center unless it has been legally dispensed and labeled by a licensed pharmacist for the person for whom it is prescribed. Participants who can self-administer medications may bring and be responsible for their own medications, unless the preservation of medicines requires refrigeration; or medication is determined, and documented by the physician, to be hazardous if kept in the personal possession of the person for whom it was prescribed; or is a safety hazard to others at the center, in which cases the medications shall be centrally stored in a locked cabinet or container.

Provisions for Groups with Special Needs

Staffing Requirements

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

If adult day health care services for aged persons or disabled adults are provided, the following staff members are required: (1) an RN or LPN on site during the primary hours of program operation and on call during all hours the center is open; (2) a social worker to supervise the provision of social services, including counseling for participants' families and caregivers and compilation of a social history and psychosocial assessment of formal and informal support systems and mental and emotional status; and (3) an activity director or recreation therapist, who may be retained as a consultant.

Staffing ratios. A minimum staff ratio of one staff member who provides direct services for every six participants shall be present in the center at all times. No fewer than two staff, one of whom has a certification in an approved first aid course and cardiopulmonary resuscitation (CPR), shall be present in the center at all times. At all times staffing shall be maintained to meet the needs of the participants as required by the participant file, including centers that serve persons with Alzheimer's disease and other dementias, persons with physical handicaps, or other special target populations. The owner or operator shall not be counted more than once in the staff-to-participant ratio, calculated on the basis of daily census.

Training Requirements

Upon beginning employment with the facility, each employee must receive basic written information about interacting with participants who have Alzheimer's disease or dementia-related disorders. In addition, newly hired adult day care center personnel who are expected to, or whose responsibilities require them to, have direct contact with participants who have Alzheimer's disease or dementia-related disorders must complete initial training of at least 1 hour within the first 3 months after beginning employment. The training must include an overview of dementias and must provide instruction in basic skills for communicating with persons who have dementia.

In addition, an employee who will be providing direct care to a participant who has Alzheimer's disease or a dementia-related disorder must complete an additional 3 hours of training within 9 months after beginning employment. This training must include, but is not limited to, the management of problem behaviors, information about promoting the participant's independence in ADL, and instruction in skills for working with families and caregivers.

Relevant Medicaid Contracting Requirements for Adult Day Services Providers

Adult day care centers that provide services under the Aged and Adult Disabled Waiver must be licensed in accordance with Chapter 400, Part V, Florida Statutes and must meet the general Medicaid provider qualifications contained in the Florida Medicaid Provider General Handbook, and the service requirements contained in the Aged and Disabled Adult Waiver Services Coverage and Limitations Handbook.

Adult day health care services are provided 4 or more hours per day on a regularly scheduled basis, for 1 or more days per week, in an outpatient setting. Adult day health care services encompass both health and social services needed to ensure the optimal functioning of the recipient. The services can be authorized up to 10 hours per day. However, authorization of more than 8 hours would be unusual and requires extensive written justification.

Location of Licensing, Certification, or Other Requirements

1. http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&URL=Ch0400/ titl0400.htm
2. http://fac.dos.state.fl.us/faconline/chapter58.pdf
3. http://floridamedicaid.acs-inc.com/XJContent/Aged%20and%20Disabled%20Ad…
4. http://floridamedicaid.acs-inc.com/XJContent/Medicaid%20Provider%20Gene…

Citations

1. The 2004 Florida Statutes (Chapter 400, Nursing Homes and Related Health Care Facilities, Part V--Adult Day Care Centers, 400.55 through 400.564).
2. Florida Administrative Code (Chapter 58A-6 Adult Day Care, 58A-6.001 through 58A-6.016). Department of Elder Affairs. [Updated 3/29/98 through 1/1/04]
3. Aged and Disabled Adult Waiver Services Coverage and Limitations Handbook, Agency for Health Care Administration. Florida Medicaid. [Effective 03/04, updated 01/05]
4. Florida Medicaid Provider General Handbook, Agency for Health Care Administration. Florida Medicaid. [Updated 01/05]

Georgia

Overview

The state's adult day services licensing standards, developed after the legislature approved licensing authority in 2003, are currently voluntary due to lack of funding for the licensing agency to administer the licensing process. However, the Division of Aging Services has standards that must be met by providers in the statewide aging network who provide day services through contracts with the Area Agencies on Aging (AAA). The standards could become a part of, or serve as a basis for, future licensing regulations.

These standards for adult day services recognize two types of adult day services programs--basic social and medical--and four service delivery models. This profile describes these standards. The Division of Aging Services in the Department of Human Resources will work with the new licensing agency to develop regulations for day service operations and cooperate with the agency in administering the licensing process for the provision of adult day services as part of its non-Medicaid Home and Community-Based Services program.

Adult day health (ADH) services in Georgia are offered under the Community Care Services Waiver Program, administered by the Division of Aging Services. Providers of ADH services under the waiver are required to follow specific Medicaid-only requirements for the provision of these services. Once the licensing process is operational, Medicaid ADH services providers will be required to be both licensed and enrolled with the State Department of Community Health as Medicaid providers and subject to the regulations of that Department.

Licensure and Certification Requirements

Definitions

Adult day services provide support for elderly individuals (and their families, if present) who do not function fully independently, but who do not need 24-hour nursing care. Participants may have physical, social, and/or mental impairments; need assistance with activities of daily living (ADL) less than that requiring placement in an institution; or be recently returned home from a hospital or institutional stay. These services are comprehensive and are based on participants' individual needs; they are family-focused when families are involved. They are outcome-oriented with a goal of enhanced independence. The programs provide safe group environments with coordinated health and social services aimed at stabilizing or improving self-care. Adult day services may prevent, postpone, or reduce the need for institutional placement. Combined social and medical model programs can be combined within the same center or facility.

Service Delivery Models for Adult Day Services

Adult day care consists of community-based programs that provide nonmedical care--primarily social and recreational activities--to persons 60 years of age or older in need of limited personal care assistance, supervision, or assistance essential for sustaining ADL; or for the protection of an individual on a less than 24-hour basis.

Adult day support consists of community-based programs that provide nonmedical care to meet the needs of functionally impaired elderly (age 60+) adults, according to individual plans of care in a structured, comprehensive program that will provide a variety of social, psychosocial, and related services in a protective setting on a less than 24-hour basis. Participants in this model of care will demonstrate moderate impairments in functioning and cognition.

Adult day health care consists of community-based programs that provide social, rehabilitative, and minor health services to physically and/or mentally functionally impaired elderly (age 60+) adults, for the purpose of restoring or maintaining optimal capacity for self-care. These programs provide services through individual plans of care and target elderly persons who could be at risk of institutional placement if intervention is not provided. These may be persons who are ineligible for or do not wish to participate in the waiver program, but whose need for assistance is greater than that of participants in the basic adult day care program. Participants in this model of care will have moderate to substantial degrees of impairments in functioning and cognition.

Alzheimer's day care consists of community-based programs that provide day care for persons in the various stages (mild, moderate, or severe) of Alzheimer's disease or other dementias, regardless of age. The programs also provide support and educational services for family caregivers and the community at large. These centers identify the psychosocial, emotional, functional, and cognitive needs of participants and assist them, through individual plans of care, to function at the highest degree possible.

Parameters for Who Can Be Served

The parameters for who can be served are defined generally in the definitions of the different service delivery models (above). The state also specifies that adult day services can be provided to persons 60 years of age or older (and collaterally their spouses/caregivers) who are limited in their ability to perform activities of daily living and instrumental activities of daily living due to physical and/or cognitive impairment, and who lack access to, or do not desire to receive, services offered through other funding sources or programs.

Adults of any age (and collaterally their spouses or caregivers) who are known to have or who exhibit symptoms of Alzheimer's disease or other dementias may be appropriate candidates for adult day services provided through State Funds for Alzheimer's Services. These program requirements supercede requirements for day care services provided through state Alzheimer's funding, issued by the Division in 1991.

Basic social model centers are not permitted to serve individuals who: (1) are bed bound or do not have the stamina or strength to attend the center, due to extreme frailty or fatigue; (2) have emotional or behavioral disorders that are so severe in nature as to cause them to be destructive to themselves or others, or who are disruptive in a group setting, unless the center has the capacity, through adequate and qualified staffing, to appropriately manage the behaviors; or (3) would not benefit from the activities and services offered at the center, due to significantly higher levels of physical and cognitive functioning.

Inspection and Monitoring

The AAA shall monitor providers of adult day care services for compliance with the requirements and evaluate program effectiveness, including client and program outcomes, at least annually.

Required and Optional Services

Provisions Regarding Medications

Clients who choose not to or who cannot self-administer their medications must have their medications administered by a person who holds a current license under state law that authorizes the licensee to administer medications.

Licensed nursing staff may provide assistance to individuals who are incapable of self-administering medications independently, including and limited to providing reminders, obtaining medications from and returning them to storage, opening and closing packaging, and pouring prescribed dosages.

Clients who are able to administer their own medications must be assessed at least once a month by licensed nursing staff to determine their continued ability to self-administer their medications/treatments.

The adult day care program shall have a written policy for medication management designating specific staff to be authorized and trained to assist with the administration of medications and the program's role in the supervision of self-administered medications and/or staff-administered medications.

Provisions for Groups with Special Needs

Staffing Requirements

Type of staff. Each program shall have a program administrator. Other required staff are the activities director, nursing staff, and day care assistants, as well as volunteers. The facility nurse must be either a registered nurse or a licensed practical nurse. The activities director may fulfill the function of program administrator if she/he meets all qualifications. The program may contract for certain staff services, including activities director, as long as all program requirements ordinarily fulfilled by employees are met.

If the program administrator also is the facility nurse, and leaves the facility to perform other duties related to the provision of the day care program, another licensed nursing professional must fulfill the duties of the facility nurse during his/her absence.

Staffing ratios. Each program shall be operated with adequate numbers of qualified staff, according to the target population(s) and models of programming provided. At least one staff member 18 years of age or older shall be on the premises at all times participants are present. In addition to administrative staff, there shall be a minimum of one direct service staff person for each eight nonseverely impaired participants, or for each four severely impaired participants.

The characteristics of the participants will determine the number and types of staff required. If a mixed model of programming is proposed, the staffing required for the highest level of care will be ensured.

Volunteers who meet the same standards, requirements, and training as employees, and who have signed a written job description, may be counted as part of the staff-to-participant ratio.

Training Requirements

All adult day care staff who interact with participants, and volunteers who are included as part of the staff-to-participant ratio, must complete an orientation within the first 2 weeks of employment. Content shall include but not be limited to participant rights, program policies (including the client population served), medical and safety emergencies, health care delivery, universal precautions, and abuse.

Substitute consultant staff, if any, must complete 3 hours of orientation.

Within 90 days of employment, all employees who provide care to participants shall have received a minimum of 18 hours of training in the areas that are relevant to their job, including the needs and abilities of the participants, physical and psychological aspects of each participant's disabilities, personal care techniques, and interpersonal communications skills, including patient rights. Staff employed as substitutes on an infrequent basis are not required to complete the 18 hours of initial training. Substitutes for direct service staff used on a regular basis with an on-call or other ongoing agreement must complete all training requirements.

After the first year of employment, all employees who have direct care or program activity responsibilities, including the program administrator, shall complete 3 hours of continuing education quarterly, or 12 hours in total annually, on pertinent topics.

The adult day care program shall provide orientation, training, and supervision to program volunteers.

Relevant Medicaid Contracting Requirements for Adult Day Services Providers

ADH services in Georgia are offered under the Community Care Services Program Waiver, administered by the Division of Aging Services with services reimbursed by the Department of Community Health. Services are offered to members at two levels: Level I services require minimal ADL and self-care assistance, medical monitoring, and oversight for safety; Level II services are more intensive and may include specialized nursing services. Relevant requirements outlined in provider manuals are as follows:

Definitions. ADH is a community-based medically oriented day program for individuals who are functionally impaired. The goal is to promote medical stability, maintain optimal capacity for self-care, and maximize function ability. Services assist members to recover from acute illnesses or injuries, facilitate rehabilitation, support members with a chronic illness, and increase opportunities for members to participate in cultural and social activities and engage in multifaceted activities. All services provided reflect the individual's needs as indicated in a comprehensive care plan.

Required services. Skilled physical, occupational, and speech therapy; assistance with ADL; health monitoring and health-related services; nursing services; and skilled nursing services.

Optional services. Transportation.

Medications. The registered nurse and licensed practical nurse assist members with medications when indicated.

Staffing type. Required positions are center director, registered nurse, aide(s), activities professional, and occupational, physical, and speech therapist (by contract). Suggested staff positions include licensed practical nurse and driver/aide.

Staffing ratios. A minimum ratio of staff-to-members is one-to-eight for Level I members and one-to-four for Level II members.

Training. Any staff member providing direct member care is required to have current certifications in cardiopulmonary resuscitation (CPR) and first aid. The ADH provider must develop an ongoing in-service training plan and schedule for staff, subcontracted individuals, and volunteers.

The plan must include, at a minimum, the following topics: orientation to the agency; CCSP overview including program policies and procedures; sensitivity to the needs and rights of older individuals; recertification and/or training in techniques of CPR and first aid; member rights/Elder Abuse Reporting Act/Advance Directives; infection control procedures; fire safety and accident prevention and safety; confidentiality of member information; medication management; disaster planning/emergency procedures; caring for members with Alzheimer's and related illnesses, an overview of Alzheimer's disease; understanding communication techniques; understanding common behaviors of members with Alzheimer's disease; care and management skills; activities appropriate for aging or chronically ill participants; safety and accident prevention; medications and side effects; elder abuse reporting; advance directives; and nutrition care, food safety, and safe feeding.

Location of Licensing, Certification, or Other Requirements

1. http://www.files.georgia.gov/DHR-DAS/DHR-DAS_Publications/adultdaycare.pdf
2. https://www.ghp.georgia.gov/wps/output/en_US/public/Provider/MedicaidMa…
3. http://www.legis.state.ga.us/legis/2003_04/fulltext/hb318.htm
4. https://www.ghp.georgia.gov/wps/output/en_US/public/Provider/MedicaidMa…

Citations

1. Adult Day Care/Day Health Services Requirements. Georgia Department of Human Resources Division of Aging Services Requirements for Non-Medicaid Home and Community Based Services §302. [7/2002]
2. (Medicaid) Part II-Chapter 1100 Policies and Procedures for Adult Day Health Services (ADH) (Community Care Services Program) Department of Community Health--Division of Medical Assistance & Department of Human Resources--Division of Aging Services. [Revised April 2004]
3. Adult Day Center for Aging Adults Licensure Act. House Bill 318. Georgia General Assembly. [7/1/03]
4. Policies and Procedures for Community Care Services General Manual. Georgia Department of Community Health. Division of Medical Assistance. [4/1/2005]

Additional Information

The Division of Aging Services operates a Mobile Day Care program under the non-Medicaid Home and Community-Based Services Program in which staff members, traveling with materials and supplies, provide day care services in different locations around the state on a rotating basis to provide respite for caregivers. It was initially designed to assist caregivers of persons with Alzheimer's disease and is now made available to other caregivers. The state has amended the Community Care Services Program waiver to cover Mobile Day Care mobile model, and is awaiting Centers for Medicare & Medicaid Services (CMS) approval.

Hawaii

Overview

The Hawaii Department of Health licenses adult day health centers (ADHC) under the state administrative rules for freestanding adult day health centers, and also under the state administrative rules for skilled nursing/intermediate care facilities (for nursing facility-based adult day health centers).

The Hawaii Department of Human Services licenses adult day centers (ADC) under the state administrative rules for licensing of adult day care centers (for providers serving solely Medicaid clients) and the administrative rules for adult day care services (for clients funded by state funds).

Adult day care and adult day health care services are provided through three 1915(c) Medicaid waivers serving the elderly and disabled population under contracts with providers licensed by either the Department of Health or the Department of Human Services.

The Hawaii Department of Health also has regulations for adult day health centers located in skilled nursing and intermediate care facilities. The relevant provider regulations are very limited, only specifying that the staff requirements shall not reduce the requirements for the overall skilled nursing or intermediate care facility, and referencing the definitions statement for skilled nursing and intermediate care facilities, which defines drug administration as giving a patient "a prescribed drug in accordance with all the existing laws and rules governing those acts."

Licensure and Certification Requirements

Definitions

Adult day care center means a licensed facility maintained and operated for the purpose of providing regular care, which includes supportive care to four or more disabled adults. The purpose of adult day care services is to provide disabled adults a sheltered setting and specified activities to support and promote the adult's level of functioning and ability to remain or be maintained safely in the community outside institutions and other care facilities. (Hawaii Department of Human Services definition for state funding under Hawaii Administrative Rules, Title 17, Chapter 1424).

Adult day care center means a licensed facility maintained and operated by an individual, organization, or agency for the purpose of providing regular supportive care to four or more disabled adult participants, with or without charging a fee. (Hawaii Department of Human Services definition for Medicaid under Hawaii Administrative Rules, Title 11, Chapter 96).

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

Adult day health center means a facility that provides adult day health care.

Parameters for Who Can Be Served

Adult day care. The definition of adult day care (above) provides general information regarding who can be served in these programs. Providers may serve individuals who need the services offered in order to maintain their current level of social, emotional, or physical functioning; have a physical or mental disability suitable to the day care program as verified by a medical or psychological report; and desire and are capable of participating in a day care program.

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

Adult day health care. The definition of adult day health care (above) provides general information regarding who can be served in these programs. Providers may serve individuals who need health, nursing, therapeutic, or social services in order to reach or maintain their highest degree of functional status practicable.

Inspection and Monitoring

Adult day care. Centers are inspected to determine compliance with applicable building and fire codes, and standards set by the state Department of Health. The Department of Human Services also inspects centers as a part of the relicensing process. (Medicaid)

Adult day health care. The director of the Department of Health or his authorized representative shall inspect each licensed freestanding ADHC at least once annually. Notice of the approximate time for the annual inspection visits may be given to the center. In addition to performing annual inspection visits, the director or his authorized representative, without prior notice, may enter the center at any reasonable time for the purposes of confirming correction of deficiencies, investigation of complaints, or both.

Facilities licensed under this chapter must be inspected at least annually by appropriate fire authorities for compliance with state and county fire and life safety rules and ordinances.

Required and Optional Services

Provisions Regarding Medications

Adult day care. Services include a reminder to take medication. (State funding)

Medication may be administered by staff members licensed by the state as a licensed practical nurse or registered nurse, or by unlicensed assistive personnel delegated the task by a licensed registered nurse, with a signed authorization from the participant's physician. (Medicaid)

Adult day health care. Medications administered to a client shall be ordered by the attending physician in writing.

Only appropriately licensed and trained staff shall be allowed to administer drugs and shall be responsible for proper recording of the medication, including the route of administration.

Provisions for Groups with Special Needs

Staffing Requirements

Adult Day Care

Type of staff. Each center shall have a director responsible for the total program of the center, who shall designate a staff member to be responsible for administration whenever the director is absent. Each center shall have staff members who are capable of providing supervision to the number of participants at the center at all times.

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

Adult Day Health Care

Type of staff. Each center shall have an administrator, and centers with a capacity of 50 or more clients shall also have a separate full-time program director. A program director of a center whose average daily attendance is 20 or less may also serve as the registered nurse, social worker, occupational therapist, physical therapist, activity coordinator, speech therapist, or dietitian provided that the program director is qualified and is not also the administrator.

Each program shall have nursing staff sufficient in qualifications to meet the needs of the clients. Nursing services shall be under the supervision of a registered nurse.

Staffing ratios. Employees shall be sufficient in number to provide the services for which the center is licensed. Each program shall have nursing staff sufficient in number to meet the needs of the clients.

Training Requirements

Adult day care. Staff are required to be certified in CPR and first aid.

Adult day health care. Each employee shall have either training or related experience in the job assigned, and a planned in-service education program, including orientation, skill training, and continuing education, shall be provided. Annual or more frequent training shall include, but not be limited to, prevention and control of infections, fire prevention and safety, accident prevention, clients' rights, and problems and needs of the aged, ill, and disabled. Provision shall be made for training appropriate personnel in CPR and appropriate first aid techniques.

Relevant Medicaid Contracting Requirements for Adult Day Services Providers

Hawaii has three 1915(c) waivers serving the aged and disabled population: the Residential Alternative Community Care Program, HIV/AIDS Community Care, and Nursing Home Without Walls. Services are provided through providers licensed by either the Department of Health or the Department of Human Services. A Program for All-Inclusive Care for the Elderly (PACE) program on the island of Oahu provides adult day health services.

Location of Licensing, Certification, or Other Requirements

1. http://www.hawaii.gov/health/about/rules/11-96.pdf
2. http://www.hawaii.gov/health/about/rules/11-94.pdf
3. http://www.state.hi.us/dhs/17-1417.pdf
4. http://state.hi.us/dhs/17-1424.pdf

Citations

1. Freestanding Adult Day Health Centers (Hawaii Administrative Rules, Title 11, Chapter 96). Department of Health. [5/31/91]
2. Skilled Nursing/Intermediate Care Facilities (Hawaii Administrative Rules, Title 11, Chapter 94). Department of Health. [4/22/85]
3. Adult Day Care Services (Hawaii Administrative Rules, Title 17, Chapter 1417, Subtitle 9). Community Long-Term Care Programs, Department of Human Services. [Revised 6/29/92]
4. Licensing of Adult Day Care Centers (Hawaii Administrative Rules, Title 17, Subtitle 9, Chapter 1424). Department of Human Services, Adult and Community Care Programs. [6/29/92]

Idaho

Overview

Adult day care (ADC) in Idaho is regulated for persons served by the Commission on Aging Senior Services Program under the Rules Governing Senior Services Programs. The Commission on Aging rules state that adult day care programs shall operate under guidelines established by the Idaho Commission on Aging that are in accordance with the standards developed by the National Council on Aging, National Institute on Adult Day Care (now known as the standards of the Commission on Accreditation of Rehabilitation Facilities).

Adult day care services are provided under the Medicaid Aged and Disabled Waiver, and waiver providers are governed by the Department of Health and Welfare Division of Medicaid, the Home and Community-Based Services (HCBS) Medicaid Guide, Provider Handbook, and additional terms for ADC to the Medicaid Provider Agreement.

