Regulatory Review of Adult Day Services: Final Report - Section 1. Parameters for Who Can Be Served

08/26/2005

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

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

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

  • Texas specifies that day activity and health services include skilled nursing and personal care services, health education and counseling, health monitoring and health-related services, medication administration, and physical rehabilitative services.
  • New York specifies that adult day health care may serve individuals who are functionally impaired, but not homebound, and require supervision; monitoring; and preventive, diagnostic, therapeutic, rehabilitative or palliative care or services, but do not require continuous 24-hour inpatient care and services.
  • Washington defines adult day health as a supervised daytime program providing skilled nursing and rehabilitative therapy services in addition to core services provided in adult day care. The state further specifies that adult day health services are only appropriate for adults with medical or disabling conditions that require the intervention or services of a registered nurse or licensed rehabilitative therapist acting under the supervision of the client's physician. 

    Washington defines adult day care also in terms of the participants who may be served (i.e., those needing: (1) personal care services, (2) routine health monitoring with consultation from a registered nurse, (3) general therapeutic activities, or (4) supervision and/or protection for clients who require supervision or protection for their safety). The regulations limit who can be served to those whose needs exceed the scope of authorized services that the adult day care center provides and those who are not capable of participating safely in a group care setting.

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

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