Regulatory Review of Adult Day Services: Final Report - Section 1. Staffing Requirements


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

  • Georgia requires programs to have an adequate number of qualified staff, according to the target population(s) and models of programming provided. In addition to administrative staff, a minimum of one direct service staff person is required for each eight non-severely impaired participants, or for each four severely impaired participants. The characteristics of the participants will determine the number and types of staff required.
  • Vermont states that providers must have a sufficient number of responsible persons to safely meet the needs of participants, including one full- or part-time direct service staff member. The direct services staff-to-participant ratio must be a minimum of one-to-seven. As the number of participants with functional or cognitive impairments increases or the severity of the impairment increases, the ratio of direct services staff to participants must be adjusted to meet the needs of the participants.

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

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

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

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

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

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

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

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

  • Louisiana requires the following staff positions. Administration: director/director designee; Health Services Qualified Professionals: consultant or full-time registered nurse (RN); licensed practical nurse (LPN) and direct care staff; Activities and Social Services: consultant (with an M.S.W.) and social service designee; Nutrition: dietician consultant and food supervisor; and Operations: housekeeping staff and transportation staff.
  • South Dakota. A minimum of 10 hours of nursing must be provided in the facility per month to provide general consultation and health screening services.
  • New Jersey requires that a registered professional nurse be the director of nursing services, and the director or a designated registered professional nurse be on duty and available in the facility at all times when the facility is operating and services are being provided.
  • Massachusetts requires a registered nurse on site each day for a minimum of 4 hours whenever participants are present. 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 an RN. 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 an RN.
  • Colorado requires all ADS centers to 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 an RN or 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. 

    Specialized ADS centers providing a restorative model of care must 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 participants.

  • Illinois requires a program nurse to be on duty at least one-half of a full-time 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 a full-time program coordinator/director or administrator who must meet the qualifications for a program nurse and fulfill responsibilities for all assigned positions.

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

  • Indiana. For Intensive (Level 3) ADS providers, an LPN must be on staff full-time with monthly documented RN supervision or a half-time RN must be available for all hours of the program and available to fulfill all duties as noted for nurses in the Basic (Level 1) and Enhanced (Level 2) levels. Additionally, an LPN or RN provides more intensive nursing interventions such as colostomy care, tube feeding, injections, dressing changes, catheter care, blood sugar checks, etc. as appropriate and/or prescribed. There also must be full-time, qualified staff available to attend to the psychosocial needs of participants. These staff must have monthly documented supervision by a licensed social workercertified therapist, or related professional.
  • South Carolina requires a licensed practical nurse on site whenever home- and community-based waiver clients are present.
  • Texas requires a minimum of one registered nurse or licensed vocational nurse on site 8 hours per day and states further that sufficient licensed nursing staff must be on site to meet the nursing needs of the clients.

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