Licensure and Certification Requirements

Definitions

Adult day care is a structured day program that provides individually planned care, supervision, social interaction, and supportive services for frail older persons in a protective group setting, and provides relief and support for caregivers. It is designed to meet the needs of eligible participants whose functional or cognitive abilities have deteriorated; it is intended to provide relief for family caregivers; and it is a comprehensive program that provides a variety of social and other elective support services in a protective setting other than the participant's home during any part of a day, but for less than 14 hours per day.

Parameters for Who Can Be Served

Providers may serve individuals who have physical or cognitive disabilities affecting ADL or instrumental ADL; are capable of being transported and of benefiting from socialization, structured, and supervised group-oriented programs; and are capable of self-care with supervision or cueing.

Inspection and Monitoring

Required and Optional Services

Provisions Regarding Medications

None identified.

Provisions for Groups with Special Needs

Staffing Requirements

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

If the site administrator is responsible for more than one site or has duties not directly related to ADC, a program manager shall be designated for each site. If the ADC occurs in other than a freestanding facility, such as in a nursing facility or assisted living facility, the rules governing that facility must also be followed. Adult day care does not, however, have a rule governing the site administrator for a stand-alone facility.

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

Training Requirements

None identified.

Relevant Medicaid Contracting Requirements for Adult Day Services Providers

Idaho provides ADC under the Aged and Disabled Waiver.

Definitions

Adult day care is a supervised, structured day program outside of the home of the client that may offer one or more of a variety of social, recreational, or health activities; supervision for safety; and assistance with ADL. Adult day care can be provided in a home or elsewhere in the community.

Admission criteria. Centers may accept clients who are receiving service through one of the participating HCBS waivers, and who do not have pressure ulcers or open wounds, draining wounds that cannot be contained, or who require continuous nursing assessment and intervention. Providers shall accept participants only if they are able to provide the level or type of service the participant requires, including skilled nursing and sufficient staffing, and whose needs are compatible with the physical, emotional, and social needs of the other participants at the facility and within the level of fire safety provided by the facility.

Required services. Medication administration and nursing.

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

Inspections. Idaho Medicaid conducts a review every 2 years of all provider agencies. Regional Medicaid Services contacts agencies at least 30 days prior to a review.

Staffing ratios. The provider shall employ sufficient personnel to ensure the safe and proper care of the participants. The staff-to-participant ratio shall be a minimum of one staff to six participants. As the number of participants and the severity of participant functional impairments increases, the staff-to-participant ratio shall be adjusted accordingly. Programs serving a high percentage of participants who are severely impaired should have a staff-to-participant ratio of one-to-four.

Training. The provider shall ensure that the staff has sufficient training. At a minimum, providers shall have training in infection control, cardiopulmonary resuscitation (CPR), and first aid.

Location of Licensing, Certification, or Other Requirements

1. http://www2.state.id.us/adm/adminrules/rules/idapa15/0101.pdf
2. http://www.healthandwelfare.idaho.gov/_Rainbow/Documents/medical/s3_015…
3. http://www.healthandwelfare.idaho.gov/_Rainbow/Documents/medical/Master…% 20Medicaid%20Provider%20Orientation%20Guide%20Part%20I%207-04.pdf
4. http://www.healthandwelfare.idaho.gov/_Rainbow/Documents/medical/Master…% 20Medicaid%20Provider%20Orientation%20Guide%20Part%20II%207-04.pdf
5. On file at RTI International, provided by Idaho Medicaid.

Citations

1. Rules Governing Senior Services Program (IDAPA 15, Title 01, Chapter 01)--Office of the Governor, Idaho Commission on Aging. [2004]
2. Medicaid Provider Handbook, Aged and Disabled Waiver Guidelines. Idaho Department of Health and Welfare. [6/1/04]
3. Idaho HCBS Medicaid Guide. General Information Part I. Idaho Department of Health and Welfare. Division of Medicaid. [July 2004]
4. Idaho HCBS Medicaid Guide. Medicaid Programs Part II. Idaho Department of Health and Welfare. Division of Medicaid. [July 2004]
5. Additional Terms--Adult Day Care. Idaho Medicaid Provider Enrollment Packet Adult Day Care Services Medicaid Provider Agreement. [5/10/04]

Illinois

Overview

The State of Illinois does not require licensing or certification for adult day care providers. The Department on Aging Community Care Program (CCP) funded by state general revenue and the Medicaid Waiver provides services designed to prevent premature and unnecessary institutionalization to individuals over 60 years of age who are determined eligible to receive such services. The regulations for CCP, as stated in the Administrative Code, require all adult day service providers to comply with the applicable local and state building, fire, health, and safety codes and standards in addition to specific accessibility and environmental barrier codes, and food service sanitation and vehicle codes. There are no provisions for adult day care other than those stated in the Administrative Code for the CCP, which are detailed in this profile.

Licensure and Certification Requirements

Definitions

Adult day service is the direct care and supervision of adults 60 years of age and over in a community-based setting for the purpose of providing personal attention and promoting social, physical, and emotional well-being in a structured setting.

Parameters for Who Can Be Served

Other than the general parameters included in the definition (above), none are specified.

Inspection and Monitoring

The Department shall have the authority to conduct performance reviews of a contracted provider agency at any time during the course of the provider's contract period. The Provider Performance Review consists of reviewing a sample of client and employee files to: evaluate provider compliance with administrative rules; ensure adherence to the policies and procedures established by the Department and the adult day service provider; and ensure that Request for Proposal (RFP) provider requirements are met or exceeded.

Required and Optional Services

Provisions Regarding Medications

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

Provisions for Groups with Special Needs

Staffing Requirements

Type of staff. A separate and identifiable staff person must be designated for sole use by the adult day service program. Each adult day service provider shall have adequate personnel in number and skill (a minimum of two staff persons) at the adult day service site to provide for program and fiscal administration; nursing and personal care services; nutritional services; planned therapeutic/recreational activities; and provision or arrangement of transportation to and from the adult day service site.

The program coordinator/director may perform the responsibilities of an adult day service program administrator; and must be on duty full-time when clients are in attendance or have a qualified substitute.

A program nurse must be on duty at least one-half of a full-time (FTE) work period when clients are in attendance, either as staff or on a contractual basis. With written Department approval, the responsibilities of a program nurse may be performed by the program coordinator/director or administrator, in which case that person must be full-time and must meet the qualifications for a program nurse and fulfill responsibilities for all assigned positions.

Nutrition staff shall include: (1) at least one staff person who meets the food service sanitation guidelines issued by the Department of Public Health; and (2) a nutrition consultant/dietitian, either paid or in-kind, who shall be a registered member of the American Dietetic Association with experience in an agency setting.

Drivers of adult day service vehicles that transport clients, and at least two program adult day service staff, shall be certified in cardiopulmonary resuscitation (CPR) and trained in first aid, and at least one of such trained staff shall be on-site when clients are present.

The adult day service team consisting of program coordinator/director and program nurse may include other staff at the option of the program coordinator/director.

Staffing ratios. The minimum ratio of full-time staff (qualified adult day service staff, trained volunteers or substitutes) or full-time equivalent staff present at the adult day service site to clients, when clients are in attendance, shall be: two staff for every 1-12 clients; three staff for 13-20 clients; four staff for 21-28 clients; with one additional staff person for each seven additional clients. Fifty percent or more of a staff member's time shall be spent in on-site direct service or supervision on behalf of one or more clients in order to be considered in the ratio.

Training Requirements

Each adult day service employee shall have initial training totaling a minimum of 12 hours face-to-face training within the first week of employment (exclusive of orientation). A worker may be exempted from initial training by the provider if the worker has had previous documented training equivalent to 12 hours, with another CCP contracted agency, or in a related field, within the past 2 years prior to this employment or holds a CNA, RN, LPN, BA, BS, BSW, or higher degree. A minimum of 12 hours continuing education per year shall be mandatory for all adult day service employees.

Relevant Medicaid Contracting Requirements for Adult Day Services Providers

There are no additional Medicaid requirements for adult day services providers. The CCP requires all providers to adhere to the same rules and regulations irrespective of funding sources.

Location of Licensing, Certification, or Other Requirements

1. http://www.ilga.gov/commission/jcar/admincode/089/08900240sections.html

Citations

1. Administrative Code (Title 89: Social Services, Chapter II: Illinois Department on Aging, Part 240--Community Care). Joint Committee on Administrative Rules. [Effective 5/21/04]

Indiana

Overview

Indiana does not have licensing requirements for adult day services. There is no oversight for adult day service (ADS) programs that serve only private pay clients. The state has, under the Indiana Family and Social Services Administration (FSSA), several Medicaid Home and Community-Based Services Waivers, including the Aged and Disabled Waiver, which include ADS as a covered service. Providers of ADS must be certified as Medicaid Providers by FSSA and must comply with any ADS standards and guidelines defined by FSSA. The Medicaid Waiver Standards and Guidelines are the only regulations Indiana has for ADS and are the source for the information in this profile.

Licensure and Certification Requirements

Definitions

Adult day services means a community-based group service designed to meet the needs of adults with impairments through individual plans of care. These structured, comprehensive, nonresidential programs provide a variety of health, social, recreational, and therapeutic activities; supervision; support services; and in some cases, personal care. Meals and/or nutritious snacks are required. These services must be provided in a congregate, protective setting. By supporting families and other caregivers, adult day services enable participants to live in the community. Participants attend on a planned basis for a minimum of 3 hours to a maximum of 12 hours. There are three levels of adult day services: Basic (Level 1), Enhanced (Level 2), and Intensive (Level 3). (see Additional Information at end of profile for description of each level.)

Parameters for Who Can Be Served

No parameters for who can and cannot be served are specified. However, the staffing requirements specified below indicate that providers may serve individuals with a high level of functional limitations and nursing needs.

Inspection and Monitoring

None specified.

Required and Optional Services

Provisions Regarding Medications

The ADS program shall store all medications administered by program staff in a locked room or cabinet with appropriate temperature control.

Provisions for Groups with Special Needs

Staffing Requirements

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

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

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

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

Staffing ratios.

Basic (Level 1)--The staff and client ratio shall be a minimum of one-to-eight.

Enhanced (Level 2)--The staff and client ratio shall be a minimum of one-to-six.

Intensive (Level 3)--The staff and client ratio shall be a minimum of one-to-four. At least two paid staff must be in the facility and available at all times when more than one participant is present. Volunteers are not included in the staff ratio unless they are professionally trained and/or certified in a health occupation and oriented and trained as staff.

Training Requirements

All staff shall receive orientation prior to providing ADS, including program policies and procedures and participants rights. If volunteers are used as staff, their orientation and training requirements must be the same as paid staff.

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

Enhanced (Level 2)--Training requirements of ADS direct care and administrative staff (if administrative is secondary staff available at times or is included in staff/client ratio) of day centers providing Enhanced care include all of the Basic (Level 1) requirements, plus training in personal care services. Personal care assistants will maintain their continuing education requirements unique to their certification and will maintain current certificates. Those centers providing services to individuals with mild to moderate cognitive impairments must provide training to all staff involved with activities programming, and personal care staff, in dementia specific care.

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

All staff and subcontractors who will be driving when clients are transported by the ADS provider must complete a Defensive Driver Training, Trauma/First Aid Training, and Passenger Assistance Course within 3 months of being hired, with annual recertifications; and must receive at least annual training regarding the special issues related to working with health-impaired and cognitively impaired adults.

Relevant Medicaid Contracting Requirements for Adult Day Services Providers

As stated in the overview, Medicaid providers of ADS must be certified by Indiana's Family and Social Services Administration and follow the Medicaid Waiver Standards and Guidelines highlighted in this profile.

Location of Licensing, Certification, or Other Requirements

None available online.

Citations

1. Medicaid Waiver Standards and Guidelines, Adult Day Services, State of Indiana. [Final Draft, June 2001]

Additional Information

Basic adult day service (Level 1) includes:

1. Monitor and/or supervise all activities of daily living (ADLs are defined as dressing, bathing, grooming, eating, walking, and toileting) with hands-on assistance provided as needed.
2. Provide comprehensive, therapeutic activities.
3. Health assessment and intermittent monitoring of health status.
4. Monitor medication or medication administration.
5. Appropriate structure and supervision for those with mild cognitive impairment.

Enhanced adult day service (Level 2) includes Basic (Level 1) service requirements and additionally:

1. Hands-on assistance with two or more ADLs or hands-on assistance with bathing or other personal care.
2. Health assessment with regular monitoring or nitervention with health status.
3. Dispensing or supervising the dispensing of medications to participants.
4. Assessment and intervention for psychosocial needs, including counseling as needed for participants and caregivers.
5. Therapeutic structure, supervision, and intervention for those with mild to moderate cognitive impairments.

Intensive adult day service (Level 3) includes Basic (Level 1) and Enhanced (Level 2) service requirements and additionally:

1. Hands-on assistance or supervision with all ADLs and personal care.
2. On or more direct health intervention(s) (required).
3. Rehabilitation and restorative services including physical therapy, speech therapy, occupational therapies (coordinated or available).
4. Therapeutic interventions to address dynamic psychosocial needs such as depression or family issues affecting care.
5. Therapeutic interventions for those with moderate to severe cognitive impairment.

In 2003, the state enacted legislation requiring the state to develop a comprehensive system of ADS. When this legislation is implemented, it is thought that the regulatory environment will change dramatically. There is more information available at <http://www.generationsproject.org>

Some clients may be receiving ADS through Indiana's CHOICE program, which is solely state-funded program for home and community services. If a provider wants to be a CHOICE provider, they must first be a waiver provider and, hence, follow the Medicaid Waiver Standards and Guidelines regarding provision of ADS.

The Indiana Association of Adult Day Services does not have any authority over individual centers. It is, however, the only organization able to certify staff as certified program assistants (CPA). This certification is the industry minimum qualification to provide personal care such as bathroom assist and hands-on transfers. It is similar to certification for nursing assistants. The ADS Guidelines state that staff must have appropriate training (CPA, CAN, QMA, LPN, RN) to provide personal care.

Iowa

Overview

Iowa certifies adult day services programs, which may include dementia-specific adult day services, under Section 321 Chapter 24 of the Iowa Administrative Code, adopted by the Department of Elder Affairs and implemented by the Department of Inspections and Appeals.

Iowa provides adult day services under its Elderly, Mental Retardation, and Ill and Handicapped Waivers, administered by the Iowa Department of Human Services, which accepts the adult day services providers that are certified by the Department of Inspections and Appeals under Section 321 Chapter 24.

Licensure and Certification Requirements

Definitions

Adult day services program means an organized program providing a variety of health, social, and related support services for 16 hours or less in a 24-hour period to two or more persons with a functional impairment on a regularly scheduled, contractual basis.

Dementia-specific adult day services program means a certified program that either serves five or more participants with dementia between stages four and seven on the Global Deterioration Scale or holds itself out as providing specialized care for persons with a cognitive disorder or dementia, such as Alzheimer's disease, in a dedicated setting.

Parameters for Who Can Be Served

Programs may not knowingly admit or retain a participant who: (1) is bedfast; (2) requires routine three-person assistance with standing, transfer, or evacuation; (3) is dangerous to self or others, including but not limited to a participant who (a) despite intervention, chronically wanders into danger, is sexually or physically aggressive or abusive, or displays unmanageable verbal abuse or aggression or (b) displays behavior that places another participant at risk; (4) is in an acute stage of alcoholism, drug addiction, or uncontrolled mental illness; (5) is under 18 years of age; (6) requires more than part-time or intermittent health-related care; or (7) on a routine basis has unmanageable incontinence.

Inspection and Monitoring

The Department of Inspections and Appeals shall conduct on-site monitoring within 90 calendar days following issuance of conditional certification, and between 60 and 90 days prior to expiration of a program's certification. The Department shall monitor a certified program at least once during the program's certification period.

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

Required and Optional Services

Provisions Regarding Medications

Each program shall have a written medication policy that includes the following:

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

When partial or complete control of medication is delegated to the program by the participant, appropriate staff may transfer medication from the original prescription containers into medication reminder boxes or medication cups in the participant's presence. A program that administers prescription medications shall provide for a registered nurse to monitor adverse reactions.

Provisions for Groups with Special Needs

Staffing Requirements

Type of staff. A program that administers prescription medications or provides professionally directed health care or health-related care shall provide for a registered nurse.

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

Training Requirements

The owner or management corporation of the program is responsible for ensuring that all personnel employed by or contracting with the program receive training appropriate to assigned tasks and the target population.

All personnel employed by or contracting with a dementia-specific program shall receive a minimum of 6 hours of dementia-specific education and training prior to or within 90 days of employment or the beginning date of the contract. The dementia-specific education or training shall include, at a minimum, the following: (1) an explanation of Alzheimer's disease and related disorders; (2) the program's specialized dementia care philosophy and program; (3) skills for communicating with persons with dementia; (4) skills for communicating with family and friends of persons with dementia; (5) an explanation of family issues such as role reversal, grief and loss, guilt, relinquishing the care-giving role, and family dynamics; (6) the importance of planned and spontaneous activities; (7) skills in providing assistance with activities of daily living; (8) the importance of the care plan and social history information; (9) skills in working with challenging participants; (10) techniques for simplifying, cueing, and redirecting; and (11) staff support and stress reduction.

All personnel employed by or contracting with a dementia-specific program shall receive a minimum of 2 hours of dementia-specific continuing education annually. Direct-contact personnel shall receive a minimum of 6 hours of dementia-specific continuing education annually.

All personnel of a program shall be able to implement the program's accident, fire safety, and emergency procedures.

Relevant Medicaid Contracting Requirements for Adult Day Services Providers

Iowa provides adult day services under its Elderly, Mental Retardation, and Ill and Handicapped Waivers, administered by the Iowa Department of Human Services. Adult day care providers shall be agencies that are certified by the Department of Inspections and Appeals as being in compliance with the standards for adult day services programs adopted by the Department of Elder Affairs in Section 321, Chapter 24 of the Iowa Administrative Code.

Location of Licensing, Certification, or Other Requirements

1. http://www.dhs.state.ia.us/policyanalysis/PolicyManualPages/Manual_Documents/Provman/ill.pdf
2. http://www.dhs.state.ia.us/policyanalysis/PolicyManualPages/Manual_Documents/Provman/eldwaiv.pdf
3. http://www2.legis.state.ia.us/rules/current/iac/321iac/32124/32124.pdf
4. http://www2.legis.state.ia.us/rules/current/iac/321iac/32126/32126.pdf

Citations

1. Medicaid Provider Manual. HCBS III and Handicapped Waiver. State of Iowa. Department of Human Services. [3/1/2003]
2. Medicaid Provider Manual. HCBS Elderly Waiver Services. State of Iowa. Department of Human Services. [7/1/2000]
3. Iowa Administrative Code, Section 321, Chapter 24. [4/14/2004]
4. Iowa Administrative Code, Section 321, Chapter 26. [9/29/2004]

Kansas

Overview

The Kansas Department on Aging licenses adult day care facilities under Kansas Department on Aging Regulations 28-39-275 - 28-39-291. Some requirements for adult care homes (39-144, 145a, 147, and 148) apply to adult day care providers.

The Kansas Medical Assistance Program (Medicaid) enrolls providers for adult day care authorized as part of the Frail Adult Waiver under the state licensure with a few additional requirements.

Licensure and Certification Requirements

Definitions

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

Parameters for Who Can Be Served

Rules governing who providers can admit and retain are the same as those for adult care homes. Providers may not serve anyone under the age of 16 and cannot serve persons in need of specialized services for mental illness unless they can provide appropriate treatment. Individuals must be admitted under the care of a physician.

Providers may define the target population they wish to serve, but shall not admit individuals (unless their negotiated service agreement includes resources to meet their needs) who:

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

Providers may discharge individuals if necessary for the resident's welfare, if the resident's needs cannot be met in the current setting, or if the safety or health of other individuals in the setting is endangered.

Inspection and Monitoring

Provisions regarding inspection are the same as for adult care homes. Adult day care facilities shall provide immediate access to any resident by any representative of the secretary of the Kansas Department of Health and Environment or the Kansas Department of Social and Rehabilitation Services.

Required and Optional Services

Provisions Regarding Medications

Self-administration of medications. Residents may manage and self-administer their own medications if an assessment by a physician or licensed nurse has determined that they can perform this function safely and accurately.

Self-administration of medications with assistance. Residents can self-administer medications using a prefilled medication reminder box or prefilled syringe if an assessment performed by a licensed nurse has determined that they can do this safely and accurately without assistance.

In both cases, staff may remind residents to take medication.

Residents who self-administer with or without assistance can choose to have some of their medications managed by a licensed nurse employed by the facility, a home health agency or hospice, or by a medication aide employed by the facility if they don't think they can perform this function safely.

Provisions for Groups with Special Needs

Staffing Requirements

Type of staff. Each adult day care facility must have an administrator or operator who may supervise more than one facility if: each facility is located within a proximate geographical location; the combined resident capacity does not exceed 100 residents; and the administrator or operator assures that the lack of full-time, on-site supervision of the facility will not adversely affect the health and welfare of residents.

Each facility shall be responsible for assuring that a licensed nurse is available on-site or by telephone to provide immediate direction to medication aides and nurse aides for residents who have unscheduled needs. The licensed nurse may be employed by the facility or by a home health agency or a hospice.

Staffing ratios. Each adult day care facility will provide sufficient numbers of qualified personnel to ensure that residents receive the services and care specified in the negotiated service agreement.

Training Requirements

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

Relevant Medicaid Contracting Requirements for Adult Day Services Providers

Adult day care is covered under the Frail Adult Waiver. Providers must be licensed and provide services in accordance with the following Medicaid provisions:

Definitions. Adult day care is designed to maintain optimal physical and social functioning for HCBS customers, providing a balance of social, intellectual, cultural, economic, emotional, and physical activities to meet their interrelated needs and interests.

Services. Basic nursing as identified in the service plan, and optional daily supervision/physical assistance with ADL as identified in the individual's plan of care. Physical, occupational, and speech therapies are not covered but may be covered through regular Medicaid.

