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

08/26/2005

Overview

The Nebraska Department of Health and Human Services (DHHS) Regulation and Licensure provides regulations to govern licensure of adult day services in the Nebraska Administrative Code (NAC). The regulations are authorized by and implement the Health Care Facility Licensure Act,Nebraska Revised Statutes. This profile contains both statutory and regulatory language.

If a licensed health care facility provides adult day services (ADS) exclusively to individuals residing in that healthcare facility, it does not have to have an ADS license. In lieu of licensure, DHHS may accept accreditation or certification by a recognized independent accreditation body or public agency with standards that are at least as stringent as those of the State of Nebraska, as evidence that the health care facility or health care service complies with the rules, regulations, and standards adopted and promulgated under the Health Care Facility Licensure Act.

The Department of Social Services (DSS) has separate requirements for providers of center or in-home adult day services. Adult day services home and center staff shall contact the Nebraska DHHS if the ADS program is to be provided in a facility licensed by that Department or if the program intends to provide medical services. (See additional information at end of profile for specific requirements.)

Adult day health care (ADHC) services are provided under the Aged Persons waiver and the Adults and Children with Disabilities waiver. Waiver providers must meet Medicaid ADHC contracting requirements. ADHC providers that serve fewer than four persons do not require licensure, but provider agreements with the DHHS are required.

Licensure and Certification Requirements

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

Definitions

Adult day service means a person or any legal entity that provides care and an array of social, medical, or other support services for a period of less than 24 consecutive hours in a community-based program to four or more persons who require or request such services due to age or functional impairment.

Care means the exercise of concern or responsibility for the comfort, welfare, and habilitation of clients, including a minimum amount of supervision and assistance with, or the provision of, personal care, activities of daily living (ADL), health maintenance activities, or other supportive services.

Medical services means those services that address the health concerns and/or needs of clients, including complex interventions within the scope of practice of the health care practitioner.

Social services means those activities that assist the client in carrying out his or her therapeutic activities as outlined in their agreement of participation.

Support services means those services that support personal care, provision of medications, ADL, and health maintenance activities.

Parameters for Who Can Be Served

ADS providers must have written admission criteria, which includes each level of care and the components of care and services provided, and ensure that the decision to admit a client is based upon its capability to meet the identified needs of the client. The ADS must also have a written program description that includes the client population served, including age groups and other relevant characteristics.

Inspection and Monitoring

Inspection and Monitoring
Yes  ☒ 
No  ☐ 

To determine compliance with operational, care, services, and physical plant standards, DHHS inspects the ADS prior to and following licensure. DHHS determines compliance through on-site inspections, review of schematic and construction plans, and reports of qualified inspectors. DHHS may conduct an on-site inspection at any time it deems necessary. Each year, DHHS may conduct an inspection of up to 25 percent of the ADS providers based on a random selection of licensed adult day services. In addition, DHHS will conduct focused inspections in response to complaints and incidents or when 5 years have passed without an inspection.

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

Medication administration means providing medications for another person according to the five rights (the right drug to the right recipient in the right dosage by the right route at the right time). Medication provision means giving or applying a dose of medication to an individual and includes helping an individual in giving or applying the medication to himself or herself. The ADS must ensure that medication aides and other unlicensed persons who provide medications are trained and have demonstrated the minimum competency standards specified in the relevant rules.

The ADS must establish and implement policies and procedures to ensure that clients receive medications only as legally prescribed by a medical practitioner in accordance with the five rights and with prevailing professional standards. Clients may be allowed to self-administer medications, with or without visual supervision, when the ADS determines that the client is competent and capable of doing so and has the capacity to make an informed decision about taking medications in a safe manner. When the ADS is not responsible for medication administration or provision, the ADS must maintain responsibility for overall supervision, safety, and welfare of the client.

Provisions for Groups with Special Needs

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

Staffing Requirements

Type of staff. The ADS must ensure that staffing resources and training are sufficient to meet the level of supervision and assistance with ADL, personal care, and health maintenance activities that are required by the clients as defined in their client service agreement. The ADS must have at least one staff person at the ADS at all times when clients are present. The administrator must be on the premises a sufficient number of hours to permit adequate attention to the management of the ADS and designate a substitute to act in his or her absence who must be responsible and accountable for management of the ADS.

Staffing ratios. No requirements for staffing ratio were specified.

Training Requirements

The ADS must provide each direct care staff person with orientation to the ADS prior to the staff person having direct responsibility for care and services to clients. The training must include but is not limited to: (1) job duties and responsibilities, (2) infection control practices, (3) information on any physical and mental special care needs of the clients served by the ADS, and (4) disaster preparedness plans.

The ADS must provide and maintain evidence of ongoing/continuous in-services or continuing education for staff. Training must include, but is not limited to: (1) infection control practices (2) the facility's emergency procedures and information regarding advanced directives, (3) information on abuse, neglect, and misappropriation of money or property of a client and reporting procedures, (4) disaster preparedness plans, (5) client rights, and (6) other topics determined by the program.

Relevant Medicaid Contracting Requirements for Adult Day Services Providers

Nebraska provides ADHC under a waiver for aged persons and a waiver for adults and children with disabilities.

