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

08/26/2005

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

Licensure and Certification Requirements
Licensure Only  ☐ 
Certification Only  ☐ 
Both Required  ☐ 
Other  ☒  standards for providers receiving public funds

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

Inspection and Monitoring
Yes  ☒ 
No  ☐ 

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

  Adult Day Services
Required Optional
ADL Assistance  ☒   ☐ 
Health Education and Counseling  ☒   ☐ 
Health Monitoring/Health-Related Services  ☐   ☒ 
Medication Administration  ☐   ☒ 
Nursing Services  ☒   ☐ 
Physical Therapy, Occupational Therapy, or Speech Therapy  ☐   ☒ 
Skilled Nursing Services  ☒   ☐ 
Social Services  ☐   ☒ 
Transportation  ☐   ☒ 

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

Provisions for Groups with Special Needs
Dementia  ☒ 
Mental Retardation/Developmental Disabilities  ☐ 
Other  ☐ 

Staffing Requirements

Type of staff. Each program shall have a program administrator. Other required staff are the activities directornursing 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 directorregistered nurseaide(s)activities professional, and occupationalphysical, 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/MedicaidManuals/adult_day_health.pdf
  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/MedicaidManuals/CCSP_Genl_and_app_04_05_V5.pdf

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.

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