Location of Licensing, Certification, or Other Requirements

1. https://www.kmap-state-ks.us/Documents/Content/Provider%20Manuals/FEAdult%20Day%20Care%2002-23.pdf
2. http://www.agingkansas.org/kdoa/lce/regs/adultdaycare/adult_day_care.htm
3. http://www.agingkansas.org/kdoa/lce/regs/statutes/LicensureStatutes.pdf
4. http://www.agingkansas.org/kdoa/lce/regs/ach_common/28-39-144.pdf
5. http://www.agingkansas.org/kdoa/lce/regs/ach_common/28-39-145a.pdf
6. http://www.agingkansas.org/kdoa/lce/regs/ach_common/28-39-147.pdf
7. http://www.agingkansas.org/kdoa/lce/regs/ach_common/28-39-148.pdf

Citations

1. HCBS-FE Adult Day Care Provider Manual. Kansas Medical Assistance Program. [2/23/05]
2. Adult Day Care Regulations. Kansas Department on Aging, (28-39-275 - 28-39-291). [3/23/2005]
3. Adult Care Homes Definitions 39-923. Kansas Statutes Annotated Chapter 39, Article 9. [2003]
4. Adult Care Homes Definitions 39-144. Kansas Department on Aging. [11/2001]
5. Adult Care Homes Licensure 39-145a. Kansas Department on Aging. [10/1999]
6. Adult Care Homes Resident Rights 39-147. Kansas Department on Aging. [2/1997]
7. Adult Care Homes Admission, Transfer, Discharge 39-148. Kansas Department on Aging. [2/1997]

Kentucky

Overview

Adult day care and adult day health care (ADHC) are regulated by the state Cabinet for Health and Family Services. The Division of Aging Services certifies facilities for the Adult Day Care and Alzheimer's Respite program, which is governed under Kentucky Administrative Regulations 910 KAR 1:160 and 1:230.

The Office of Inspector General licenses adult day health care providers under the Department for Medicaid Services' Home and Community-Based Waiver Program, governed under Kentucky Administrative Regulations 907 KAR 1:160 and 170.

Licensure and Certification Requirements

Definitions

Adult day care means a supportive and therapeutic social program of supervision and care: (1) provided to an eligible adult during a part of the day, but for less than 24 hours and (2) for self-administration of medications, personal care services, self-care training, social activities, and recreational opportunities.

Adult day center means a community-based facility in which adult day supervision is provided in a group setting.

Adult day health care means a licensed program to provide continuous supervision of the participant's medical and health needs.

An adult day health care center is licensed to provide nursing services and is certified for Medicaid participation by the department.

Adult day health care program means a program licensed by the Cabinet for Health and Family Services, Office of Inspector General, that provides organized health care for its clients during specified daytime hours, that may include continuous supervision to assure that health care needs are being met, supervision of self-administration of medications, and provision of nursing services, personal care services, self-care training, and social and recreational activities for individuals of all ages.

Parameters for Who Can Be Served

Adult day care. Participation criteria for adult day care programs indicate the parameters for who may be served. Participants must be 60 years of age or older and be able to respond and share in program activities without health and safety problems to self or others. Providers may serve individuals who are physically disabled or frail as a result of medical condition or age; are mentally confused; need supervision to prevent injury and assure proper nutrition and medication use; who, due to emotional or social needs, may benefit from the individualized attention and social structure these services offer, which are not otherwise available; and who have a diagnosis of dementia. No discharge requirements were identified.

Adult day health care. These programs may serve aged persons or disabled persons over the age of 21 who meet the eligibility criteria for waiver services, and who without these services, would be admitted to a nursing facility. The eligibility groups include the mandatory categorically needy and optional categorically needy. No discharge requirements were identified.

Inspection and Monitoring

Compliance with the health, safety, and treatment standards established in this administrative regulation shall be documented. Documented compliance shall be confirmed by unannounced inspections by the office. Agents of the Cabinet for Health and Family Services may enter any certified adult day care center at any time for the purpose of inspection or investigation. All inspections of adult day care centers by the cabinet shall be unannounced.

Required and Optional Services

Provisions Regarding Medications

Adult day care. A service provider may allow staff to assist participants in medication usage if those staff members have received training in medication assistance and the participants have care plans including this service. The provider will set a daily medication schedule, assure that the correct medication is given, assure that the correct method of taking the medication is followed, explain to the client the importance of taking the medication as directed, place certain medications within the client's reach so that the client can place the tablet under the tongue the moment chest pain occurs, put away sleep and pain medications after each use, review the evening medication schedule with the client if no assistance can be given at that time, and encourage the client to consult a doctor with questions.

Adult day health care. Basic services include monitoring and supervision of self-administered medications. Drugs and treatments shall be administered by ADHC staff only as ordered by the physician. ADHC staff shall evaluate and monitor all patient medications for possible adverse reactions, significant side effects, drug allergies, and contraindicated medication.

Provisions for Groups with Special Needs

Staffing Requirements

Adult Day Care

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

Staffing ratios. Staffing ratios shall be one staff for each five participants. There shall be at least two responsible persons, one of whom shall be a paid staff member, at the center at times when there is more than one participant in attendance. At least one staff member who has completed first aid training shall be present at times that participants are in attendance. There shall be at least one staff member present who is currently certified in cardiopulmonary resuscitation (CPR) by the American Heart Association or the American Red Cross whenever clients are at the center.

Adult Day Health Care

Type of staff. An ADHC program shall have an administrator who shall be responsible for the operation of the facility and shall delegate such responsibility in his absence. An ADHC program shall employ or have access to a sufficient number of qualified personnel as may be required to provide the services required by this administrative regulation and indicated by the need of the program's patients. The ADHC may provide required therapy services through a contractual arrangement with a qualified therapist.

Staffing ratios. None identified.

Training Requirements

Adult day care. Staff training shall be provided by appropriate qualified professionals. Prior to assuming duties, paid and volunteer personnel shall receive orientation to the program and center including: (1) program objectives; (2) center policies and procedures; (3) health, sanitation, emergency and safety codes and procedures; (4) client confidentiality; and (5) personnel policies and procedures. Policies and procedures shall be explained verbally and provided in writing.

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

A minimum of 8 hours of annual training to review and update knowledge and skills shall be provided.

In addition to basic training, Alzheimer's respite personnel shall be provided training in: (1) dementia, (2) causes and manifestations of dementia, (3) managing the participant with dementia, (4) crisis intervention with combative participants, and (5) effects of dementia on the caregiver.

Adult day health care. An ADHC program shall conduct an orientation for new employees. The administrator shall attend educational programs appropriate to the responsibilities of the position and arrange for other professional personnel to attend appropriate educational programs on supervision and subjects related to personal care, activities, nutrition, and other pertinent subjects.

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

Relevant Medicaid Contracting Requirements for Adult Day Services Providers

Kentucky provides ADHC under the Home and Community-Based Waiver. Requirements are noted under Adult Day Health Care above.

Location of Licensing, Certification, or Other Requirements

1. http://lrc.ky.gov/kar/910/001/230.htm
2. http://www.lrc.state.ky.us/kar/910/001/160.htm
3. http://www.lrc.state.ky.us/KRS/205-00/950.PDF
4. http://lrc.ky.gov/KRS/205-00/955.PDF
5. http://www.khha.org/publicinfo/day_health_manual.pdf
6. http://lrc.ky.gov/kar/907/001/170.htm
7. http://www.lrc.state.ky.us/kar/902/020/066.htm
8. http://www.lrc.state.ky.us/krs/205-00/635.PDF
9. http://www.lrc.state.ky.us/KRS/216B00/0441.PDF
10. http://lrc.ky.gov/kar/907/001/160.htm
11. http://www.lrc.state.ky.us/kar/910/001/220.htm

Citations

1. Adult Day Care Center Certification. Kentucky Administrative Regulations 910 KAR 1:230. [7/8/99]
2. Adult day and Alzheimer's respite program. Kentucky Administrative Regulations 910 KAR 1:160. [7/8/99]
3. Certification of Adult Day Care Centers. Kentucky Revised Statutes 205.950. [7/14/00]
4. Unannounced Inspection of Adult Day Care Centers. Kentucky Revised Statutes 205.955. [7/14/92]
5. Adult Day Health Care Services Manual. Department for Medicaid Services. Transmittal #1. [March 2003]
6. Technical Amendment. Reimbursement for Home And Community-Based Waiver Services. Kentucky Administrative Regulations 907 KAR 1:170. [10/28/04].
7. Operation and Services; Adult Day Health Care Programs. Kentucky Administrative Regulations 902 KAR 20:066. [Undated]
8. Skilled Nursing Services Provided to Medicaid Recipients by Adult Day Health Care Programs. Kentucky Revised Statutes 205.635. [4/9/02]
9. Cabinet to License and Regulate Adult Day Care Health Programs. Kentucky Revised Statutes 216B.0441. [7/14/00]
10. Home and Community Based Waiver Services. Kentucky Administrative Regulations 907 KAR 1:160. [7/9/2004]
11. General Administration, Programs for the Elderly. Kentucky Administrative Regulations 910 KAR 1:220. [7/8/99]

Louisiana

Overview

Adult day health care (ADHC) in Louisiana is regulated by the Department of Health and Hospitals (DHH), Bureau of Community Supports and Services (BCSS) under Title 50 of the Louisiana Administrative Code. Providers are licensed to provide service to Medicaid adult day health care waiver clients, to private pay clients, and under private contracts with Health Administrations (e.g., the Veterans Administration).

Adult day care in Louisiana is regulated by minimum licensing standards as published in Title 48 of the Louisiana Administrative Code, administered by the Bureau of Licensing in the Department of Social Services. The regulatory responsibility for adult day care is scheduled to be transferred to the Department of Health and Hospitals (DHH) before the end of 2005.

Louisiana adult day care is a unique system with six distinct types of licensed services providing structured and productive settings for developmentally disabled clients at levels of independence related to their capacities. The system is funded by DHH under the New Opportunities Waiver. Because the focus of this regulatory review is on programs that serve older persons, only limited information about adult day care is included in this profile

Licensure and Certification Requirements

Definitions

Adult day care is a group program for persons with developmental disabilities designed to meet the individual needs of functionally impaired adults, which is structured and comprehensive and provides a variety of health, social, vocational, or related services in a protective setting for a portion of a 24-hour day. Several types of adult day care programs are licensed: Sheltered Workshop, Enclave Module, Mobile Work Crew Module, Psychosocial Module, and the Competitive Jobs Module.

Adult day health care programs are designed to meet the individual needs of the functionally impaired elderly and adults by providing a structured and comprehensive variety of health, social, and related support services in a protective setting for a portion of a 24-hour day. The ADHC Waiver covers a 5-hour stay.

An adult day care center is any place that is owned or operated for profit, or not for profit, by a person, society, agency, corporation, institution, or any other group and that serves for a portion of a 24-hour day, 10 or more functionally impaired adults who are not related to the owner or operator of the facility.

Parameters for Who Can Be Served

Few provisions other than the type of services provided indicate the parameters for who may be served in ADHC programs. Services that may be provided indicate that providers may serve individual with extensive activities of daily living (ADL) and nursing needs. Providers may not admit any client whose presence would pose a documented health and safety risk to themselves or other ADHC participants.

Inspection and Monitoring

The DHH/BCSS is required to conduct inspections for ADHC Licensing as required by the Department, and for ADHC Waiver continued stay by the Centers for Medicare & Medicaid Services (CMS). The Department also investigates any report of mistreatment of clients (abuse, neglect, and exploitation) and any person, agency, or organization suspected of operating an adult day care facility without a license or provisional license or of operating in violation of the Adult Day Health Care Licensing Minimum Standards, ADHC Waiver Standards for Participation.

Required and Optional Services

Provisions Regarding Medications

Medication administration and oversight must be provided by licensed nurses (registered nurse [RN] or licensed practical nurse [LPN]).

Provisions for Groups with Special Needs

Staffing Requirements

Type of staff. The following staff positions are required. Administration: director/director designee; Health Services Qualified Professionals: RN; Health Services Consultant or Full-time: LPN and direct care staff; Activities and Social Services: MSW consultant and social service designee; Nutrition: dietician consultant and food supervisor; and Operations: housekeeping and transportation.

Staffing ratios. The client to staff ratio shall be one staff per nine clients.

Training Requirements

Where certification or licensing standards exist for professional staff, these individuals shall possess current certifications/licenses and continuing education training.

ADHC providers will furnish orientation and annual training for all employees. Topics for training include but are not limited to ADHC goals, mission, organization, and structure; ADHC program and policy; instruction in the specific responsibilities of the employee's job/job description; the ADHC emergency policy, emergency disaster plan/evacuation plan, and safety procedures including medical emergencies; the detection and reporting of suspected abuse, neglect, and exploitation and the reporting of complaints and critical incidents.

All direct care employees shall have certification in adult cardiopulmonary resuscitation (CPR) and first aid upon hire, maintain documentation of certification and be recertified annually. Direct care staff shall receive additional annual training related to the care of the elderly and adults.

Professional staff will have certification of professional annual training and additional supervisory or management training as required by the ADHC provider.

Relevant Medicaid Contracting Requirements for Adult Day Services Providers

1. Adult day health services are provided under the state Medicaid 1915(c) Adult Day Health Care Waiver.
2. Adult day care services are provided under the state Medicaid 1915(c) New Opportunities Waiver.

Location of Licensing, Certification, or Other Requirements

1. http://www.dss.state.la.us/Documents/OS/AdultDayCare.pdf
2. On file at RTI International, provided by the Department of Health and Hospitals.

Citations

1. Adult Day Care and Day Health Services Standards for Licensing, Louisiana Administrative Code, Title 48--Chapter 43. [1/20/98]
2. Adult Day Health Care. Subpart 3 of Home and Community Based Services Waivers. Louisiana Administrative Code, Title 50--Chapter 21. [9/20/2004]

Maine

Overview

The Division of Licensing and Certification, Department of Health and Human Services (DHHS), promulgates regulations in accordance with Title 22, Maine Revised Statutes Annotated, governing the licensing and functioning of adult day services (ADS) programs. All providers are required to be licensed by the DHHS Community Services Programs and this profile contains information from these licensing requirements.

There are two types of ADS programs, adult day health services (ADHS) and social adult day services, which are different in scope and intensity of service delivery. There is also a night program, which provides ADS to persons with dementia between the hours of 5 PM and 7 AM. Providers may be licensed for more than one program, as long as record keeping is distinct.

Providers of ADS programs under the Medicaid State Plan and the Home and Community Benefits for the Elderly and for Adults with Disabilities Waiver must also be licensed, and there are some additional provisions for providers of Medicaid-funded ADS beyond the licensing requirements.

Licensure and Certification Requirements

Definitions

Adult day health services program means an ADS program licensed by the DHHS, Community Services Programs, Division of Licensing and Certification, which provides health monitoring and personal care services in addition to a group program of care, therapeutic activities, and supervision.

Adult day services program is a group program designed to meet the needs of adults who, through an assessment and service plan, are determined to need therapeutic activities and services of socialization, supervision, support services, assistance with activities of daily living (ADL), and/or health monitoring. The program is maintained or carried out on a regular basis by a person or persons in a private dwelling or other facility, for consideration, for any part of a day, for at least 2 hours a day, for more than two adults 19 years of age or older who are not blood relatives and are coming to the facility for up to 7 days a week for the express purpose of participating in this program.

Night programs are ADS programs staffed by awake staff and delivered between the hours of 5 PM and 7 AM to persons with dementia who are awake and participating in activities during some of those hours. A night program may be offered by either a social adult day services program or an adult day health services program, but it must have applied for and received a license to provide a night program. Requirements are the same as for programs offered between 7 AM and 5 PM. Programs may not provide 24-hour consecutive services to consumers.

Social adult day services program means an ADS program designed to meet the social and supervisory needs of participating adults.

Therapeutic activities means restorative activities designed to maintain or improve the quality of life or delay skill deterioration. Examples of therapeutic activities include gross motor activities, social activities, sensory enhancement activities, crafts, outdoor activities, spiritual activities, and ADL.

Parameters for Who Can Be Served

Adult day services and adult day health services. The definitions of ADS and ADHS above and the list of services provided under the waiver indicate the parameters for who can be served in these programs (i.e., individuals who need health monitoring, assistance with ADL, personal care services, rehabilitation, health promotion activities, and counseling). Providers may discharge participants if they endanger the safety and/or health of other consumers in the program.

Inspection and Monitoring

DHHS and any duly designated representative has the right to enter the premises of any licensed program at any time, to determine compliance with regulatory requirements. DHHS may talk with consumers in private.

Required and Optional Services

Provisions Regarding Medications

Providers may assist with medication if requested in writing by participants or their designated representative on a form approved by the DHHS. Unlicensed employees may administer medications only if they have completed, at a minimum, a DHHS-approved medication course within the previous 12 months or were employed in a health care setting during the previous 12 months where medication administration was part of the employee's responsibilities. Consumers may keep possession of medications for self-administration as long as it poses no danger to other consumers and the consumer is able to self-administer medications appropriately. Medications administered by staff must be stored in a locked cabinet.

Provisions for Groups with Special Needs

Staffing Requirements

Type of staff. The program administrator is responsible for the development, coordination, supervision, fiscal management, and evaluation of services provided at the ADS program. When the administrator is not on site for at least 50 percent of the hours of operation, the administrator shall appoint an individual to be responsible for site operation and management during those hours of operation. The program must employ the number of persons needed to carry out regulatory requirements with preference given to staff with a minimum of 1 year of training or experience in social or health care services.

Staffing ratios. ADS programs shall maintain a minimum staff-to-consumer ratio of one-to-six at all times when consumers are present. Programs with 3-6 consumers must maintain a second staff person to be on call and available for emergencies at all times that consumers are present. DHHS may require additional staff based on the needs of the consumers served. Volunteers may be included in the staff ratio only when they conform to the same standards and requirements as paid staff, meet the job qualification standards, and have designated responsibilities.

Training Requirements

There shall be an orientation program for all new employees and volunteers that includes a review of applicable program policies, consumer rights, emergency procedures and fire safety, job description, and related responsibilities, confidentiality, communication skills, needs of the population served, elder abuse reporting, standard precautions, and licensing regulations.

The program must provide annually at least 6 hours of education and training for part-time (<21 hours a week) staff and volunteers, and 12 hours for full-time staff and volunteers who meet the job qualification standards and have designated responsibilities. Required topics include consumer rights, emergency preparedness, body mechanics, choking prevention and intervention techniques, workplace safety, basic nutrition and food safety, first aid, and behavioral interventions and specific training for services related to consumers with cognitive impairments and those conditions which may be applicable to the consumer population served.

Relevant Medicaid Contracting Requirements for Adult Day Services Providers

The Home and Community Benefits for the Elderly and for Adults with Disabilities Waiver Program defines ADHS as health and social services provided to promote the optimal functioning of the MaineCare member. Services are delivered according to an individual plan of care at an adult day health site, which has in effect a current license pursuant to DHHS "Regulations Governing the Licensing and Functioning of Adult Day Services Programs," for 4 or more hours per day, on a regularly scheduled basis, up to 7 days a week.

Services. If a member's plan of care specifies that a particular covered personal care service is needed, such as a bath, it must be provided. Based on individual needs the ADHS may include monitoring of health care, supervision, assistance with ADL, nursing, personal care services, rehabilitation, health promotion activities, exercise groups, and counseling. There must also be a regular, ongoing schedule of group and individual activities planned with the participants and based on the assessment of an individual participant's needs and interests. Transportation services provided by individuals or private carriers (taxi) are covered only when it is documented that other personal, family, or community resources and public regional transportation agencies are unavailable and/or have been exhausted.

Staff. Services shall be provided by the following staff: registered nurse, practical nurse, master's social worker (a social worker must hold a master's degree from a school of social work accredited by the Council on Social Work Education), physical therapist, occupational therapist (registered), and speech-language pathologist. Other qualified staff members, other than professional staff detailed above, must have appropriate education, training, and experience as verified by the Health Care Coordination Agency (HCCA).

Monitoring. Providers of services must have a current provider contract in effect with the HCCA. The HCCA is responsible for verifying and maintaining documentation of all applicable licenses, certifications, or other required qualifications. In addition, the HCCA is responsible for documenting the activities it performs in order to monitor the service providers (i.e., review of provider progress notes).

ADHS provided under the Medicaid State Plan have the same or similar requirements as the waiver program.

Location of Licensing, Certification, or Other Requirements

1. ftp://ftp.maine.gov/pub/sos/cec/rcn/apa/10/144/ch101/c2s019.doc
2. ftp://ftp.maine.gov/pub/sos/cec/rcn/apa/10/144/ch101/c2s026.doc
3. ftp://ftp.maine.gov/pub/sos/cec/rcn/apa/10/144/144c117.doc

Citations

1. MainCare Benefits Manual (Chapter II, Section 19, Home and Community Benefits for the Elderly and For Adults with Disabilities), Department of Health and Human Services, Bureau of Medical Services. [Effective 2/20/86]
2. MainCare Benefits Manual (Chapter II, Section 26, Day Health Services), Department of Health and Human Services, Bureau of Medical Services. [Effective 6/15/90]
3. Regulations Governing the Licensing and Functioning of Adult Day Services Programs (10-144, Chapter 117), Department of Health and Human Services, Bureau of Medical Services, Division of Licensing and Certification. [Effective 2/1/98]

Additional Information

Participants in a day time program and/or a night program are limited to seven dates of participation in a 7-day period. At no time should an adult day services program provide 24-consecutive-hour services to a consumer.

Providers previously licensed to provide Certified Adult Day Care Programs shall automatically be converted to the ADHS Program. Providers previously licensed to offer Small Group Adult Day Care and Social Adult Day Care shall automatically be converted to the Social Adult Day Services Program unless an application for an ADHS Program is submitted to DHHS.

Maryland

Overview

Maryland licenses two types of adult day services--day care and medical day care--through the Office of Health Care Quality (OHCQ) in the Department of Health and Mental Hygiene. Day care services are offered and managed by the Department's Office of Health Services (OHS) through state-funded contracts, and are subject to the state's licensing requirements. Medical day care services are offered and managed by OHS under the Medicaid state plan. Licensed providers may also serve private pay participants.

In addition to meeting the same licensing requirements as day care service providers, medical day care providers must meet the general requirements for participation in the Medicaid program and the specific requirements for Medicaid's medical day care program. This profile describes both day care and medical day care licensing requirements.

The Maryland Department of Aging (MDoA) 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 MDoA certification requirements; to be reimbursed by Medicaid, they must also meet waiver standards. Providers already licensed for medical day care may also provide Senior Center Plus services. Certification requirements are found under Additional Information at the end of this profile.

