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

08/26/2005

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

Licensure and Certification Requirements
Licensure Only  ☐ 
Certification Only  ☒ 
Both Required  ☐ 
Other  ☐ 

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

Inspection and Monitoring
Yes  ☐ 
No  ☐ 

None specified.

Required and Optional Services

  Adult Day Service
Required Optional
Activities of Daily Living (ADL) Assistance  ☒   ☐ 
Health Education and Counseling  ☒   ☐ 
Health Monitoring/Health-Related Services  ☒   ☐ 
Medication Administration  ☒   ☐ 
Nursing Services  ☒   ☐ 
Physical Therapy, Occupational Therapy, or Speech Therapy  Level 3 only   ☐ 
Skilled Nursing Services  Level 3 only   ☐ 
Social Services  ☒   ☐ 
Transportation  ☐   ☒ 

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

Provisions for Groups with Special Needs
Dementia  ☐ 
Mental Retardation/Developmental Disabilities  ☐ 
Other  ☒  mild to severe cognitive impairments and high physical acuity 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.

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