Adult day health care is a service that allows for structured social, habilitation, and health activities. It may: (1) alleviate deteriorating effects of isolation, (2) aid in transition from one living arrangement to another, (3) provide a supervised environment while the regular caregiver is working or otherwise unavailable, and/or (4) provide a setting for receipt of multiple health services in a coordinated setting. ADHC is provided outside of the client's place of residence for a period of 4 or more hours daily, but less than 24 hours. The need for this service must be reflected in one or more assessment areas of the client's plan of services and supports.

Services. Depending on the client's assessed needs, providers shall offer, or make available through arrangements with community agencies or individuals, the following services: ADL assistance, health education and counseling, health monitoring/health-related services, medication administration, nursing services, skilled nursing services, social services, and transportation.

Staffing. Each center must be staffed at all times by at least one full-time trained staff person. The center shall maintain a ratio of direct care staff member to clients sufficient to ensure that client needs are met. The provider must have a licensed nurse on staff, or contract with a licensed nurse, who will provide the health assessment/nursing service component of ADHC and supervise ADL/personal care and ADL training. Counseling may be provided only by a certified social worker, a certified master social worker, or a certified professional counselor.

DHHS annually contracts with providers of ADHC to ensure that all applicable federal, state, and local laws and regulations are met. Provider agreements must be renewed based on the same procedures used for initial approval, including conducting an in-person interview and completing provider checklists. DHHS staff shall provide ongoing monitoring of the quality of services provision.

Location of Licensing, Certification, or Other Requirements

  1. http://www.sos.state.ne.us/business/regsearch/Rules/Health_and_Human_Services_System/Title-175/Chapter-5.pdf
  2. http://www.hhs.state.ne.us/reg/t473.htm
  3. http://www.sos.state.ne.us/business/regsearch/Rules/Health_and_Human_Services_System/Title-480/Chapter-5.pdf
  4. http://www.hhs.state.ne.us/crl/Medfac/HCFstat.pdf

Citations

  1. Nebraska Administrative Code--(Title 175, Health Care Facilities and Services Licensure--Chapter 5, Adult Day Services). Nebraska Health and Human Services Regulation and Licensure. [12/24/03]
  2. Nebraska Administrative Code--(Title 473, Social Services for Aged and Disabled Adults--Chapter 3, Services Providers; Chapter 5.002, Adult Day Services). [Effective 10/1/83]
  3. Nebraska Administrative Code--(Title 480, Chapter 5, Home and Community-Based Waiver Services for Aged Persons or Adults or Children with Disabilities, Adult Day Health Care). [Revised 6/8/98]
  4. Health Care Facility Licensure Act, Nebraska Revised Statutes, (Adult Day Service, §§71-401 to 71-462). Department of Health And Human Services Regulation and Licensure. [Operative 01/01/05]

Additional Information

Application for licensure includes a statement that the program will be: (1) a free-standing facility, (2) part of a health care facility, or, (3) an agency that provides adult day services in the clients' home.

DSS has specific requirements for adult day providers with DSS contracts. adult day service definitions are as follows.

Adult day services--home or center. These services provide a program of structured and monitored social, manual, physical, and intellectual services/activities provided for a minimum of 3 hours per day. These services are provided in a supervised, ambulatory (including wheelchairs) setting--either a day services home or a center--outside an individual's own home. Adult day services are directed toward adults who do not require 24 hour institutional care and yet, because of physical or mental impairment (including social isolation), require services in a group setting to meet the goals identified in 473 NAC 5-002.01A.

In-home adult day services. Supervision provided for part of a day in a client's home to enable the usual caretaker (i.e., another resident of that home) to participate in employment or training. Part-time chore and homemaker activities may be included.

Adult day services center. A facility which meets established standards and provides supervision and activities for four or more adults.

Adult day services home. A facility which meets established standards and provides supervision and activities for less than four adults.

Admission. The worker shall authorize adult day services only for those individuals age 19 or older who are: (1) current SSI or State Supplemental recipients, or (2) low income aged or disabled persons. Day services activities must be necessary to: (1) avoid unnecessary institutionalization or delay institutionalization, (2) facilitate community readjustment after institutionalization, (3) improve level of functioning (i.e., self-sufficiency), (4) alleviate deteriorating effects of isolation and self-neglect, or (5) aid in the transition from one living arrangement to another, probably more independent, living arrangement.

Staffing. Personnel who provide adult day services must have had training or home or work experience in performing day service duties. Adult day services staff must be present with clients at all times during the provision of any adult day service activity.

Required services. Adult day services home or center staff shall offer the following activities: (1) intellectual activities for exploring subjects of interest to the client population (e.g., budgeting, art, book discussion, nutrition information, music appreciation), (2) manual activities--hobbies and home arts and crafts (e.g., knitting, sewing, woodworking, simple repair of home or car, cooking, gardening), (3) physical activities which stress physical fitness, either individually or as group programs (e.g., exercises, walking, swimming, bowling, croquet), and (4) social activities involving groups (e.g., field trips, dances, singing, shopping, games, lectures, and discussions).

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