Licensure and Certification Requirements

Definitions

Day Care

Day care center for adults means a place that is operated to provide, with or without charge, care for medically handicapped adults. Centers are designated as group day care for four or more medically handicapped adults or as a family home that provides day care for two or three medically handicapped adults.

Day care center for the elderly means a place that is operated to provide, with or without charge, care for elderly individuals. Centers are designated as group day care for at least four elderly individuals or as a family home that provides day care for two or three elderly individuals.

Elderly individual means an individual who is 55 years old or older; lives alone or with a spouse, family relative, or friend; needs temporary care and supervision during part of a day in a protective group setting; and has a disability that prevents gainful employment or the accomplishment of a routine of normal daily activities without assistance, or a permanent and recurrent mental impairment.

Medically handicapped adult means an individual who is 16 years of age or older; lives alone or with a spouse, relative, or friend; and has a disability that is a reasonably static physical impairment that prevents gainful employment or the accomplishment of a routine of normal daily activities outside of an institutional or sheltered environment or a permanent and recurrent mental impairment that requires domiciliary or institutional care in a sheltered environment.

Medical Day Care

Medical day care means a program of medically supervised, health-related services provided in an ambulatory setting to medically handicapped adults who, due to their degree of impairment, need health maintenance and restorative services supportive to their community living.

Medical day care center means a facility operated for the purpose of providing medical day care services in an ambulatory care setting to medically handicapped adults who do not require 24-hour inpatient care, but, due to their degree of impairment, are not capable of full-time independent living.

Participant means a health-impaired adult who is certified by the Department as requiring nursing facility services, but whose illness or disability does not require 24-hour inpatient care, unless medical day care services are not available; and whose disabilities and needs cannot be satisfactorily and totally met in an episodic ambulatory care setting, but require participation at least 1 day a week in a day-long rehabilitative or maintenance ambulatory care program that provides a mix of medical and social services.

Parameters for Who Can Be Served

The target populations are elderly and medically handicapped adults. Parameters for individuals who can be served are specified generally in the definitions of day care and medical day care (above). Providers may not serve individuals whose needs they cannot realistically meet.

Providers may not deny admission to or involuntarily discharge individuals solely because they have a communicable disease. However, providers that intend to serve such individuals shall notify the licensing authority before admission; the authority may prohibit the admission if it is determined that doing so could pose a risk to the health, safety, or welfare of any other individuals associated with the center.

Inspection and Monitoring

Upon application for a license, the Department's authorized representative shall inspect the proposed facility. A reinspection of the center shall be made for renewal of a license and periodic reinspection of a center may be conducted by the Department at any time.

Required and Optional Services

Provisions Regarding Medications

Providers must have written policies specifying the individual authorized to procure, receive, control, and manage the drug program. Participants who are independently responsible for taking their own medication at home shall be permitted, if authorized by the participant's physician, to continue to be responsible for taking their own medications during the hours spent in the center. If any participant requires supervision of medication, all federal, state and local laws, ordinances, standards, and codes shall be followed.

Medication may not be administered without a written order signed by the attending physician. Only licensed nurses may give injectable medications. For participants not capable of self-medicating, the individual assigned the responsibility of administering medications shall prepare the dosage, observe the participant swallowing the oral medication, and document that the participant has taken the medication. If a reaction to medications is observed, the participant's physician or the physician on call shall be called immediately.

Provisions for Groups with Special Needs

Staffing Requirements

Day Care

Type of staff. Required staff include a full-time director, who may work half time in each of two facilities if the employing organization operates more than one center; a half-time registered nurse; a full or half-time activities coordinator; and program assistants as needed to meet program goals and the staff to participant ratio. A full-time center director who is a registered nurse may also serve as the registered nurse. If a center is part of another facility, the center shall have its own full-time director and program staff.

At least one staff member who is trained in first aid and cardiopulmonary resuscitation (CPR) shall be present at all times at the center, during outings, or during transportation of participants.

Staffing ratio. The staff ratio shall be one staff to six participants exclusive of the director, volunteers, and consultants, and any staff member who does not provide direct care to participants may not be included in computing the staff ratio.

Medical Day Care

Type of staff. The medical day care center shall have adequate staff capability to monitor and appropriately serve the participants at all times. Medical services must be supervised by a staff physician. The composition of the staff depends in part on the needs of the participants and on the number of participants the program serves. When regular employment, full-time or part-time, is not justified by the needs of the participants, contractual employees may be used to meet the service and training needs of the center. As a minimum, the medical day care center shall have a full-timeregistered nurse (additional nursing services may be required due to the number or level of impairment of the participants), an activities coordinator (full-time or part-time), a medical social worker (full-time or part-time), and a staff physician (full-time, part-time, or contractual).

The provider shall designate a program director and a health director. The program director shall be full-time and have either a bachelor's degree or be a registered nurse. The health director shall be the registered nurse or the staff physician if the staff physician is required to be present at least half of the hours the medical day care center is open. For mandatory services that required staff cannot perform, such as physical therapy, occupational therapy, and nutrition, the medical day care center has the option of adding staff or establishing written agreements with licensed specialists.

At least one staff member trained in first aid and certified in CPR shall be on the premises at all times that participants are in attendance.

Staffing ratios. The medical day care center shall have adequate staff capability to monitor and appropriately serve the participants at all times with the same minimal staffing ratio as for day care programs.

Training Requirements

The program director shall ensure that staff and volunteers receive orientation and training and that an ongoing educational program is planned and conducted for the development and improvement of all personnel's skills, including training related to problems and needs of the elderly, health-impaired, and disabled.

The center shall provide a minimum of eight in-service training sessions annually, which shall include at least prevention and control of infections, fire prevention and emergency safety procedures, accident prevention, care of persons with Alzheimer's disease or other dementias, and recognition and reporting of abuse.

First aid training shall be taken from the American Red Cross or another source approved as comparable to the Red Cross. At a minimum, training shall be taken every 3 years. Recertification in CPR shall be obtained annually.

Relevant Medicaid Contracting Requirements for Adult Day Services Providers

Maryland provides medical day care under the Medicaid state plan. In addition to state licensing requirements, Medicaid providers must also meet the general requirements for participation in the Medicaid program and the specific requirements for the Medicaid medical day care program.

Provider means a licensed medical day care facility furnishing services through an appropriate agreement with the Department and identified as a program provider by the issuance of an individual account number.

Provider agreement means a contract between the Department of Health and Mental Hygiene and the provider of medical day care, specifying the services to be performed, the methods of operation, and financial and legal requirements that must be in force before program participation in medical day care.

Providers who are certified by the DMoA for the Senior Center Plus program may serve waiver clients, but do not need to be licensed as with day care and medical day care. Licensed medical day care providers may also provide Senior Center Plus services.

Location of Licensing, Certification, or Other Requirements

1. http://www.dsd.state.md.us/comar/subtitle_chapters/10_chapters.htm#subt…
2. http://www.dsd.state.md.us/comar/subtitle_chapters/10_chapters.htm#subt…
3. http://www.dsd.state.md.us/comar/10/10.09.54.00.htm
4. http://mlis.state.md.us/cgi-win/web_statutes.exe?ghg&14-201 and http://mlis.state.md.us/cgi-win/web_statutes.exe?ghg&14-301

Citations

1. Day Care for the Elderly and Medically Handicapped Adults. (Title 10 Department of Health and Mental Hygiene Regulations, Subtitle 12 Adult Health, Chapter 04). COMAR. [11/10/2004]
2. Medical Day Care Services. (Title 10 Department of Health and Mental Hygiene Regulations, Subtitle 09 Medical Care Programs, Chapter 07. [Most recent revision 11/24/2003]
3. Senior Center Plus. (Title 10 Department of Health and Mental Hygiene Regulations, Subtitle 09 Medical Care Programs, Chapter 54). [Most recent revision 06/21/2004]
4. Health-General Article, Title 14, Subtitles 2 and 3, Annotated Code of Maryland. [Effective date 1982]

Additional Information

Day Care

The state drafted revised regulations for Day Care for the Elderly and Medically Handicapped Adults in November 2004, but they are not yet scheduled for adoption. The purpose of the revision is to: (1) update licensure requirements to achieve quality of care and safe outcomes for adult day care services participants, (2) establish a license fee, and (3) reorganize the regulations for ease of reading and interpretation.

Senior Center Plus

Senior Center Plus services designed for elderly disabled individuals include a program of structured group recreational activities, supervised care, assistance with ADL and instrumental ADL, and enhanced socialization, provided for at least 4 hours a day, 1 or more days a week on a regularly scheduled basis in an out-of-home, outpatient setting. The program is designed to promote participants' optimal functioning and have a positive impact on their cognition. The center shall provide social and recreational activities and one nutritious meal, but not direct health care or transportation.

To participate in the program a provider must: (1) be approved and monitored by the Maryland Department of Aging as a nutrition service provider, (2) be issued a provider number by the program to be used only for billing Senior Center Plus services for participants, and (3) meet all local and state requirements to operate as a nutrition site.

There must be at least one staff person per eight clients, with additional staffing if required by the Maryland Department of Aging, depending on participants' functional levels. The provider must employ as the center's manager or in another staff position an individual who: (a) is a licensed health professional or licensed social worker; (b) has at least 3 years' experience in direct patient care at an adult day care center, nursing facility, or health-related facility; (c) is literate and able to communicate in English; and (d) participates in training specified and approved by the Maryland Department of Aging.

Massachusetts

Overview

Massachusetts provides adult day health services through its Medicaid state plan program, MassHealth. Provider services are governed by regulations published in the Adult Day Health Provider Manual under a contract between MassHealth and the provider.

Massachusetts also offers and regulates a Supportive Day Program through the Executive Office of Elder Affairs Program for Councils on Aging and Senior Centers. Providers must agree to the Supportive Day Program requirements as an attachment to their provider agreement to provide services under state funding.

The only requirements for adult day health services are those contained in the Adult Day Health Care Provider Manual for the MassHealth Program. These requirements are described in this profile.

Licensure and Certification Requirements

Definitions

Adult day health care. Adult day health services are all services provided at a MassHealth-approved adult day health program that meets the conditions of the Adult Day Health Provider Manual. The general goal of these services is to provide an organized program of services including nursing and supervision, therapy, nutrition, counseling, activities, case management. An adult day health program must operate at least Monday through Friday for 8 hours a day. There are two levels of care: adult day health basic and adult day health complex. Level of care is based on the member's care needs.

Supportive day programs (SDP) provide support services in a group setting to help participants recover and rehabilitate from an acute illness or injury or manage a chronic illness.

Parameters for Who Can Be Served

Adult day health care. The definition of adult day health care above indicates the parameters for who can be served in these programs. Providers may serve anyone aged 18 or older.

Providers may discharge an individual who develops behavioral problems that may endanger or seriously disrupt other members or staff, or requires increased services that the program is unable to provide, in which case the program must arrange for discharge to a more appropriate setting and may not discharge the member until appropriate services are available.

Supportive day programs. Providers may serve individuals who are in need of supervision, supportive services, socialization, and minimal assistance with activities of daily living (ADL). Participants may have multiple physical problems, but must be stable and not need nursing observation or intervention. Participants may have some cognitive impairment but behavior problems must be able to be handled with redirection and reassurance. Participants must be able to communicate personal needs.

Inspection and Monitoring

Adult day health care. A provider must agree to periodic inspections that assess the quality of member care and ensure compliance with the regulations.

Supportive day program. The Office of Elder Affairs Program for Councils on Aging and Senior Centers may inspect providers but has no regular schedule or requirement to do so.

Required and Optional Services

Provisions Regarding Medications

Adult day health care. Nursing services for all levels of care provided in adult day health care must include nursing services which administer medications and treatments prescribed by the member's physician during the time the member is at the program.

Supportive day program. Participants are responsible for administering their own medications.

Provisions for Groups with Special Needs

Staffing Requirements

Adult Day Health Care

Type of staff. The provider must employ a full-time program director. One professional staff person must be designated as an assistant program director and assume the responsibilities of program director as needed.

There must be a registered nurse on site each program day that members are on site, for a minimum of 4 hours. The center must provide nursing coverage on site for a minimum of 8 hours total, four of which may be provided by a licensed practical nurse. When the average daily census reaches 35 or more, the center must provide nursing coverage on site for a minimum of 12 hours, of which 4 must be provided by a registered nurse. When the average daily census reaches 50, the center must provide nursing service for 16 hours a day, 8 of which must be provided by a registered nurse.

The program must employ an activity director for a minimum of 4 scheduled hours each day.

If the program's average daily census is 24 or more members, the program must employ a social worker on site for a minimum of 20 scheduled hours each week. Licensed staff may perform the social service requirements when the program's average daily census is 23 or fewer members.

Licensed practical nurses, aides, and consulting therapists are to be hired as needed.

Staffing ratios. Programs must have available sufficient direct-care staff to meet the needs of their members: for basic level of care services, a minimum-staffing ratio of one direct care staff person to six members and for complex level of care services, one staff person to four members. Programs offering both levels of care must maintain proportionate direct-care staff ratios to meet the needs of members based on the ratio of members requiring each level of care.

For the programs specializing in serving members with dementia, the program must maintain a staff-to-member ratio of at least one-to-four on site.

Supportive Day Program

Type of staff. The organization shall provide an adequate number of staff whose qualifications are commensurate with defined job responsibilities to provide essential program functions.

The defined positions are administrator, program director, and activities coordinator. The program director may also be the administrator.

Staffing ratios. There shall be at least two responsible persons, one a paid staff member at the center at all times when there are two or more participants present. The staff-participant ratio must be at least one-to-eight.

Training Requirements

Adult day health care. Programs must provide staff training appropriate to the mix of services provided. Programs must provide a minimum of 8 hours of in-service training sessions per year.

For programs specializing in serving members with dementia, staff training must include dealing with dementia, verbal and nonverbal communication skills, behavior management skills, group process skills, family functioning, dealing with difficulty in group participation, dealing with high anxiety, dealing with aggressive behavior, and dealing with wandering.

Supportive day program. Staff will be trained in signs and indicators of potential abuse. Orientation, in-service training, and evaluations shall be provided to all employees and volunteers, including the use of standard protocols for communicable diseases and infection control.

Relevant Medicaid Contracting Requirements for Adult Day Services Providers

The only requirements for adult day health services are those contained in the Adult Day Health Care Provider Manual for the MassHealth Program. These requirements are described in this profile.

Location of Licensing, Certification, or Other Requirements

1. http://www.mass.gov/Eeohhs2/docs/masshealth/transletters_2002/adh-15.pdf
2. http://www.mass.gov/Eeohhs2/docs/masshealth/transletters_2002/adh-16.pdf
3. http://www.mass.gov/Eeohhs2/docs/masshealth/transletters_2003/adh-17.pdf
4. http://www.mass.gov/Eeohhs2/docs/masshealth/transletters_2003/adh-18.pdf
5. http://www.mass.gov/Eeohhs2/docs/masshealth/transletters_2004/adh-19.pdf
6. Provided by the Executive Office of Elder Affairs. On file at RTI.

Citations

1. MassHealth Transmittal Letter ADH 15. Adult Day Health Manual, Revised. Commonwealth of Massachusetts, Executive Office of Health and Human Services, Office of Medicaid. [October 2002]
2. MassHealth Transmittal Letter ADH 16. Adult Day Health Manual Revisions. Commonwealth of Massachusetts, Executive Office of Health and Human Services, Office of Medicaid. [December 2002]
3. MassHealth Transmittal Letter ADH 17. Adult Day Health Manual Revisions. Commonwealth of Massachusetts, Executive Office of Health and Human Services, Office of Medicaid. [April 2003]
4. MassHealth Transmittal Letter ADH 18. Adult Day Health Manual Revisions. Commonwealth of Massachusetts, Executive Office of Health and Human Services, Office of Medicaid. [11/01/03]
5. MassHealth Transmittal Letter ADH 19. Adult Day Health Manual Revisions. Commonwealth of Massachusetts, Executive Office of Health and Human Services, Office of Medicaid. [September 2004]
6. Supportive Day Program. Attachment A to provider agreement. Executive Office of Elder Affairs. [FY 2003]

Michigan

Overview

Adult day care centers that are funded by the Office of Services to the Aging (OSA) are not licensed. The OSA provides Operating Standards for Service Programs to be followed by providers of services to older persons in Michigan. Services may be provided only under an approved area plan through a formal contractual agreement between the area agency on aging and service provider agency.

The state identifies two types of adult day community services: adult day care and dementia adult day care. There are additional standards for dementia adult day care. Adult day health services are a Medicaid-funded service through the Program of All Inclusive Care for the Elderly (PACE) and the MI-Choice Home and Community-Based Waiver program. Medicaid providers under these two programs are required to follow the OSA standards included in their contracting requirements in addition to federal and state waiver program requirements.

Licensure and Certification Requirements

Definitions

Adult day care is daytime care for any part of a day but less than 24 hours, for functionally impaired elderly persons and is provided through a structured program of social and rehabilitative and/or maintenance services in a supportive group setting other than the client's home.

Dementia adult day care is daytime care for any part of the day but less than 24 hours, for older persons with dementia, and is provided through a structured program of social and rehabilitative and/or maintenance services in a supportive or group setting other than the client's home.

Parameters for Who Can Be Served

The programs that fund adult day care services have eligibility criteria for these programs that indicate the parameters for who can be served. Participants must be 60 years of age and older unless otherwise allowed under eligibility criteria for a specific program.

Adult day care. Providers may serve participants who:

• Require regular supervision in order to live in their own homes or the home of a relative.
• Require assistance with activities of daily living (ADL).
• Are capable of leaving their residence, with assistance, to receive service.
• Need intervention in the form of enrichment and opportunities for social activities in order to prevent and/or postpone deterioration that would likely lead to institutionalization.

Dementia adult day care. Providers may serve individuals who:

• Have a diagnosis of Alzheimer's disease or other type of dementia.
• Have significant impairments in cognition, communication, and personal care ADL.
• Are responsive to redirection and other supportive verbal interventions when angry, anxious, lost, or upset.

Providers may not serve individuals who have an acute medical illness, a communicable respiratory disease, or hepatitis.

Inspection and Monitoring

Programs that receive federal and state funding through OSA are monitored at least one time per year by the area agencies on aging to assure compliance with OSA's minimum operating standards. PACE and MI-Choice Home and Community-Based Waiver programs are monitored per federal and state requirements.

Required and Optional Services

Provisions Regarding Medications

Pharmaceutical services may be provided under order from a physician by licensed professionals. Participants can be assisted in taking either prescriptions or nonprescription medications.

Provisions for Groups with Special Needs

Staffing Requirements

Adult Day Care

Type of staff. Each adult day care program shall employ a full-time program director with a minimum of a bachelor's degree in a health or human services field or be a qualified health professional. Health support services may be provided only under the supervision of a registered nurse.

Staffing ratios. The program shall continually provide support staff at a ratio of no less than one staff person for each ten participants.

Dementia Adult Day Care

Type of staff. Each dementia respite program shall have a coordinator who possesses both formal education and prior work experience commensurate with the responsibilities of program development and operation; supervision and training of staff; interagency relations; and coordination and maintenance of all appropriate administrative, program and client records. All program personnel shall be knowledgeable about Alzheimer's disease and other dementias and demonstrate the ability to communicate effectively with people who have dementia. The program shall arrange to useprogram consultants such as medical and mental health professionals, environmental specialists, and other therapists as necessary.

Staffing ratios. Dementia adult day care programs shall have a minimum staff/volunteer/student-to-participant ratio of one-to-three. At least one staff shall be on site at all times when participants are in attendance.

Training Requirements

General. Service program staff are to participate in relevant OSA or area agency-sponsored or -approved in-service training workshops, as appropriate and feasible. New program staff must receive an orientation training which includes, at a minimum, introduction to the program, the aging network maintenance of records and files (as appropriate), the aging process, ethics, and emergency procedures.

Adult day care. Program staff shall be provided with an orientation training that includes at a minimum introduction to the program, assessment/observation skills, maintaining records and files, basic first-aid, aging process, and emergency procedures. At least twice each year program staff shall be provided in-service training specifically designed to increase their knowledge and understanding of the program and clients and to improve their skills at tasks performed in the provision of service.

Dementia adult day care. All programs shall have a formal staff development program. Dementia adult day care program staff shall be trained in crisis procedures. Inexperienced personnel shall complete dementia care training prior to being scheduled to work with clients. All staff shall complete an initial training program that includes content in areas including normal aging vs. Alzheimer's disease and related conditions, impact of Alzheimer's disease and other dementias on the person with dementia and family caregivers, and communication enhancement techniques. All personnel shall attend, at a minimum, two in-service training programs per year after completing the initial training program above. All programs shall have specific training for volunteers and students in the areas including communication enhancement techniques, assessment, and management of difficult behaviors, and physical care techniques related to ADL.

Relevant Medicaid Contracting Requirements for Adult Day Services Providers

As stated in the overview, adult day and dementia adult day services (called "adult day health services" in Medicaid contracting language) are Medicaid-funded services through PACE and the MI-Choice Home and Community Based Waiver program. Medicaid providers under these two programs are required to follow the OSA standards included in the contracting requirements in addition to federal and state waiver program requirements. PACE contracting requirements addressing staffing ratios and emergency situations are taken from OSA standards.

The MI-Choice waiver contractual requirements for adult day health services adopt many elements from the OSA standards (e.g., admission criteria). Under the waiver, adult day health services are furnished 4 or more hours per day on a regularly scheduled basis, for 1 or more days per week, in an outpatient setting, encompassing both health and social services needed to ensure the optimal functioning of the individual.

Location of Licensing, Certification, or Other Requirements

1. http://www.miseniors.net/NR/rdonlyres/1B67EFED-7DC7-4EFE-99AE-E7E43B8618D2/214/standards2004.pdf

Citations

1. Operating Standards for Service Programs (General Requirements for all Service Programs (II-K), Community Services-Adult Day Care (III-C C-1), and Community Services-Dementia Adult Day Care (III-C C-2). Michigan Office of Services to the Aging. April 1999.
2. Operating Standards for the MI Choice Waiver Program (Section III). Michigan Department of Community Health. Last Revised 08/25/2004. [Hard copy only]
3. Operating Standards for PACE Program (Section D.1.). Michigan Department of Community Health. [Hard copy only]

Additional Information

Specific program requirements for dementia adult day care. The program shall demonstrate evidence of:

1. outreach services to nonenrolled families through home visits, follow-up phone calls, and dissemination of printed materials that clearly describe services provided by the program;
2. provision of opportunities for caregivers to discuss concerns, feelings, physical care and stress management techniques via case consultation, care conferences, or supportive counseling; and
3. provision of caregiver information and education about dementia or assistance for caregivers in obtaining it through referral to local self-help organizations or dementia resource libraries.

