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

08/26/2005

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

Licensure and Certification Requirements
Licensure Only  ☒  day care and medical day care
Certification Only  ☒  Senior Center Plus
Both Required  ☐ 
Other  ☐ 

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

Inspection and Monitoring
Yes  ☒ 
No  ☐ 

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

  Day Care Medical Day Care
Required Optional Required Optional
* Required if in the care plan.
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  ☐   ☒   ☒*   ☐ 
Skilled Nursing Services  ☐   ☐   ☒   ☐ 
Social Services  ☐   ☒   ☒   ☐ 
Transportation  ☒   ☐   ☒   ☐ 

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

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

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#subtitle12
  2. http://www.dsd.state.md.us/comar/subtitle_chapters/10_chapters.htm#subtitle09
  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.

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