The program shall also have clear provisions for ensuring the availability of crisis response services for persons with dementia and their families.

Minnesota

Overview

Minnesota Rules, Rule 223 and Minnesota Statutes, Chapter 245A establish procedures and standards for the licensure of adult day care centers or adult day services centers and family adult day services providers that regularly provide care for functionally impaired adults.

Licensure and Certification Requirements

Definitions

Adult day care, adult day services, and family adult day services mean a program operating less than 24 hours per day that provides functionally impaired adults with an individualized and coordinated set of services--including health services, social services, and nutritional services--that are directed at maintaining or improving the participants' capabilities for self-care.

Adult day care center, adult day services center, or center means a facility that provides adult day care or adult day services on a regular basis for periods of less than 24 hours a day in a setting other than a participant's home or the residence of the facility operator. An identifiable unit in a nursing home, hospital, or boarding care home licensed by the commissioner of health that regularly provides day care for six or more functionally impaired adults at any given time who are not residents or patients of the nursing home, hospital, or boarding care home must be licensed as an adult day care center or adult day services center.

Family adult day services are provided in the license holder's primary residence, and the license holder is the primary provider of care. A licensed adult foster care provider may be licensed to provide family adult day services in addition to providing adult foster care.

Parameters for Who Can Be Served

Adult day care/services. Adult day services are provided to functionally impaired adults. A center shall have available for review, and shall distribute to participants and their caregivers upon admission, a description of individual conditions that the center is not prepared to accept (e.g., communicable disease requiring isolation, a history of violence to self or others, unmanageable incontinence, or uncontrollable wandering).

Family adult day services. Family adult day services are provided to functionally impaired adults over the age of 55, none of whom may have serious or persistent mental illness, or have mental retardation or a related condition. Before admitting an individual into any adult day services program, the license holder shall screen the individual to determine how or whether the license holder can serve the individual, based on the license holder's policies, services, expertise, and the individual's needs and condition.

Inspection and Monitoring

Unless otherwise specified in statute, the commissioner may conduct routine inspections biennially. Where appropriate and feasible the commissioner shall identify and implement alternative methods of regulation and enforcement, including the use of an abbreviated inspection that employs key standards that have been shown to predict full compliance with the rules. Where administratively feasible and appropriate, the commissioner shall work with the commissioners of health, public safety, administration, and education in conducting joint agency inspections of programs.

Required and Optional Services

Provisions Regarding Medications

Medication assistance means assisting participants to take medication and monitoring the effects of medication but does not include administering injections.

For adult day care or adult day services centers, the relevant rule states that "An employee, other than a physician, registered pharmacist, registered nurse, or licensed practical nurse, who is responsible for medication assistance shall provide a certificate verifying successful completion of a trained medication aid program for unlicensed personnel approved by the Minnesota Department of Health or shall be trained by a registered nurse to provide medication assistance in accordance with Part 9555.9710, Subpart 3."

For family adult day services, the relevant statute states that "Unless the person is a licensed health care practitioner qualified to administer medications, the person responsible for medication administration or assistance shall provide a certificate verifying successful completion of a trained medication aid program for unlicensed personnel approved by the Department of Health or comparable program, or biennially provide evidence of competency as demonstrated to a registered nurse of physician."

Provisions for Groups with Special Needs

Staffing Requirements

Adult Day Care/Services

Type of staff. In the temporary absence of the center director, a staff member shall be designated to supervise the center. A person trained in basic first aid and certified in cardiopulmonary resuscitation and the treatment of obstructed airways must be present at all times.

Adult day care/services centers shall offer health services developed in consultation with a registered nurse, who shall review the health services at least monthly. Health services must include developing policies and monitoring procedures for participant self-administration of medications, for training unlicensed personnel who provide medication assistance, and for supervising staff distribution of medication and assistance with participant self-administration of medication.

Staffing ratios. 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, the center shall maintain a staff to participant ratio of one staff member present for every five participants present who are not capable of self-preservation and one staff member present for every eight participants present who are capable of self-preservation.

Only those employees whose primary center duties, as defined in their job descriptions, are to work directly with participants by providing care, supervision, and assistance in achieving plan of care objectives shall be counted as staff members in calculating the staff to participant ratio. A volunteer may be counted as a staff member in calculating the staff to participant ratio if the volunteer meets the same standards and requirements as paid staff. When only one staff member is needed to meet the staff ratio requirement a volunteer or other adult who is not a participant shall be present when six or more participants are in attendance.

Family Adult Day Services

Type of staff. Family adult day services providers shall provide health services as specified in the service plan under the direction of the designated caregiver or county or private case manager. Whenever participants are in the home, there must be present at least one individual who is trained in basic first aid and certified in cardiopulmonary resuscitation and the treatment of obstructed airways.

Staffing ratios. In family adult day services homes, whenever there are 6-8 participants present there must be a second staff person present.

Training Requirements

Adult day care/services. Adult day care/services centers shall provide all center employees with 20 hours of orientation to the center within the employee's first 40 hours of employment at the center. At least 4 hours of supervised orientation must be provided before employees work directly with center participants. The orientation must include training related to the kinds of functional impairments of current center participants and safety requirements and procedures. A center shall provide a minimum of 8 hours of in-service training annually in areas related to the care of center participants, including provision of medication assistance.

Adult day care facilities that serve persons with Alzheimer's disease or related disorders shall ensure that the facility's direct care staff and their supervisors are trained in dementia care. Areas of required training include: (1) an explanation of Alzheimer's disease and other dementias, (2) assistance with ADL, (3) problem solving with challenging behaviors, and (4) communication skills. The facility shall provide to consumers in written or electronic form a description of the training program, the categories of employees trained, the frequency of training, and the basic topics covered.

Family adult day services. License holders and staff providing family day care services must annually complete 12 hours of training related to the health, nutritional, and social needs of the license holder's target population. License holders with 6 or more years of licensure under this section or as an adult foster care provider must annually complete 6 hours of training. The annual training must include training on the reporting of maltreatment of vulnerable adults, license holder requirements governing maltreatment of vulnerable adults, and, when a license holder serves participants who rely on medical monitoring equipment to sustain life or monitor a medical condition, training on medical equipment as required under Minnesota Statutes Section 245A.155 for foster care providers.

Relevant Medicaid Contracting Requirements for Adult Day Services Providers

The Elderly Waiver program defines adult day care as a service available to persons who are 18 years of age or older that encompasses both health and social services needed to ensure optimal functioning. Services may be furnished 2 or more hours per day, 1 or more days per week, on a regularly scheduled basis. If necessary, an adult day care provider may provide a bath for clients.

Providers of adult day care center services must meet the licensure requirements of Minnesota Rules, Parts 9555.9600 to 9555.9730. Family adult day services providers must meet the licensure requirements of Minnesota Statutes, Section 245A.143.

Location of Licensing, Certification, or Other Requirements

1. http://www.revisor.leg.state.mn.us/stats/245A
2. http://www.revisor.leg.state.mn.us/arule/9555/
3. http://www.dhs.state.mn.us/main/groups/business_partners/documents/pub/…

Citations

1. Minnesota Statutes, 2004, (Chapter 245A.01 to .17). Human Services Licensing Act. [Effective 2004]
2. Minnesota Rules, Rule 223, (Chapter 9555--Parts 9555.9600 to 9555.9730). Department Of Human Services, Social Services For Adults. [Current as of 01/20/05]
3. Minnesota Health Care Programs (MHCP) Provider Manual (Chapter 26: Home and Community-Based Services (HCBS) Waivers and the Alternative Care (AC) Program). [Updated 03/04/05]

Mississippi

Overview

The Mississippi Department of Human Services, Division of Aging and Adult Services, administers and monitors adult day care centers that wish to enter into an agreement to provide services through the Area Agencies on Aging under Older Americans Act funding under a set of Quality Assurance Standards described in this profile.

The Division of Medicaid provides adult day center services under the Elderly and Disabled Waiver through providers who comply with Division of Medicaid regulations published in the Home and Community Based Services Manual and the Quality Assurance Standards for the waiver.

As of June 2005, the Mississippi legislature is considering certification or licensure requirements.

Licensure and Certification Requirements

Definitions

Adult day care is a place for aged and disabled individuals with serious health problems or impairments to go during the day for recreational activities, personal care supervision, nutrition, limited health care, and the opportunity to interact socially with other people in group or individual activities. Its purpose is to: (1) provide care, supervision, and services to individuals who are capable of only limited self-care; (2) meet health maintenance, prevention/intervention, and rehabilitation needs; and (3) promote a maximum level of independent functioning.

Parameters for Who Can Be Served

The definition of adult day care (above) indicates the parameters for who can be served.

Inspection and Monitoring

Adult day care center providers are monitored on site quarterly by Area Agencies on Aging. The Bureau of Audit and Evaluation, Department of Human Services, monitors the providers annually and usually does not visit the site, although the agency may conduct an on-site evaluation.

Required and Optional Services

Provisions Regarding Medications

Registered nurse services for preparing and administering medications shall be provided if needed by the participants.

Provisions for Groups with Special Needs

Staffing Requirements

Type of staff. There must be a person designated to be responsible for the day-to-day operation of the center. Qualifications are established for the program director, social worker, nurse, activities coordinator, program assistant/aide, secretary/bookkeeper, driver, and custodian. Volunteers are permitted to supplement staff in established activities or provide additional services for which the volunteer is qualified.

Staffing ratios. There must be an adequate number of staff to accomplish the purpose of the program.

Training Requirements

All staff must complete first aid, cardiopulmonary resuscitation (CPR), and Heimlich Technique training. A minimum of 8 hours per year in-service training shall be provided, preferably quarterly, appropriate to job function and participant care needs.

All center staff providing direct care and participating in the day-to-day operation of the center must complete the Division's Adult Day Care Certification training within 12 months of hire date.

Relevant Medicaid Contracting Requirements for Adult Day Services Providers

Mississippi provides adult day center services under the Elderly and Disabled Waiver administered by the Division of Medicaid.

Definitions. Adult day care services are defined as services for an aged and disabled individual, and consist of the provision of services for part of a day at a day care program site. Adult day care is the arrangement of a structured, comprehensive program that provides a variety of health, social, and related supportive services in a protected setting during daytime and early evening hours.

Admission criteria. Each adult day center shall define the target population it intends to serve and shall serve only participants whose needs while at the center do not exceed the center's resources or who would be served more appropriately in a different setting. The target population includes one or more of the following groups: adults with physical, psychosocial, or mental impairments who require assistance and supervision, adults who need functional maintenance therapy in order to restore or maintain an optimum level of functioning, and adults who require services by or under the supervision of an appropriately licensed nurse or other health care professional. Participants who are inappropriate for all adult day service programs include adults who are bedfast or do not have the strength or stamina to attend adult day services for the minimum hours defined in state licensing requirements; adults in an infectious stage of a communicable disease, unless a physician states there is no significant hazard; adults with emotional or behavioral disorders destructive to self or others or disruptive in a group setting, unless the center has the capacity to manage these problems; and adults who are too independent to benefit from the program.

Inspections. Commission on Accreditation of Rehabilitation Facilities accreditation is accepted in lieu of inspection.

Required services. ADL assistance, health monitoring/health related services, medication management, social services, transportation, health education, professional therapy services.

Optional services. Nursing and skilled nursing services.

Medications. Adult day services without full-time registered nurse (RN) services will maintain medication information and provide reminders or prompt the participant to initiate and follow through with self administration of medications brought by the client. If a client is unable to self medicate, an RN will be available to assist as indicated.

Staffing type. A sufficient number of staff with the skills needed to provide essential administrative and service functions is required. The center will have an administrator, and if the administrator is responsible for more than one site or has duties not related to the day services program, aprogram director should be designated to be on site. There shall be a social service staff person, activities coordinator, food service coordinator, driver, and program assistants. For programs offering nursing services, the nurse shall be an RN.

Staffing ratios. There shall be at least two responsible persons, one a paid staff member, at the center at all times when there are two or more participants in attendance. The staff-to-participant ratio shall be between one-to-six and one-to-ten, except in programs serving a high percentage of severely impaired participants in which case the ratio should be one-to-four, or, in programs serving more than 20 participants, one-to-five. Volunteers can be included in this ratio only if they conform to the same standards as paid staff.

Training. All staff and volunteers who have contact with and responsibility for special populations should receive specific training in serving that population.

All paid and volunteer staff should receive general orientation including but not limited to the purpose and goals of adult day services, roles and responsibilities of other staff members, needs of the target population, depression, medication management, the center's policies and regulations, communication skills, basic terminology, advance directive policies, elder abuse reporting, safely and appropriately assisting participants with ADLs, and risk management.

Ongoing training includes at least four in-service training sessions per year. At the time of employment and annually each employee must receive training in the needs of the participants in the center target population; infection control; the fire, safety, and disaster plan; choking prevention and intervention techniques; body mechanics, transfer techniques, and ADL assistance; mandatory reporting laws for abuse/neglect; basics of nutritional care, food safety, and safe feeding techniques; CPR and first aid; behavioral intervention/acceptance/accommodation; and additional topics as available.

Location of Licensing, Certification, or Other Requirements

1. http://www.dom.state.ms.us/Provider/Provider_Manuals/hcbs.pdf
2. On file at RTI, provided via fax by the Division of Aging and Adult Services.
3. On file at RTI, provides by the Division of Medicaid.

Citations

1. Mississippi Home and Community Based Services Manual. Office of the Governor, Division of Medicaid. [1996]
2. Quality Assurance Standards. Adult Day Care. Mississippi Department of Human Services, Division of Aging and Adult Services. [Revised 8/99]
3. Adult Day Care Quality Assurance Standards. Home and Community-Based Services Elderly and Disabled Waiver. [7/1/2002]

Missouri

Overview

Missouri regulates adult day care by licensure through the Department of Health and Senior Services. Adult day health care is provided through the Medicaid Aged and Disabled Waiver with additional provider requirements.

Licensure and Certification Requirements

Definitions

An adult day care program is a group program designed to provide care and supervision to meet the needs of five or more functionally impaired adults for periods of less than 24 hours but more than 2 hours per day in a place other than the adult's own home.

Parameters for Who Can Be Served

Providers may serve functionally impaired adult age 18 or older who, by reason of age or infirmity, require care and supervision. No provider shall knowingly admit participants whose needs cannot be met by the program. No parameters for retaining or discharging participants were identified.

Inspection and Monitoring

The Director of the Department of Social Services or his authorized representative shall have the right to enter the premises of an applicant for or holder of a license at any time during the hours of operation of a center to determine compliance with the provisions of the license. Entry shall also be granted for investigative purposes involving complaints regarding the operations of a program. The division of aging shall make at least two inspections per year, at least one of which shall be unannounced to the operator or provider. The division may make other inspections, announced or unannounced, as it deems necessary.

Required and Optional Services

Provisions Regarding Medications

Participants who are responsible for taking their own medication at home shall be permitted and encouraged to continue to be responsible for taking their own medication during the hours spent in the center. If a participant is unable to self-administer medication, then the adult day care provider may assume responsibility. The licensed nurse shall be the only individual authorized to receive, control, and manage the medication and drug program. The licensed nurse shall be responsible for the administration of medications and treatments.

Provisions for Groups with Special Needs

Staffing Requirements

Type of staff. The adult day care program shall have a director. Direct care paid staff shall be at least 18 years old and they and any volunteer staff shall be qualified by education and experience to perform the duties in the written job description.

Staffing ratios. The adult day care provider shall provide a sufficient number of direct care staff on duty at all times to meet the needs of each participant and assure that participants are never left unattended. At a minimum, there shall be at least two direct care staff persons when 2-16 participants are present and one additional direct care staff person for any portion of eight additional participants present.

The director shall not be counted to meet the required staff ratio if there are nine or more participants present unless he or she is providing direct care to participants. Trained volunteers at least 18 years of age may be counted in the direct care staff-to-participant ratio provided a volunteer program description, including the volunteer training to be provided and the system for assuring the presence of volunteer help as scheduled, has been submitted to and approved by the Division of Aging. Secretaries, cooks, accountants and other non-direct care staff members shall not be considered in calculating the staffing ratio. Direct care staff shall not be counted simultaneously to meet the required staffing ratios for both the long-term care or medical care facility and the associated adult day care program.

Training Requirements

All staff, including non-direct care, direct care, and volunteers, shall be given a general orientation to the program, its policies, and its fire, safety, and emergency procedures prior to performing job responsibilities.

In-service training shall be provided at least quarterly to staff, as appropriate to their job function and participant care needs. At a minimum, in-service training shall address participant care needs, both general and individualized; participants' rights; program policies; and specialized care needs, such as Alzheimer's disease or related dementias, appropriate to the needs of participants. For employees providing care to persons with Alzheimer's disease or related dementia, the training shall include the following: an overview of Alzheimer's disease or related dementia, communicating with persons with dementia, behavior management, promoting independence in ADL, and understanding and dealing with family issues.

Relevant Medicaid Contracting Requirements for Adult Day Services Providers

Missouri provides adult day health care through its Aged and Disabled Waiver.

Adult day health care is a program of organized therapeutic, rehabilitative, and social activities provided outside the home for periods of time under 24 hours per date of service. The adult day care program is designed to provide care for part of the day to persons who are physically, mentally, socially, or emotionally impaired and who need daytime supervision and services to maintain or improve their level of functioning. It is a program of organized therapeutic, rehabilitative, and social activities provided outside the home for a period of less than 24 hours to persons with functional impairments requiring at least an ICF level of care.

Admission criteria. The recipient must be assessed to have certain impairments and unmet needs which would require admission to a hospital or a long-term care facility if adult day care services were not provided. The program shall develop its own written admission criteria specific enough that the program does not accept persons whose needs it cannot reasonably expect to meet.

Persons who reside in a long-term residential or intermediate care facility licensed by the Division of Senior Services and Regulation or any group home or residential type facility licensed by the Department of Mental health are not eligible for the Medicaid adult day health care program.

Staffing requirements. At least one staff member trained in first aid and cardiopulmonary resuscitation (CPR) shall be on the premises at all times.

A registered nurse (RN) or licensed practical nurse (LPN) must be available at all times during the program's daily operating hours. The RN or LPN must be available by being a staff member of the adult day health care program or located in the same building provided that a formalized agreement is executed that outlines the responsibilities of the RN or LPN to the adult day health care program. Part of each day must be committed by the RN or LPN to the adult day health care program.

There shall be one full-time person in charge of the adult day health care program who is responsible for day-to-day operations, either a director or the director's designee. If an adult day health care program is associated with another facility, it shall have its own full-time director and designated full and/or part-time direct care staff. If a facility has an associated adult day health care program with a daily participant census under five, the adult day health care director may also be responsible for other sections of the facility.

Staffing ratios. Direct care staff-to-recipient ratio shall be no less than one-to-eight. Direct care staff shall be sufficiently qualified and in sufficient number to meet the needs of the adult day health care program recipients. Trained volunteers may be counted in the staff ratio provided a volunteer program description is submitted and approved by the department specifying the formal training and regular work scheduling of such volunteers. Secretaries, cooks, accountants, and other non-direct care staff members must not be considered in calculating this one-to-eight ratio. It is required that in any case there should always be at least one person besides the director or the director's designee on the premises so that recipients are never left unattended. A long-term care facility is not to use the adult day health care direct care staff to meet the required staff ratio for the licensing of its long-term care facility and vice versa.

Training. All personnel, paid and volunteer, shall be given a general orientation to the facility, its normal routine, fire and safety measures, and policies and regulations.

Location of Licensing, Certification, or Other Requirements

1. http://www.sos.mo.gov/adrules/csr/current/19csr/19c30-90.pdf
2. http://www.medicaid.state.mo.us/lpBin22/lpext.dll?f=templates&fn=main-j…
3. http://www.moga.mo.gov/STATUTES/C660.HTM

Citations

1. Adult Day Care Program Licensure, Missouri Code of State Regulations. Rules of Department of Health and Senior Services, Division 30, Division of Health Standards and Licensure Chapter 90. [11/30/01]
2. Missouri Medicaid Adult Day Health Care Provider Manual. Missouri Department of Social Services. [Undated]
3. Missouri Revised Statutes, Chapter 660, Sections 400-420, Department of Social Services. [August 28, 2004]

Montana

Overview

Montana statues require adult day care licensure through the Department of Health and Human Services. Regulations for licensing are described in this profile.

The Department of Health and Human Services provides adult day care under the Physically Disabled and Elderly Waiver and the Developmentally Disabled Waiver through licensed providers.

Licensure and Certification Requirements

Definitions

Adult day care center means a facility, freestanding or connected to another health care facility, that provides adults, on a regularly scheduled basis, with the care necessary to meet the needs of daily living but that does not provide overnight care.

Parameters for Who Can Be Served

Providers may serve frail, impaired elderly or other disabled adults. No other provisions identified.

Inspection and Monitoring

After receipt of an application for a new license, the department shall conduct an initial inspection within 45 days. After receipt of an application for renewal of a license, the department shall inspect the facility without prior notice to the operator or staff.

Routine licensure surveys are conducted every 1-3 years and are unannounced. Duration of the license is dependant on the number and type of deficiencies found during inspection, and if any deficiencies relate to the health, safety, and welfare of a resident, a provisional license or a 1-year license will be issued.

In addition to its annual licensure inspections, the department may inspect any facility for compliance without prior notice to the owner or staff of the facility.

Required and Optional Services

Provisions Regarding Medications

If a client is required to take medication while at the center, the client must be capable of taking his or her own medications, with the following assistance from staff: (1) reminding the client to take the medication at the proper time, (2) removing medication containers from storage, (3) assisting with removal of a cap, (4) guiding the hand of the client, and (5) observing the client take the medication.

Provisions for Groups with Special Needs

Staffing Requirements

Type of staff. Each adult day care center must employ a manager. The center must at all times employ sufficient staff to provide the services required by the number and characteristics of its clients.

Under the Administrative Code for Developmental Disability, an adult day service provider must employ staff experienced in providing services to persons with developmental disabilities, particularly to persons of advanced age.

Staffing ratios. At least one employee must be present in the center at all times in which a client is present at the center.

Training Requirements

Orientation must include: (1) an overview of the center's policies and procedures manual and a presentation regarding how the policies and procedures are to be used and implemented; (2) a review of the employee's job description; (3) a review of services provided by the facility; (4) simulated fire prevention, evacuation, and disaster drills; (5) basic techniques of identifying and correcting potential safety hazards in the facility; and (6) emergency procedures, such as basic first aid.

Under the Administrative code for Developmental Disability, a provider must provide in-service training in first aid, cardiopulmonary resuscitation (CPR), behavior management, and "other identified needs."

Relevant Medicaid Contracting Requirements for Adult Day Services Providers

None identified.

Location of Licensing, Certification, or Other Requirements

1. http://data.opi.state.mt.us/bills/mca_toc/50_5_1.htm
2. http://data.opi.state.mt.us/bills/mca_toc/50_5_2.htm
3. http://arm.sos.state.mt.us/37/37-7421.htm
4. http://www.dphhs.mt.gov/programsservices/adultdaycarecenter/adultdaycar…
5. http://www.dphhs.mt.gov/programsservices/adultdaycarecenter/statutesrul…

Citations

1. General Provisions, Hospitals and Related Facilities, Health and Safety. Montana Code Annotated. TITLE 50, Chapter 5, Part 1. [2003]
2. Licensing, Hospitals and Related Facilities, Health and Safety. Montana Code Annotated. TITLE 50, Chapter 5, Part 2. [2003]
3. Developmental Disabilities Program. Administrative Rules of Montana 37.34.938. [6/30/95]
4. Adult Day Care Center Packet. Department of Public Health and Human Services. [Undated]
5. Adult Day Care Center. Administrative Rules of Montana 37.106, Subchapter 2600. [11/26/04]

Additional Information

Some adult day care centers are located in nursing homes. In this case, the nursing home monitors the center in cooperation with the Department.

Nebraska

Overview

The Nebraska Department of Health and Human Services (DHHS) Regulation and Licensure provides regulations to govern licensure of adult day services in the Nebraska Administrative Code (NAC). The regulations are authorized by and implement the Health Care Facility Licensure Act,Nebraska Revised Statutes. This profile contains both statutory and regulatory language.

If a licensed health care facility provides adult day services (ADS) exclusively to individuals residing in that healthcare facility, it does not have to have an ADS license. In lieu of licensure, DHHS may accept accreditation or certification by a recognized independent accreditation body or public agency with standards that are at least as stringent as those of the State of Nebraska, as evidence that the health care facility or health care service complies with the rules, regulations, and standards adopted and promulgated under the Health Care Facility Licensure Act.

The Department of Social Services (DSS) has separate requirements for providers of center or in-home adult day services. Adult day services home and center staff shall contact the Nebraska DHHS if the ADS program is to be provided in a facility licensed by that Department or if the program intends to provide medical services. (See additional information at end of profile for specific requirements.)

Adult day health care (ADHC) services are provided under the Aged Persons waiver and the Adults and Children with Disabilities waiver. Waiver providers must meet Medicaid ADHC contracting requirements. ADHC providers that serve fewer than four persons do not require licensure, but provider agreements with the DHHS are required.

Licensure and Certification Requirements

Definitions

Adult day service means a person or any legal entity that provides care and an array of social, medical, or other support services for a period of less than 24 consecutive hours in a community-based program to four or more persons who require or request such services due to age or functional impairment.

Care means the exercise of concern or responsibility for the comfort, welfare, and habilitation of clients, including a minimum amount of supervision and assistance with, or the provision of, personal care, activities of daily living (ADL), health maintenance activities, or other supportive services.

Medical services means those services that address the health concerns and/or needs of clients, including complex interventions within the scope of practice of the health care practitioner.

Social services means those activities that assist the client in carrying out his or her therapeutic activities as outlined in their agreement of participation.

Support services means those services that support personal care, provision of medications, ADL, and health maintenance activities.

Parameters for Who Can Be Served

ADS providers must have written admission criteria, which includes each level of care and the components of care and services provided, and ensure that the decision to admit a client is based upon its capability to meet the identified needs of the client. The ADS must also have a written program description that includes the client population served, including age groups and other relevant characteristics.

Inspection and Monitoring

To determine compliance with operational, care, services, and physical plant standards, DHHS inspects the ADS prior to and following licensure. DHHS determines compliance through on-site inspections, review of schematic and construction plans, and reports of qualified inspectors. DHHS may conduct an on-site inspection at any time it deems necessary. Each year, DHHS may conduct an inspection of up to 25 percent of the ADS providers based on a random selection of licensed adult day services. In addition, DHHS will conduct focused inspections in response to complaints and incidents or when 5 years have passed without an inspection.

Required and Optional Services

Provisions Regarding Medications

Medication administration means providing medications for another person according to the five rights (the right drug to the right recipient in the right dosage by the right route at the right time). Medication provision means giving or applying a dose of medication to an individual and includes helping an individual in giving or applying the medication to himself or herself. The ADS must ensure that medication aides and other unlicensed persons who provide medications are trained and have demonstrated the minimum competency standards specified in the relevant rules.

The ADS must establish and implement policies and procedures to ensure that clients receive medications only as legally prescribed by a medical practitioner in accordance with the five rights and with prevailing professional standards. Clients may be allowed to self-administer medications, with or without visual supervision, when the ADS determines that the client is competent and capable of doing so and has the capacity to make an informed decision about taking medications in a safe manner. When the ADS is not responsible for medication administration or provision, the ADS must maintain responsibility for overall supervision, safety, and welfare of the client.

Provisions for Groups with Special Needs

Staffing Requirements

Type of staff. The ADS must ensure that staffing resources and training are sufficient to meet the level of supervision and assistance with ADL, personal care, and health maintenance activities that are required by the clients as defined in their client service agreement. The ADS must have at least one staff person at the ADS at all times when clients are present. The administrator must be on the premises a sufficient number of hours to permit adequate attention to the management of the ADS and designate a substitute to act in his or her absence who must be responsible and accountable for management of the ADS.

Staffing ratios. No requirements for staffing ratio were specified.

Training Requirements

The ADS must provide each direct care staff person with orientation to the ADS prior to the staff person having direct responsibility for care and services to clients. The training must include but is not limited to: (1) job duties and responsibilities, (2) infection control practices, (3) information on any physical and mental special care needs of the clients served by the ADS, and (4) disaster preparedness plans.

The ADS must provide and maintain evidence of ongoing/continuous in-services or continuing education for staff. Training must include, but is not limited to: (1) infection control practices (2) the facility's emergency procedures and information regarding advanced directives, (3) information on abuse, neglect, and misappropriation of money or property of a client and reporting procedures, (4) disaster preparedness plans, (5) client rights, and (6) other topics determined by the program.

Relevant Medicaid Contracting Requirements for Adult Day Services Providers

Nebraska provides ADHC under a waiver for aged persons and a waiver for adults and children with disabilities.

Adult day health care is a service that allows for structured social, habilitation, and health activities. It may: (1) alleviate deteriorating effects of isolation, (2) aid in transition from one living arrangement to another, (3) provide a supervised environment while the regular caregiver is working or otherwise unavailable, and/or (4) provide a setting for receipt of multiple health services in a coordinated setting. ADHC is provided outside of the client's place of residence for a period of 4 or more hours daily, but less than 24 hours. The need for this service must be reflected in one or more assessment areas of the client's plan of services and supports.

Services. Depending on the client's assessed needs, providers shall offer, or make available through arrangements with community agencies or individuals, the following services: ADL assistance, health education and counseling, health monitoring/health-related services, medication administration, nursing services, skilled nursing services, social services, and transportation.

Staffing. Each center must be staffed at all times by at least one full-time trained staff person. The center shall maintain a ratio of direct care staff member to clients sufficient to ensure that client needs are met. The provider must have a licensed nurse on staff, or contract with a licensed nurse, who will provide the health assessment/nursing service component of ADHC and supervise ADL/personal care and ADL training. Counseling may be provided only by a certified social worker, a certified master social worker, or a certified professional counselor.

DHHS annually contracts with providers of ADHC to ensure that all applicable federal, state, and local laws and regulations are met. Provider agreements must be renewed based on the same procedures used for initial approval, including conducting an in-person interview and completing provider checklists. DHHS staff shall provide ongoing monitoring of the quality of services provision.

Location of Licensing, Certification, or Other Requirements

1. http://www.sos.state.ne.us/business/regsearch/Rules/Health_and_Human_Se…
2. http://www.hhs.state.ne.us/reg/t473.htm
3. http://www.sos.state.ne.us/business/regsearch/Rules/Health_and_Human_Se…
4. http://www.hhs.state.ne.us/crl/Medfac/HCFstat.pdf

Citations

1. Nebraska Administrative Code--(Title 175, Health Care Facilities and Services Licensure--Chapter 5, Adult Day Services). Nebraska Health and Human Services Regulation and Licensure. [12/24/03]
2. Nebraska Administrative Code--(Title 473, Social Services for Aged and Disabled Adults--Chapter 3, Services Providers; Chapter 5.002, Adult Day Services). [Effective 10/1/83]
3. Nebraska Administrative Code--(Title 480, Chapter 5, Home and Community-Based Waiver Services for Aged Persons or Adults or Children with Disabilities, Adult Day Health Care). [Revised 6/8/98]
4. Health Care Facility Licensure Act, Nebraska Revised Statutes, (Adult Day Service, §§71-401 to 71-462). Department of Health And Human Services Regulation and Licensure. [Operative 01/01/05]

Additional Information

Application for licensure includes a statement that the program will be: (1) a free-standing facility, (2) part of a health care facility, or, (3) an agency that provides adult day services in the clients' home.

DSS has specific requirements for adult day providers with DSS contracts. adult day service definitions are as follows.

Adult day services--home or center. These services provide a program of structured and monitored social, manual, physical, and intellectual services/activities provided for a minimum of 3 hours per day. These services are provided in a supervised, ambulatory (including wheelchairs) setting--either a day services home or a center--outside an individual's own home. Adult day services are directed toward adults who do not require 24 hour institutional care and yet, because of physical or mental impairment (including social isolation), require services in a group setting to meet the goals identified in 473 NAC 5-002.01A.

In-home adult day services. Supervision provided for part of a day in a client's home to enable the usual caretaker (i.e., another resident of that home) to participate in employment or training. Part-time chore and homemaker activities may be included.

Adult day services center. A facility which meets established standards and provides supervision and activities for four or more adults.

Adult day services home. A facility which meets established standards and provides supervision and activities for less than four adults.

Admission. The worker shall authorize adult day services only for those individuals age 19 or older who are: (1) current SSI or State Supplemental recipients, or (2) low income aged or disabled persons. Day services activities must be necessary to: (1) avoid unnecessary institutionalization or delay institutionalization, (2) facilitate community readjustment after institutionalization, (3) improve level of functioning (i.e., self-sufficiency), (4) alleviate deteriorating effects of isolation and self-neglect, or (5) aid in the transition from one living arrangement to another, probably more independent, living arrangement.

Staffing. Personnel who provide adult day services must have had training or home or work experience in performing day service duties. Adult day services staff must be present with clients at all times during the provision of any adult day service activity.

Required services. Adult day services home or center staff shall offer the following activities: (1) intellectual activities for exploring subjects of interest to the client population (e.g., budgeting, art, book discussion, nutrition information, music appreciation), (2) manual activities--hobbies and home arts and crafts (e.g., knitting, sewing, woodworking, simple repair of home or car, cooking, gardening), (3) physical activities which stress physical fitness, either individually or as group programs (e.g., exercises, walking, swimming, bowling, croquet), and (4) social activities involving groups (e.g., field trips, dances, singing, shopping, games, lectures, and discussions).

Nevada

Overview

All facilities offering adult day or adult day health care (ADHC) must be licensed by the Bureau of Licensure and Certification in the Department of Human Resources Division.

Nevada provides adult day care and adult day health care under the Community Home Based Initiatives Program (CHIP) and Medicaid State Plan (hereafter referred to as State Plan) and provides adult day care under the Frail Elderly Waiver. Frail Elderly Waiver providers have additional requirements outlined in their waiver manual. All Medicaid providers must be licensed, and State Plan providers must also meet adult day health care certification standards.

The Department of Human Resources Division for Aging Services also provides adult day care in licensed facilities through grants to licensed providers who also comply with additional service specifications described below for the Grant program. The profile contains licensing requirements, grant specifications, and State Plan certification standards.

Licensure and Certification Requirements

Definitions

Licensing

Facilities for the care of adults during the day means an establishment operated and maintained to provide care during the day on a temporary or permanent basis for aged or infirm persons. The term does not include a halfway house for recovering alcohol and drug abusers.

Grant Specifications

Adult day care/adult day health. Provision of personal care for dependent adults in a supervised, protective, congregate setting during some portion of a 24-hour day.

Adult day care/social model. Provision of personal care for adults in a supervised, protective, congregate setting during some portion of a 24-hour day.

State Plan

Adult day care facility is defined as an establishment operated and maintained to provide temporary or permanent care during the day for aged or infirm persons but does not include halfway houses for recovering alcoholics or drug abusers.

Adult day health care facilities provide medical services and oversight in addition to social, health, and nutrition services. ADHC consists of structured, comprehensive, and continually supervised components that are provided in a protective setting. Recipients receive services and attend on a planned basis during specified hours.

Adult day health care. The goals of adult day health care services are to: (1) safeguard the recipient's safety and well being and maintain and/or enhance his/her quality of life and (2) improve and maintain the recipient's level of functioning or to lessen any decline in functioning due to disease and/or the aging process.

Parameters for Who Can Be Served

Licensing requirements. None identified.

Grant specifications. Providers may not serve participants who are bedridden, unmanageable, contagious, or lacking in the stamina to attend the program for 5 hours per day. Persons who are human immunodeficiency virus (HIV) positive or have acquired immune deficiency syndrome (AIDS) are not considered contagious.

State plan. Providers may serve individuals age 18 or older who meet the criteria for placement in a nursing facility and are in need of the medical and social services provided by adult day health care.

Medicaid-eligible individuals whose primary diagnosis includes alcohol or drug abuse or mental health disorders will not be commingled in an adult day health care facility with individuals whose primary diagnosis is an age-related disorder (dementia, physical illness, physical infirmity).

Inspection and Monitoring

Licensing requirements. None identified.

Grant specifications. None identified.

State plan. Medicaid conducts an initial review, and may schedule an on-site review at any given time without cause to assure the facility maintains compliance with the Medicaid criteria.

Required and Optional Services

Provisions Regarding Medications

Licensing requirements. Procedures must be established for the administration of medication to clients, either directly by the client or by an employee.

Grant specifications. Adult day care/adult day health participants typically receive medication assistance. Participants of social adult day care programs must be able to administer their own medications. If the facility accepts a participant who is not able to administer his/her medication, a licensed practical nurse (LPN) may be allowed to provide this service under the supervision of a contracted registered nurse (RN).

State plan. Medication assistance will be provided for participants receiving adult day health services. An RN, or LPN under the supervision of an RN, will administer medications provided to the recipient while in the facility's care.

Provisions for Groups with Special Needs

Staffing Requirements

Licensing Requirements

Type of staff. Each facility must have the number and kind of employees required by the physical characteristics of the facility, the number of clients, and the services provided. The facility director must designate an acting director to act when the director is absent from the facility.

Staffing ratios. A client must be supervised by an employee of the facility at all times during the operational hours of the facility. At least one employee trained to administer first aid and cardiopulmonary resuscitation (CPR) must be on the premises at all times.

Grant Specifications

Type of staff. None identified.

Staffing ratios. A client must be supervised by an employee of the facility at all times during the operational hours of the facility.

State Plan

Type of staff. The facility must employ an RN to oversee and provide medical services ordered by a physician. An RN, or LPN under the supervision of an RN, must be on duty during the hours in which a Medicaid-eligible recipient is in attendance at the facility.

The facility must employ a program director. The facility must have direct care staff, who observe the recipient's functioning and provide assistance to the recipient in the skills of daily living.

The facility must also provide for activity staff or other staff as necessary to provide the required services and ensure each recipient's needs are met.

Staffing ratios. None identified.

Training Requirements

Licensing requirements. All employees and volunteers shall participate in a program of general orientation to inform them of the programs, policies, and services of the facility, and must receive training at the facility on a regular basis, but not less than 12 hours per year.

Grant specifications. Staff and volunteers must be provided training in working with disabled adults.

State plan. Staff must have the necessary training to provide the Medicaid required services.

Relevant Medicaid Contracting Requirements for Adult Day Services Providers

Nevada provides adult day care and adult day health care under the CHIP waiver service, and the State Plan as outlined in this profile.

Nevada also provides social model adult day care under the Frail Elderly Waiver with the following adult day care specific provider provisions from Section 2200 of the Medicaid Services Manual:

Social model adult day care means day care service provided for 4 or more hours per day on a regularly scheduled basis, for 1 or more days per week, in an outpatient setting. Day care centers provide care and supervision, the monitoring of general health, social interaction and peer contact for the physically or mentally impaired or socially isolated adult so that he or she can remain in the community.

Providers are required to meet and maintain the specifications as a social day care center provider outlined in Nevada Revised Statutes 449, which are outlined under the Licensing Requirements headings in this profile.

Location of Licensing, Certification, or Other Requirements

1. http://www.dhcfp.state.nv.us/msm/ch%201800%208-26-03.pdf
2. http://www.nvaging.net/grants/serv_specs/adc.htm or http://www.nvaging.net/grants/serv_specs/Adult%20Daycare%202-05.pdf
3. http://www.leg.state.nv.us/NAC/NAC-449.html#NAC449Sec4061
4. http://www.leg.state.nv.us/NRS/NRS-449.html#NRS449Sec240
5. http://www.dhcfp.state.nv.us/MSM/Ch%202200%208-26-03.pdf

Citations

1. Medicaid Services Manual, Adult day Health Care. Division of Health Care Financing and Policy. [8/26/2003]
2. Service Specifications Adult Day Care. State of Nevada Division for Aging Services. [2/2005]
3. Facilities for Care of Adults During the Day. Nevada Administrative Code Chapter 449. Medical and Other Related Facilities.
4. Licensing, Regulation, and Inspection. Nevada Revised Statutes Chapter 449. Medical and Other Related Facilities.
5. Medicaid Services Manual, Home and Community Based Waiver for the Frail Elderly. Division of Health Care Financing and Policy. [8/26/03]

New Hampshire

Overview

The Bureau of Health Facilities Administration (BHFA) in the Department of Health and Human Services develops, establishes, and enforces basic standards for the care and treatment of persons in hospitals and other health care facilities in which medical, nursing, or other remedial care is rendered. NH Revised Statutes Annotated (RSA) serves as the legal authority for the Department and requires providers of adult day services to acquire a license under RSA 151:2. Program and licensing rules for adult day care (ADC) providers are promulgated in the NH Code of Administrative Rules, Chapter He-P 818.

Adult medical day care services are provided under the Medicaid State Plan and through the Home and Community-Based Care for the Elderly and Chronically Ill (HCBC-ECI) waiver program. To be reimbursed by Medicaid, providers of adult medical day care must be licensed as adult day care providers, as detailed above, and be enrolled as Medicaid providers. The chapter on Medical Assistance in the NH Code of Administrative Rules describes the program requirements.

Licensure and Certification Requirements

Definitions

Adult day care means services that offer medical supervision, care or treatment, or provide assistance in daily living activities, to three or more individuals, whether operated for profit or not.

Adult day care center means a facility that provides supervision, assistance with activities of daily living (ADL), recreational, social, and nutritional services to adults who need such assistance because of infirmity or physical or mental disability.

Parameters for Who Can Be Served

The parameters for who can be served are stated generally in the definition of ADC as those needing medical supervision, care or treatment, or ADL assistance. Providers may discharge any participant who poses a danger to self or others.

Medicaid provisions regarding waiver participants indicate that individuals whose needs place them at risk for immediate institutionalization can be served. They also state that providers may not serve anyone whose needs they cannot meet or whose primary or secondary diagnosis is mental illness or mental retardation and who are primarily in need of mental health services or habilitation services.

Inspection and Monitoring

The Department of Health and Human Services shall make at least one annual unannounced inspection and shall monitor the utilization of adult day program services.

Required and Optional Services

Provisions Regarding Medications

Providers are required to develop policies addressing medication handling, supervision, and administration.

Provisions for Groups with Special Needs

Staffing Requirements

Type of staff. Staffing assignments shall include an administrator, who may perform direct care or programmatic functions in addition to administrative functions; a program/activities coordinator, who may also perform direct care, administrative, or other programmatic functions; a registered nurse (RN) who may serve as a consultant; and a social worker if social services are provided. There shall be provisions for substitute staff of adequate qualifications to maintain the ongoing program of the ADC center.

Staffing ratios. When fewer than three participants are in the facility, one staff member shall be present at all times; when there are 3-8 participants in attendance, at least two staff members shall be present at all times, but one of the staff persons may be a trained volunteer. When there are more than eight participants, there must be a minimum of one staff member for each additional eight participants, but volunteers may be used to meet these staff requirements.

Training Requirements

All staff members must complete an orientation program that includes their roles and responsibilities at the ADC center as well as the center's policies and procedures. An annual in-service training program, which includes cause, effect, transmission, and prevention of infections, is required for all personnel.

Relevant Medicaid Contracting Requirements for Adult Day Services Providers

New Hampshire's Medical Assistance program requires that adult medical day care services be provided by agencies licensed in accordance with RSA 151:2 and in accordance with the administrative rules promulgated in Chapter He-P 818 for all adult day care providers, and in the Medicaid Chapter He-E 800 of the NH Code of Administrative Rules.

Adult medical day care center means a licensed facility providing adult medical day care services on an outpatient basis for the medically frail and/or elderly.

Adult medical day care services means those services provided at an adult day care center to eligible participants in accordance with an individual treatment plan for 4 or more hours per day on a regularly scheduled basis, for 1 or more days per week.

Admission. Adult day program services shall be available to anyone who: (1) is age 18 or older; (2) is eligible for Medicaid; (3) is living in his/her own home or in a relative or friend's home and is at risk for immediate institutionalization if adult medical day care services are not provided; (4) has had a physical examination and referral by his/her personal physician within the last 60 days of the request for adult medical day care services; (5) has been diagnosed as having a subacute or chronic illness, except for mental illness or mental retardation, and requires services provided by the adult medical day care center; and (6) needs to receive adult medical day care services for a minimum of 4 hours per day on a regularly occurring basis. The following shall not be eligible for adult medical day care services under Medicaid: individuals whose needs cannot be met by the adult medical day care center as determined by the relevant assessment and individuals whose primary or secondary diagnosis is mental illness or mental retardation and who are primarily in need of mental health services or habilitation services, respectively.

Required services. Medicaid requires providers to offer the following services:

• maintenance level therapies, which are defined as repetitive therapeutic services--physical, occupational, and speech therapy--required to maintain maximum functional capabilities, as assessed and established by a professional therapist and rendered by trained personnel;
• nursing care and supervision, which are defined as the care identified in individual care plans, which are provided to assist participants in daily living and to ensure that their medical needs are met;
• social services, which are defined as nonmedical services identified in the individual care plan, including but not limited to: (1) case management, except that case management shall only be covered for participants who are not already receiving case management through the HCBC-ECI waiver program; (2) liaison services between the participant and the community; (3) referrals for medical or other necessary services; (4) counseling the participant, or the participant's family or representative; and (5) scheduling appointments for medical or other necessary services;
• specialized transportation, which is defined as conveying participants from their residence to the adult day program or from the program back to their residence, and includes medical components identified in the individual's treatment plan, but does not include ambulance or wheelchair van transport; and
• therapeutic services, which is defined as services identified in the individual care plan for the participant's disease or medical disorder, including activities and recreation appropriate to the participant's intellectual, medical, and social functioning.

Type of staff. The facility must have on staff at least one full-time RN, a licensed practical nurse (LPN), or both, who shall be available at the center whenever one or more participants are present, and have an interdisciplinary team that includes, at a minimum, the following professionals: a medical director, the participant's personal physician, an RN, an LPN, an activities coordinator, a social worker, a physical therapist, an occupational therapist, and a speech therapist.

Location of Licensing, Certification, or Other Requirements

1. http://www.gencourt.state.nh.us/rules/he-e800.html
2. http://www.gencourt.state.nh.us/rsa/html/indexes/151.html

Citations

1. NH Code of Administrative Rules (Chapter He-E 800 Medical Assistance, Part He-E 801--Home and Community-Based Care for the Elderly and Chronically Ill; PART He-E 803--Adult Medical Day Care Services). Department of Health and Human Services. [Effective 5/01/03]
2. State of New Hampshire Revised Statutes Online (Title XI, Hospitals and Sanitaria, Chapter 151: Residential Care and Health Facility Licensing. Section 151:2-9). [Effective 1992, 1995, 2003, 2004]
3. NH Code of Administrative Rules (Chapter He-P 818, Rules for Adult Day Care Providers). Department of Health and Human Services. [Effective 11/25/98]

New Jersey

Overview

Adult day health care (ADHC) providers in New Jersey (NJ) are licensed by the state Department of Health and Senior Services Division of Long Term Care Systems under NJ Administrative Code (NJAC), Chapter 8:43F, whose provisions are summarized in this profile.

New Jersey provides adult day health services, currently called medical day care services, and human immunodeficiency virus (HIV) medical day care, under the Medicaid State Plan, Medicaid waivers, and the Home Care Expansion Program, through licensed providers who also comply withNJAC, Chapter 8:86.

The NJ Department of Health and Senior Services adult day services program for persons with Alzheimer's disease or related disorders is a fully state-funded program that subsidizes the cost of care in adult day services programs through letters of agreement with social adult day agencies and licensed adult day health care providers in compliance with NJAC, Chapter 8:92.

New Jersey provides social adult day care under the Community Care Program for the Elderly and Disabled and the Enhanced Community Options Medicaid Waivers. The Division of Aging and Community Services also provides social adult day care through Social Services Block Grant funding administered by the Area Agencies on Aging. Social adult day care center providers do not have to be licensed.

Licensure and Certification Requirements

Definitions

Adult day health services facility means a facility or a distinct part of a facility licensed by the NJ Department of Health and Senior Services to provide preventive, diagnostic, therapeutic, and rehabilitative services under medical supervision to meet the needs of functionally impaired adult participants who are not related to the members of the governing authority by marriage, blood, or adoption. Adult day health services facilities may not provide services to participants for longer than 12 hours in a calendar day.

Adult day care program for victims of Alzheimer's disease and related disorders means a program administered by the Division of Senior Affairs, NJ Department of Health and Senior Services, that provides services to individuals who have a diagnosis by a physician as having Alzheimer's disease or a related disorder, such as Huntington's disease, Parkinson's disease with dementia, Cruetzfeldt-Jacob disease, or Pick's disease.

HIV medical day care center means an adult day health services facility that provides additional services to individuals with HIV infection in an identifiable and separate setting and that conforms to NJAC, Chapter 8:43A.

Parameters for Who Can Be Served

The parameters for who can be served are specified in eligibility requirements for publicly funded adult day health services. Providers may serve individuals who need ongoing skilled nursing and/or physical, occupational, or speech therapy, and assistance in one or more activities of daily living (ADL), but who do not need services 24 hours a day on an inpatient basis in a hospital or nursing facility, except under special circumstances. Persons can be served only if their needs can be satisfactorily met by a 5-hour-a-day adult day health services program, exclusive of transportation time, 5 days per week.

Providers may not admit or retain participants who manifest such a degree of behavioral disorder that they are a danger to themselves or others, or whose behavior may interfere with the health or safety or well-being of other participants. Providers may discharge participants for medical reasons or for the participant's welfare or that of other participants upon the written order of the participant's physician, except in an emergency situation, in which case the administrator shall notify the physician and the family immediately following the transfer.

Inspection and Monitoring

When a written application for licensure is approved and the building is ready for occupancy, the Department conducts a survey of the facility at its discretion to determine compliance with the rules. The facility shall be notified in writing of the survey's findings, including any deficiencies found. The facility shall notify the Department's Division of Long Term Care Systems when the deficiencies, if any, have been corrected, and the Assessment and Survey Program will schedule one or more resurveys of the facility prior to occupancy.

Facilities are inspected in connection with the annual renewal of the license, although inspections may be more than a year apart due to delays in scheduling. The Department shall conduct an ongoing evaluation of the day health services facility by on-site visits. Survey visits may be made to a facility at any time by the Department's authorized representatives. Such visits may include, but not be limited to, a review of all facility documents and participants' records, as well as conferences with participants.

Required and Optional Services

Provisions Regarding Medications

Medications shall be accurately administered by properly authorized licensed nursing staff who shall ensure that the right drug is administered to the right person in the right dose through the right route of administration at the right time.

Provisions for Groups with Special Needs

Staffing Requirements

Type of staff. At a minimum, the facility shall have an administrator/director, a registered professional nurse, a social worker, an activities director, and a medical consultant, as well as having a registered pharmacist and a qualified dietitian as consultants. The administrator shall be a full-time employee of the facility.

A registered professional nurse shall be the director of nursing services, and the director or a designated registered professional nurse shall be on duty and available in the facility at all times when the facility is operating and services are being provided. Additional licensed professional personnel shall be present in facilities where the daily attendance exceeds 60 participants.

A social worker shall provide social work services in the facility for at least 30 minutes per week per participant equivalent, calculated on the basis of the daily census. An activities director shall be responsible for the direction, provision, and quality of the activities services. A physician shall be designated to serve as medical consultant. The facility shall designate a pharmaceutical consultant, who is not the pharmacy provider and does not have an affiliation with the pharmacy provider.

Staffing ratios. Adult day health service facilities shall provide at least one full-time, or full-time equivalent, direct care staff member for every nine participant equivalents, calculated on the basis of the daily census.

Training Requirements

The facility shall develop and implement a staff orientation and staff education plan, including plans for each service and designation of person(s) responsible for training. All personnel shall receive orientation at the time of employment and at least annual in-service education regarding, at a minimum, emergency plans and procedures, the facility's infection prevention and control services, and elder abuse.

Relevant Medicaid Contracting Requirements for Adult Day Services Providers

New Jersey provides medical day care services under the Medicaid State Plan, Medicaid waivers, and the Home Care Expansion Program through the Division of Medical Assistance and Health Services, using licensed providers who agree to comply with NJAC, Chapter 8:86.

Definitions

Medical day care is a program of medically supervised, health-related services provided in an ambulatory care setting to persons who are nonresidents of the facility and who, due to their physical and/or mental impairment, need health maintenance and restorative services supportive to their community living. (1.1)

Medical day care center means an identifiable part of a nursing facility, a hospital-affiliated facility, a freestanding ambulatory care facility, or such other facility that is licensed by the NJ State Department of Health and Senior Services, which possesses a valid and current provider agreement from the Division of Medical Assistance and Health Services (the Division) and which provides services required by NJAC, Chapter 8:86. (1.2)

A medical day care recipient is a person who is a Medicaid recipient, or a recipient who is served under the Division's Home Care Expansion Program, and who is eligible for services and is diagnosed as having an identifiable medical condition; lacks sufficient social support, which impacts negatively on this condition; and whose assessed physical and psychosocial needs: (1) do not require services 24 hours a day on an inpatient basis in a hospital or nursing facility, except under special circumstances; (2) cannot be met totally in any other ambulatory care setting; (3) require and can be met satisfactorily by a 7-hour, including portal-to-portal travel time, day-long active medical day care program; (4) are such that current health status would deteriorate without the direct services and health monitoring available at the center; and (5) cannot be met while a resident of a residential health care facility setting except that if a resident of a residential health care facility was in medical day care prior to admission, services can continue for a limited period to allow adjustment into the residential facility.

Admission criteria. See definition of medical day care recipient.

Discharge criteria. None specified in these regulations--to be determined through the recipient's individualized plan of care.

Inspections. The Division shall conduct an ongoing evaluation of the center's day care program by on-site visits to the medical day care center.

Required services. Skilled nursing services; medication administration; health monitoring/health related services; ADL assistance; physical, occupational, and speech-language therapy when in a recipient's individualized plan of care; social services; and transportation.

Medications. The registered professional nurse shall be responsible for administration and supervision of prescribed medications and treatments.

To ensure quality personal care, the center staff shall make daily checks to assure that recipients are receiving medications as prescribed.

Staffing type. Other specified staff members are a center administrator/director, social worker, activities coordinator, pharmaceutical consultant, dietician, and medical director. Various staff positions can combine functions within one person, but in adult medical day care programs serving 36 or more recipients, the director may not serve a dual function. Adult programs with less than ten recipients may have no fewer than two full-time staff positions.

A registered professional nurse shall be available on the premises of the medical day care center at all times when the center is operating. The registered professional nurse shall be responsible for the supervision of ancillary nursing staff.

Staffing ratios. Additional registered professional nurses shall be present in centers where the daily attendance exceeds 60 participants.

Adequate staff is defined as a ratio of one regular full-time, or full-time equivalent, staff person to nine recipients, calculated on the basis of the daily census. The ratio shall include the center administrator/director and all other personnel (except the medical director) who are involved in direct patient care, excluding volunteers.

Training. The center's medical director shall be responsible for providing staff with training on medically related topics.

The registered professional nurse shall be responsible for providing in-service training to center staff about the recipient's health care needs.

NJAC, Chapter 8:86, as cited in this profile, is currently under revision.

Location of Licensing, Certification, or Other Requirements

1. http://www.state.nj.us/health/ltc/documents/regnjac843f.pdf
2. http://www.state.nj.us/health/rules/njac886.pdf [NJAC, Chapter 8:86, is currently under revision]
3. On file at RTI, provided by the Division of Aging and Community Services.

Citations

1. Adult Day Health Services Manual--Standards for Services and Licensure of Adult and Pediatric Day Health Services Facilities. NJAC, Chapter 8:43F, NJ Department of Health and Senior Services. [Undated]
2. Medical Day Care Services, Chapter 8:86, Adult and Pediatric Health Services Rules, Division of Medical Assistance and Health Services, NJ Department of Health and Senior Services. [Undated]
3. Alzheimer's Day Services Program for Persons with Alzheimer's Disease or Related Disorders. NJ Register, Chapter 92. 33 N.J.R. 1198 - 1201. [April 16, 2001]

Additional Information

Adult day services program for persons with Alzheimer's disease or related disorders (NJAC, Chapter 8:92). The NJ Department of Health and Senior Services adult day services program for persons with Alzheimer's disease or related disorders is a fully state-funded program that subsidizes the cost of care in adult day services programs through letters of agreement with social adult day agencies and licensed adult day health care providers in compliance with NJAC, Chapter 8:92.

Definitions. The adult day services program for persons with Alzheimer's disease or related disorders is intended to provide relief and support to family caregivers of persons with Alzheimer's disease or a related disorder through the provision of subsidized adult day services.

Adult day services means a community-based group program designed to meet the needs of functionally or cognitively impaired adults through an individual plan of care structured to provide a variety of health, social, and related supportive services in a protective setting during any part of a day, but less than 24 hours.

Admission criteria. Since most clients served shall be in moderate to severe stages of dementia, and the applicant is most likely incompetent or discharge planning, initiated at the time of admission, shall address the potential for progressive deterioration, which would alter the appropriateness of day care and necessitate helping the caregiver to access alternative resources.

Required services. Provide or arrange for transportation, counseling, education, and referral services.

Medications. A registered professional nurse shall dispense medications in accordance with the established procedures.

Staffing type. It is specified that the agency shall provide services from a registered professional nurse as needed by clients.

Staffing ratios. The agency shall maintain a minimum staff-to-client ratio of one-to-five for programming for clients with a form of dementia.

Training. New staff shall receive an orientation within 30 days of employment, which, in addition to job responsibilities, includes methods of dealing with the specific problems encountered in the care of people with Alzheimer's disease, such as communicating with clients, necessary safety measures, and common behavior concerns, and an overview of the progression of dementia and the different types of dementia.

Staff shall regularly attend specialized training through, for instance, associations and universities, in order to have the most current information about people affected with Alzheimer's disease and related disorders.

New Mexico

Overview

The licensing requirements summarized in this template--Requirements for Adult Day Care Facilities--apply to public or private facilities that provide care, services, and supervision for three or more nonresident adults for fewer than 24 hours of any day, come within the statutory definition of "health facilities," and are required to be licensed by the licensing authority. There are three types of facilities and scope of services: adult day care center, adult day care home, and new or innovative programs for providing adult day care. The state instituted additional requirements in theMedical Assistance Division Program Policy Manual for the provision of two levels of adult day health care through the Disabled and Elderly (D&E) Home and Community-Based Services (HCBS) Waiver Program by eligible providers.

Licensure and Certification Requirements

Definitions

Adult day care center means a licensed facility where care, services, and supervision are provided to three or more adults who, because of diminished mental or physical capacity, find it difficult to care for themselves in their own residence during the day. An adult day care center may be located in any building that meets the applicable state and local building and safety codes.

Adult day care home means a private residence licensed pursuant to regulations where care, services, and supervision are provided to at least three adults but not more than five adults who, because of diminished mental or physical capacity, find it difficult to care for themselves in their own residence during the day.

New or innovative programs for providing adult day care. Professional organizations that have demonstrated a need for new or innovative services for day care for three or more adults with special needs that do not fit into one of the types of facilities above may be licensed at the sole discretion of the licensing authority, if all initial licensure procedures are met.

Parameters for Who Can Be Served

Participants may have diminished mental or physical capacity that makes it difficult to care for themselves in their own residence during the day, but they must be able to ambulate on their own or use a wheelchair with minimal assistance. No provisions for discharge are specified.

Inspection and Monitoring

An annual license is issued for a 1-year period to a facility that has met all regulatory requirements. An initial survey of the proposed facility will be scheduled by the licensing authority upon receipt of a properly completed application with all supporting documentation. A survey will be conducted at least once annually by personnel of the licensing authority. Additional surveys or visits may be made to assist the facility with technical advice, to check on progress in correction of identified violations, or to investigate complaints.

Required and Optional Services

Provisions Regarding Medications

Any licensed facility with staff who supervise self-administration of medication for participants or safeguard medications must have an appropriate custodial drug permit as determined by the state board of pharmacy. Only medications that can be self-administered by the participant, unless they will be administered by a licensed physician, dentist, or nurse, can be kept by a facility.

Provisions for Groups with Special Needs

Staffing Requirements

Type of staff. The adult day care center shall have a full-time program director who shall have the authority and responsibility for the management of activities and direction of staff to ensure that activities and services are provided appropriately and in accordance with established policies. When volunteers are used in an adult day care program, the volunteer must be provided with a written description of his or her duties and responsibilities prior to placement.

Staffing ratios for adult day care centers. One full-time equivalent staff position with responsibility for direct participant care for each five participants.

Staffing ratios for adult day care homes. One full-time equivalent staff position with responsibility for direct care for no more than five participants.

Staff/participant ratios must be maintained at all times. The responsibility of staff members included in the staff/participant ratio shall be direct care of the participants.

Training Requirements

All facilities shall provide training for each staff member. Before beginning work, all facilities shall provide for each staff member an orientation that includes the following as a minimum: (1) scope of services, activities, and programs offered by the facility; (2) emergency first aid procedures, recognition of illness, and indicators of abuse; (3) fire prevention measures and emergency evacuation plans; (4) review of licensing regulations; (5) special problems of the elderly and disabled; (6) participant rights; and (7) sanitation procedures.

Volunteers shall take part in a formal or informal orientation and training session to inform them of the program's goals, the operation and daily schedule of the program, specific needs of the adults being served, and any necessary, specialized approaches the volunteer will be expected to use.

Additional training requirements:

Adult day care centers. All staff members, including the director, shall participate in at least 40 documented hours of training during each year of employment. Twenty of the 40 hours shall be in areas covering the physical, emotional, intellectual, and social needs of adults. Other training may include, but is not limited to, nutrition, sanitation procedures, first aid, and cardiovascular resuscitation techniques.

Adult day care homes. All staff members shall participate in at least 24 documented hours of training during each year of licensure. The required training shall be in the subjects specified for adult day care centers.

Relevant Medicaid Contracting Requirements for Adult Day Services Providers

Relevant provisions for eligible providers in the D&E HCBS Waiver Program:

Adult day health providers must meet all licensing requirements and regulations set forth by the Licensing and Certification Bureau, Public Health Division, New Mexico Department of Health. Adult day health centers requesting authorization to provide new and innovative approaches to adult day health must provide the Long Term Care and Restorative Services Division (LTC and RSD) with the specified written plan for services prior to application for licensure.

• Adult day health centers must comply with the provisions of Title II and III of the Americans with Disabilities Act (ADA) of 1990, P.L. 101-336 (42 U.S.C. Section 12101).
• Adult day health centers must abide by all applicable city, county, or state regulations governing transportation services, as well as waiver-specific requirements.
• Adult day health centers must make appropriate provisions to meet the needs of adults who require special services as indicated in the plan of care.
• Adult day health providers must meet all other qualification criteria in accordance with the LTC and RSD Standards Document.

Adult day health services consist of the following two separate levels:

Level 1. Adult day health services provide structured therapeutic, social, and rehabilitative health services 2 or more hours per day on a regularly scheduled basis, 1 or more days per week, in an outpatient setting in order to assure the optimal functioning of the recipient. Meals provided as part of this service shall not constitute a "full nutritional regime" (three meals per day). Recipients of adult day health services are provided a program that activates, motivates, and rehabilitates them in all aspects of their physical and emotional makeup. Transportation to and from the adult day health center must be provided as part of the adult day health program. The cost of this transportation is included in the rate paid to the provider for Level 1 or Level 2 services.

Level 2. Adult day health services that provide the same level of therapeutic intervention as Level 1 with the addition of nursing services and skilled maintenance therapies (physical, occupational, and speech). Nursing services and skilled maintenance therapies must be provided in a private setting at the center by a licensed practical nurse, a licensed registered nurse, a licensed speech therapist, a licensed occupational therapist, or a licensed physical therapist.

The provision of nursing services and skilled maintenance therapies does not have to be directly provided by the center. If directly provided, the center must meet all program requirements for the provision of these services. Adult day health centers provide structured therapeutic, social, and rehabilitative services designed to meet the specific needs and interests of D&E Waiver participants as determined by the plan of care.

The health, safety, and welfare of the recipient must be the primary concern of all activities and services provided. These services include the following:

• transportation to and from the adult day health center;
• small and large group activities;
• individualized activities, including the provision of ancillary care;
• supervision of self-administered medication as determined by the New Mexico Nurse Practice Act;
• assisting the recipient with toileting needs;
• providing a rest or quiet area with beds or sofas;
• active and spectator participation;
• intergenerational experiences; and
• involvement in the greater community.

Adult day health services must be provided in accordance with the LTC and RSD Standards Document.

Location of Licensing, Certification, or Other Requirements

1. http://www.nmcpr.state.nm.us/nmac/parts/title07/07.013.0002.pdf
2. http://www.state.nm.us/hsd/mad/pdf_files/provmanl/prov733.pdf

Citations

1. Requirements for Adult Day Care Facilities (Title 7 Health-Chapter 13 Adult Day Care-Part 2). Licensing and Certification Bureau, Public Health Division, New Mexico Department of Health. [Effective 10/31/96; Recompiled 10/31/01]
2. Medical Assistance Division Program Policy Manual--Disabled And Elderly Home And Community-Based Services Waiver--Qualifications of Adult Day Health Service Providers and Covered Waiver Service (Adult Day Health) (733.192 and 733.491). New Mexico Human Services Department. [Effective 7/01/95]

New York

Overview

New York State (NYS) law provides general standards under which some adult day programs operate, and the NYS Department of Health (DOH) is responsible for quality assurance of adult day programs. The standards to which the services must adhere relate to admission, assessment, staffing qualifications, and patients rights. There are three types of adult day care programs:

Adult day health care (ADHC) provides medically supervised services for individuals with physical and mental impairments. The program is available through the Medicaid state plan and also serves private pay participants. All ADHC programs are operated by nursing homes, otherwise known as residential care facilities (RCFs), although they are not necessarily located at the nursing home. ADHC program operators must submit a certificate of need (CON) application and obtain written approval from the Department, and must comply with the pertinent provisions in Title 10,NYS Health Rules and Regulations. An RCF must be approved as a provider of specialized services by the Department to provide ADHC services for acquired immune deficiency syndrome (AIDS)/human immunodeficiency virus (HIV) registrants.

Day programs, which provide personal care, supervision, and other services, serve nonresidents in certified adult care facilities (adult homes, residences for adults, or enriched housing programs) and must comply with the pertinent provisions in Title 18, NYS Health Rules and Regulations. The operator of an adult care facility must obtain written approval from the Department to provide services to nonresidents, which is granted only when the Department finds that a consistently high level of care is being provided to residents of the facility.

Social adult day services (SADS) programs provide a variety of long-term care services to a group of individuals with functional limitations--due to either physical or cognitive impairments--in a congregate setting in accordance with an individualized plan of care. Social adult day services are not regulated unless the program is located in a certified adult care facility, where it will be subject to the facility's relevant requirements. Currently, there are over 200 social adult day programs in NYS supported by a wide array of sources with no dedicated funding stream. In 2004, the New York Legislature created an elder law for New York, which included provisions for the promulgation of rules and regulations to establish standards and requirements with regard to the operation of all social adult day care programs receiving funding from the State Office for the Aging. An analysis is underway regarding the projected costs and benefits of establishing uniform standards and requirements for SADS.

Licensure and Certification Requirements

Definitions

Adult Day Health Care

Adult day health care is defined as health care services and activities provided to a group of registrants with functional impairments to maintain their health status and enable them to remain in the community.

Operator of an adult day health care program is defined as the operator of a residential health care facility that is approved by the Department to be responsible for all aspects of the adult day health care program.

Registrant is defined as a person: (1) who is not a resident of a residential health care facility; is functionally impaired and not homebound; and requires supervision, monitoring, preventive, diagnostic, therapeutic, rehabilitative or palliative care or services, but does not require continuous 24-hour-a-day inpatient care and services; (2) whose assessed social and health care needs can satisfactorily be met in whole or in part by the delivery of appropriate services in the community setting; and (3) who has been admitted to an adult day health care program based on an authorized practitioner's order and the adult day health care program's interdisciplinary comprehensive assessment.

Day Program

Day program means an organized program for nonresidents of adult homes, residences for adults, or enriched housing programs, which includes personal care, supervision, and such other services that the operator is authorized to provide to residents of such facilities, but which are provided for less than 24 hours during any period of the day or night. Services are provided to nonresidents who are aged or disabled for the purpose of enabling such persons to remain in or return to the community.

Operator means any natural person or entity that provides or purports to provide residential care and services in an adult care facility and is responsible for the overall operation of the day program.

Parameters for Who Can Be Served

Adult day health care. The definition of "registrant" (above) specifies the parameters for who can be served. Additionally, operators may admit and retain only those persons for whom adequate care and needed services can be provided and who, according to their interdisciplinary needs assessments, can benefit from the services and require a minimum of at least one visit per week to the program. No individual suffering from a communicable disease that constitutes a danger to other registrants or staff may be registered or retained for services on the premises of the program.

Day program. Persons over 18 years of age with social, physical, and/or mental dependencies and who require the program's services to remain in or return to the community may be served. Operators are required to give admission priority to persons who: (1) require supervision in order to live in the community, (2) need assistance with activities of daily living (ADL) in order to remain in the community, (3) are socially isolated or disoriented and need opportunities for social interaction to prevent deterioration that would lead to placement in congregate facilities, (4) are in transition from a higher level of care, (5) are in danger of being neglected or abused by a caregiver or have needs that the caregiver is unable to meet, or (6) are receiving services as part of a protective services for adults program.

The operator of an adult home, residence for adults, or enriched housing program may not admit or retain any person who would be inappropriate for admission to the facility (e.g., individuals who have a serious physical or mental dysfunction that constitutes an immediate and present danger to themselves or others).

Inspection and Monitoring

Adult day health care. The program is surveyed when the RCF is being surveyed by the staff of the NYS DOH.

Day program. The commissioner of the NYS DOH administers a system of supervision, inspection, and enforcement for approved services for nonresidents in certified adult care facilities, to ensure compliance with department regulations and the maintenance of standards to ensure that appropriate care is provided to participants.

Required and Optional Services

Provisions Regarding Medications

Adult day health care. The operator must develop and implement written policies and procedures governing medications brought to the program site by registrants. All medications administered to residents shall be ordered in writing by a legally authorized practitioner unless unusual circumstances justify a verbal order, in which case the verbal order shall be given to a licensed nurse or to a licensed pharmacist, immediately recorded in writing, authenticated by the nurse or registered pharmacist, and countersigned by the prescriber within 48 hours. In the event a verbal order is not signed by the prescriber or a legally designated alternate practitioner within 48 hours, the order shall be terminated and the facility shall ensure that the resident's medication needs are promptly evaluated by the medical director or another legally authorized prescribing practitioner.

Day program. Participants must be permitted to retain and self-administer their own medications provided their physicians have certified, in writing, that they are capable of doing so. For participants who require, by order of their physicians, assistance with self-administration of medication, the operator may: (1) remind the participant when it is time to take the medication, (2) read the label to the participant, (3) help the participant to open the container, and (4) observe the participant to see that the correct dosage is being taken according to the prescription. Neither the operator nor staff of a nonresident services program can administer medication to a participant in the program.

Provisions for Groups with Special Needs

Staffing Requirements

Adult Day Health Care

Type of staff. Operators of ADHC programs in licensed residential care facilities must, without limiting its responsibility for the operation and management of the program: (1) assign the operator's residential health care facility's medical board, medical advisory committee, medical director, or consulting practitioner responsibility for: (a) developing and amending clinical policies; (b) supervising medical services; (c) advising the operator regarding medical and medically related problems; and (d) establishing procedures for emergency practitioner coverage, records, and consultants; and (2) ensure that medical services, including arranging for necessary consultation services, are provided to registrants of the program.

The operator must designate a person responsible for day-to-day direction, management, and administration of the ADHC services, including but not limited to assigning adequate and appropriately licensed personnel to be on duty at all times when the program is in operation to ensure safe care of the registrants.

Nursing services are provided to registrants under the direction of a registered professional nurse who is on site in the ADHC program during all hours of program operation. Based on the care needs of the registrants, for a program located at the sponsoring licensed residential health care facility, a licensed practical nurse may provide the on-site services when a registered professional nurse is available in the nursing home or on the campus to provide immediate direction or consultation.

The ADHC program shall employ a full or part-time qualified social worker to ensure that psychosocial needs are assessed, evaluated, and recorded, and that services are provided to meet the identified needs as part of the coordinated care plan.

Additional staffing requirements for services provided to registrants with AIDS include: (1) specialty oversight of the AIDS program by a practitioner who has experience in the care and clinical management of persons with AIDS, and (2) nursing services for the AIDS program under the supervision of a registered professional nurse with experience in the care and management of persons with AIDS.

Staffing Ratios. None specified.

Day Program

Type of staff. The operator shall provide staff sufficient in number and qualified by training and experience to render, at a minimum, those services mandated by statute or regulation. In a facility with a resident census in excess of 200 persons, a significant number of mentally disabled persons, or a population with special needs, the department may require additional staff or specially qualified staff. Such requirements shall be based upon the number of residents, resident needs, physical layout, and location of the facility.

The operator must designate a program director who will coordinate the services provided to both day program recipients and residents of the adult care facility. If fewer than 15 daily participants are enrolled in a day program, the following facility staff, approved by the Department, may act as program director: the facility administrator, the case manager, or the activities director.

Each operator shall designate sufficient staff to perform supervision functions during all hours of operation. Staff shall be immediately accessible at all times while on duty, and provision shall be made for backup staff. At least one individual currently qualified by a recognized organization to administer basic first aid shall be on duty and on site at all times.

Staffing ratios. The operator must ensure that adequate personnel are on duty at all times when the nonresident services program is in operation to assure safe care of the program's participants. Adequate is defined as a ratio of one staff member, in addition to those required for residents of the home, to each seven full-time participants receiving day and evening care, and one additional staff member for each 15 daily participants receiving night care. This ratio may include the program director if the program director is not serving in any other capacity on the adult home staff, or if the individual's time as director is in addition to the hours required for adult home or residence duties.

Training Requirements

Adult day health care. The operator must designate a person responsible for arranging in-service orientation, training, and staff development.

Day program. The operator shall conduct an initial program of orientation and in-service training for employees and volunteers, which includes: (1) orientation to the characteristics and needs of the population, (2) discussion of the residents' rights and the facility's rules and regulations for residents, (3) discussion of the duties and responsibilities of all staff, (4) discussion of the general duties and responsibilities of the individual(s) being trained, (5) discussion relative to the specific duties and tasks to be performed, and (6) training in emergency procedures.

The operator shall conduct ongoing in-service training and shall provide opportunities for employees and volunteers to participate in work-related training provided by the operator or others.

Relevant Medicaid Contracting Requirements for Adult Day Services Providers

ADHC services are provided under the Medicaid State plan. There are no additional requirements for ADHC services providers. The Department requires all providers to adhere to the same standards irrespective of funding sources.

Location of Licensing, Certification, or Other Requirements

1. http://public.leginfo.state.ny.us/menugetf.cgi
2. http://www.health.state.ny.us/nysdoh/phforum/nycrr10.htm
3. http://www.health.state.ny.us/nysdoh/phforum/nycrr18.htm
4. http://www.health.state.ny.us/nysdoh/cons/cons_application/data_ready_c…

Citations

1. Social Model Adult Day Services Programs, Elder Law 215, Laws of New York.
2. Adult Day Health Care, (Title 10, Part 425). NYS Health Rules and Regulations. [Effective 3/17/2004]
3. Services For Nonresidents of Adult Care Facilities, (Title 18, Section 485). NYS Health Rules and Regulations. Law upon which Title 18 was authorized was first passed in 1986 (Chapter 779), as Section 461-k of the Social Services Law. [Extended every 3 years, most recently 2005]
4. Schedule 19--Certificate of Need (CON) Forms Specific to Adult Day Health Care Programs. Department of Health. [Effective 09/09/2004].

North Carolina

Overview

Providers of adult day care and day health services must meet certification standards. The Division of Aging and Adult Services in the Department of Health and Human Services oversees the standards, which are based on North Carolina Administrative Code. These standards are summarized in this profile.

Adult day health programs and programs that provide adult day health in combination with adult day care must meet applicable state standards to be eligible for Medicaid reimbursement funds. There are no additional Medicaid provider requirements beyond the certification standards.

Licensure and Certification Requirements

Definitions

Adult day care means the provision of group care and supervision in a place other than their usual place of abode on a less than 24-hour basis to adults who may be physically or mentally disabled.

Adult day health services is the provision of an organized program of services during the day in a community group setting for the purpose of supporting an adult's personal independence and promoting his or her social, physical, and emotional well-being. Services must include health care services as defined in state standards and a variety of program activities designed to meet the individual needs and interests of the participants and referral to and assistance in using appropriate community resources.

Services must be provided in a home or a center certified to meet state standards for such programs. Adult day care homes can operate a day care program for 2-6 people in a single family dwelling. Adult day care centers can operate a day care program in a structure other than a single family dwelling.

Adult day health centers and adult day health homes can operate day health programs in a structure other than a family dwelling, but day health programs for 2-5 persons can operate in a single family dwelling. Adult day health combination programs can operate both adult day care and adult day health in one program. A minimum of 25 percent of the participants in daily attendance in a combination program must be enrolled for adult day care services.

Special care services are services by a certified adult day care center that promotes itself as providing programming, activities, or care specifically designed for persons with Alzheimer's disease or other dementias; mental health disabilities; or other special needs, diseases, or conditions as determined by the Medical Care Commission.

Parameters for Who Can Be Served

General. Providers must have specific enrollment policies to guard against enrolling people whose needs cannot realistically be met by the planned activities. The policies should also provide for dismissal of participants whose needs can no longer be met or who can no longer be cared for safely. Providers may serve both semiambulatory and nonambulatory persons.

Adult day health programs have additional requirements. Day health programs shall not enroll or continue to serve persons whose needs exceed the capability of the program. Providers may serve individuals who are 18 years of age or older who need day health services in order to support their independence and who require: (1) monitoring of a medical condition, (2) provision of assistance with or supervision of activities of daily living (ADL), and (3) administration of medication, special feedings, or provision of other treatment or services related to health care needs.

A participant transferring from standard day care services to special care services must meet the criteria for the special care service.

Inspection and Monitoring

Adult day care and adult day health care programs shall be inspected annually and monitored at least monthly to assure compliance with standards. The certificate will be in effect for 12 months from the date of issuance unless it is revoked for cause, voluntarily or involuntarily terminated, or changed to provisional certification status. Following review of the certification application, a precertification visit may be made by staff of the state Division of Aging and Adult Services.

Required and Optional Services

Provisions Regarding Medications

Participants may keep and administer their own medicines while attending the day care program. If a participant is determined to be unable to be responsible for his or her medication, it shall be kept for him or her during the time the participant is present at the program and given at the prescribed time and dosage by the health care coordinator.

Provisions for Groups with Special Needs

Staffing Requirements

Type of staff. Adult day care and adult day health centers must have a full-time director. Adult day health centers must have a health care coordinator (a registered nurse (RN) or a licensed practical nurse (LPN) currently licensed to practice in North Carolina). If the health care coordinator is an LPN, supervision must be provided by an RN consistent with the Nursing Practices Act and on-site supervision by the RN must occur no less frequently than every 2 weeks. In adult day health centers with ten or fewer participants, the director may also serve as the health care coordinator. Adult day care homes must have an operator.

Staffing ratios. The staffing pattern shall be dependent upon the enrollment criteria and the particular needs of the participants who are to be served. The ratio of paid staff to participants shall be adequate to meet the goals and objectives of the program. The minimum ratios shall be as follows:

• Adult day care homes--One paid staff person for up to six participants.
• Adult day care centers--One paid staff person for each eight participants.
• Adult day health centers and adult day health homes--One paid full-time equivalent staff person with responsibility for direct participant care for each five participants.
• Adult day health combination--One paid full-time equivalent staff person with responsibility for direct participant care for each six participants.
• Special care services--Adult day care program must disclose in writing procedures that address staff to participant ratios in the special care service to meet the needs of participants.

Training Requirements

Special care services. An adult day care program providing special care services shall assure that special care services staff document receipt of training specific to the population(s) to be served; have a written plan for training staff that identifies content, sources, evaluations and schedules of training; assure that within 1 month of employment each staff person assigned to special care services shall demonstrate knowledge of the needs, interests, and levels of abilities of the participants; and assure that within 6 months of employment, each staff person assigned to special care service shall complete three training experiences including but not limited to population-specific techniques for communication, behaviors, and ADL.

An adult day care program must disclose in writing procedures that address the amount and content areas of staff training both at orientation and annually based on the special care needs of the participants.

An adult day care program providing special care services shall assure that special care services staff receive at least the following orientation and training: (1) the program director shall assure that within a month of employment, each staff person assigned to special care services shall demonstrate knowledge of the needs, interests, and levels of abilities of the participants; (2) within 6 months of employment, each staff person assigned to special care service shall complete three training experiences including but not limited to, population-specific techniques for communication, behaviors, and ADL; and (3) each staff person working directly with participants in special care service shall complete a minimum of two population-specific educational experiences annually.

Relevant Medicaid Contracting Requirements for Adult Day Services Providers

Adult day health programs and programs that provide adult day health in combination with adult day care must be certified as meeting these standards in order to be eligible to receive Medicaid funds. The certification process is described in Section VI of the Adult Day Care and Day Health Services Standards for Certification.

Location of Licensing, Certification, or Other Requirements

1. http://www.dhhs.state.nc.us/aging/adcdhstd.pdf

Citations

1. Adult Day Care and Day Health Services Standards for Certification 10A NCAC 06R .0101 and 06S .0101 (previously 10 NCAC 42E .0704 and 42Z .0501). North Carolina Department of Health and Human Services, Division of Aging and Adult Services. [September 2003]

Additional Information

The certification standards include additional requirements for both adult day health care programs and adult day care programs who market themselves as providing special care services.

Special care services. An adult day care program that provides or that advertises, markets, or otherwise promotes itself as providing special care services for persons with Alzheimer's disease or other dementias, a mental health disability, or other special needs, disease, or condition shall provide written disclosures to the Department and to persons seeking adult day care program special care services. The disclosure must address the process and criteria for enrollment in and discharge from special care services.

Only programs that meet these requirements may advertise or represent themselves as providing special care services. However, an adult day care program that does not advertise, market, or otherwise promote itself as providing special care services for persons with Alzheimer's disease or other dementias, is not prohibited from providing adult day care services to persons with Alzheimer's disease or other dementias, a mental health disability, or other special needs disease or condition.

North Dakota

Overview

Adult day care services facilities operated in a licensed basic care or skilled nursing facility must obtain approval from the Department of Health to provide adult day care services. The Department of Health may grant approval to licensed basic care facilities under State Administrative Rules, Chapter 33-03-24.1 or to licensed skilled nursing facilities under State Administrative Rules, Chapter 33-07-03.2-25. These rules are referenced in this profile. We were not able to identify additional requirements for adult day care providers not based in a skilled nursing facility.

Adult day care is provided under the Medicaid Aged and Disabled waiver administered by the Department of Human Services under State Administrative Rules, Chapter 75-03-23.

Licensure and Certification Requirements

Definitions

Adult day care services means the provision of basic care or skilled nursing facility services to meet the needs of individuals who do not remain in the facility overnight.

Parameters for Who Can Be Served

None identified.

Inspection and Monitoring

Upon receipt of an application for an initial basic care facility license, the department may schedule an inspection, and may act upon the application after the inspection. The department may inspect a basic care facility at any time.

Required and Optional Services

Provisions Regarding Medications

Medications administration services must be available for residents, and medications must be administered only by order of a licensed health care practitioner.

Provisions for Groups with Special Needs

Staffing Requirements

Type of staff. None identified.

Staffing ratios. None identified.

Training Requirements

None identified.

Relevant Medicaid Contracting Requirements for Adult Day Services Providers

Adult day care is provided under the Aged and Disabled waiver administered by the Department of Human Services under State Administrative Rules Chapter 75-03-23.

Definitions. A program of nonresidential activities for individuals 18 years of age and older that encompasses activities needed to ensure the optimal functioning of the individual. The program must be provided 3 or more hours per day, on a regularly scheduled basis, one or more times per week. Adult day care services may be provided to a client:

• Who requires assistance in activities of daily living or instrumental ADL.
• Who is able to function in an ambulatory care setting.
• Who is able to participate in group activities.
• Whose primary caregiver, who shall reside with the client, will benefit from the temporary relief of caregiving.

Inspection. Adult day care services that are provided in a home or in an unlicensed freestanding facility must meet standards established by the Department of Human Services. The County Social Service Board is responsible for inspecting and assuring that these facilities meet the required standards.

Required services include assistance with ADL, social, leisure, and educational activities. A nutrition program is also required for residents who attend day services over a mealtime.

Optional services include transportation, physical, occupational, and speech therapies. Therapies can only be provided if the provider is licensed by the Department of Health as a Basic Care or Skilled Nursing Facility.

Medication administration. Limited to self-administration.

Types of staff. All staff who work in a home or free-standing adult day care facility must meet the standards required to be enrolled as a Qualified Service Provider with the Department of Human Services.

Staffing ratio. One employee for every eight clients.

Training. Adult day care providers are required to show evidence that they meet Qualified Service Provider competency standards every 2 years.

Location of Licensing, Certification, or Other Requirements

1. http://www.state.nd.us/lr/information/acdata/pdf/75-03-23.pdf
2. http://www.state.nd.us/lr/information/acdata/pdf/33-03-24.1.pdf
3. http://www.state.nd.us/lr/information/acdata/pdf/33-07-03.2.pdf

Citations

1. Provision of Home and Community-Based Services under the Service payments for Elderly and Disabled Program and the Medicaid Waiver for the Aged and Disabled Program. State Administrative Rules, Department of Human Services, Chapter 75-03-23. [6/1/1995]
2. Basic Care Facilities. State Administrative Rules. State Department of Health, Chapter 33-03-24.1. [1/1/1995]
3. Nursing Facilities. State Administrative Rules. State Department of Health, Chapter 33-07-03.2. [7/1/96]

Ohio

Overview

Ohio certifies providers for adult day service (ADS) under Medicaid through the Pre-Admission Screening System Providing Options and Resources Today (PASSPORT) Waiver, administered by the Department of Aging. The certification requirements for PASSPORT are described in this profile. Ohio also provides and regulates providers for Center-based Day Health (CBDH) services under the Ohio Home Care Waiver under the Department of Job and Family Services. Regulations related to the Ohio Home Care Waiver are listed as Relevant Medicaid Contracting Requirements later in this profile. Ohio does not otherwise regulate ADS providers.

Licensure and Certification Requirements

Definitions

Adult day service is a nonresidential community based service designed to meet the needs of functionally and/or cognitively impaired adults through an individualized care plan that encourages optimal capacity for self care and/or maximizes functional abilities. It consists of structured, comprehensive, and continually supervised components that are provided in a protective setting. Enrollees who receive ADS attend on a planned basis during specified hours. There are two levels of ADS: enhanced and intensive.

Enhanced adult day service includes supervision of all activities of daily living (ADL) and supervision of medication administration and/or hands on assistance with one ADL (except bathing) and medication administration, comprehensive therapeutic activities, and health assessment and intermittent monitoring of health status.

Intensive adult day service includes all services mentioned in enhanced services above plus assistance with two or more ADLs; assistance with bathing; health assessment and regular monitoring of, or intervention with, health status; skilled nursing services (e.g., dressing changes and other treatments) and rehabilitative nursing procedures; rehabilitative and restorative services, including physical therapy, speech therapy, and occupational therapy; and social work services.

ADS programs shall be certified by the Ohio Department of Aging as enhanced or intensive providers.

Parameters for Who Can Be Served

The definitions of enhanced and intensive adult day services listed above indicate the parameters for who can be served in ADS programs. Participants must meet the state's waiver criteria. No specific criteria for discharge were identified.

Inspection and Monitoring

The PASSPORT Administrative Agency conducts an on-site visit within 45 calendar days after the receipt of a complete certification application to measure compliance with the PASSPORT conditions of participation.

An on-site provider structural compliance review shall occur at least annually.

Providers are required to allow representatives of the Centers for Medicaid & Medicare Services (CMS), the Ohio Department of Human Services, the Ohio Department of Aging, and the PASSPORT Administrative Agency general access to the provider facility.

Required and Optional Services

Provisions Regarding Medications

No provisions were identified.

Provisions for Groups with Special Needs