States regulations pertaining to admission and retention typically consider applicants’ or residents’ general condition, physical and cognitive function, behavioral problems, and health-related needs including the need for nursing care.
Only a few states (e.g., North Carolina and Illinois) do not allow individuals who meet the state’s minimum nursing home LOC criteria to be served in residential care settings. However, no states allow persons who need a skilled level of nursing home care to be served in residential care settings (e.g., individuals who require 24-hour-a-day skilled nursing oversight or daily skilled nursing services).
State approaches for setting admission and retention policies can be grouped into three categories:
- Full Continuum -- states allow facilities to serve people with a wide range of needs;
- Discharge Triggers -- states develop a list of medical needs or treatments that cannot be provided in a facility and that will result in a resident’s discharge from a facility; and
- Levels of Licensure -- states license facilities based on the needs of residents or the services that may be provided in a specific kind of facility.
These approaches are not mutually exclusive and states may use more than one approach. States may also grant facilities waivers that allow them to serve residents whose needs exceed the limits stated in statutes or regulations.
States using a full continuum approach have broad criteria that allow facilities to serve residents with a wide range of needs, in theory permitting residents to age in place. However, providers are not required to serve everyone who meet these criteria and can establish their own admission and discharge standards within state parameters. For example, Massachusetts allows providers to meet personal care needs and at a minimum must provide assistance with bathing, dressing, and ambulation. However, they are not required to offer assistance with other ADLs such as toileting and eating. Most other states allow, but do not require, residences to serve people with ADL needs. Facilities are often required to inform prospective residents about the type of conditions that would trigger discharge. Giving providers a great deal of discretion regarding discharge criteria can limit residents’ ability to age in place.
States using the full continuum approach include Hawaii, Kansas, Maine, Minnesota, Nebraska, New Jersey, and Oregon, and those with the most flexible rules include Arizona, Hawaii, Kansas, Maine, Maryland, Minnesota, New Jersey, Oklahoma, and Oregon. Examples of this approach follow.
Oregon generally does not limit whom facilities may serve. The rules contain “move out” criteria that allow residents to choose to remain in their living environment despite functional decline as long as the facility can meet the resident’s needs. However, facilities are not required to serve all residents whose needs increase. Providers may ask residents to move if: (1) their needs exceed the level of ADL services available; (2) the resident exhibits behaviors or actions that repeatedly interfere with the rights or well-being of others; (3) the resident, due to cognitive decline, is not able to respond to verbal instructions, recognize danger, make basic care decisions, express need, or summon assistance; (4) the resident has a complex, unstable, or unpredictable medical condition; or (5) the resident has failed to make payment for charges.
Hawaii’s rules do not specify who may be admitted and retained. Rather, each facility may use its professional judgment and the capacity and expertise of the staff to determine who it will serve. Facilities are required to develop their own admission and discharge policies and procedures. Discharge with 14 days notice is allowed based on behavior, needs that exceed the facility’s ability to meet them, or a resident’s established pattern of non-compliance.
Washington allows facilities to accept and retain residents if: (1) they can meet the individual’s needs, and provide required specialized training to resident care staff; (2) the individual’s health condition is stable and predictable, as determined jointly by the “boarding home” and the resident or the resident’s representative if appropriate; and (3) the individual is ambulatory, unless the boarding home is approved by the Washington State director of fire protection to care for semi-ambulatory or non-ambulatory residents. Individuals must also meet all of the boarding home’s established acceptance criteria.
Maine allows facilities to determine whom they will admit and the type of services they will provide. They may discharge residents who pose a direct threat to the health and safety of others, damage property, or whose continued occupancy would require modification of the essential nature of the program. Rules regarding the provision of nursing care vary by setting. Residential care facilities may provide nursing services with their own staff only to residents who do not meet the state’s nursing home LOC criteria. Residents who meet the LOC criteria can be served, but nursing services must be provided by a licensed home health agency. Congregate housing programs may receive a license to provide nursing and medication administration services by registered nurses (RNs) employed by the program.
New Jersey’s rules state that assisted living is not appropriate for people who are incapable of responding to their environment, expressing volition, interacting, or demonstrating independent activity. The rules allow facilities to provide a very high LOC, but they are not required to do so. The rules specifically state that facilities may choose to serve residents who:
- Require 24-hour, seven day a week nursing supervision;
- Are bedridden longer than 14 days;
- Are consistently and totally dependent in four or more ADLs;
- Have cognitive decline that interferes with simple decisions;
- Require treatment of Stage III or IV pressure sores or multiple Stage II sores;
- Are a danger to self or others; or
- Have a medically unstable condition and/or special health problems.
Facilities may not serve residents who require a respirator or mechanical ventilator or people with severe behavior management problems, such as combative, aggressive, or disruptive behaviors.
States use discharge triggers to regulate the types of medical treatments that can and can not be provided by specific facilities and to determine when a resident can no longer reside in a facility. Most prohibited treatments require performance by skilled nursing personnel. States that use these triggers include: California, Delaware, Florida, Idaho, Illinois, Maryland, Mississippi, Nevada, New Mexico, South Carolina, Tennessee, Virginia, and West Virginia. State rules may overlap as Idaho, Maryland, and Mississippi also license by LOC, and New Jersey allows a full continuum of care. Examples of this approach follows.
Tennessee requires facilities to discharge individuals who require intravenous (IV) or daily intramuscular injections; gastronomy feedings; insertion, sterile irrigation, and replacement of catheters; sterile wound care; or treatment of extensive Stage III or IV decubitus ulcers or exfoliative dermatitis; or who require four or more skilled nursing visits per week for any other condition. Facilities may retain current residents who develop these needs for up to 21 days but may not admit individuals with these needs.
Virginia does not allow residential care facilities to serve people who are ventilator dependent; have Stage III or IV dermal ulcers (unless a Stage III ulcer is healing); need IV therapy or injections directly into the vein except for intermittent care under specified conditions; have an airborne infectious disease in a communicable state; need psychotropic medications but do not have an appropriate diagnosis and treatment plan; or have nasogastric tubes and gastric tubes (except when individuals are capable of independently feeding themselves and caring for the tube.)
Levels of Licensure
Several states -- Arizona, Arkansas, Florida, Maine, Maryland, Mississippi, Missouri, Utah and Vermont -- have two or more levels of licensure based on the needs of residents or the services that may be provided. Idaho dropped licensing by levels of care in 2006. Examples of this approach follow.
Arizona licenses three levels of care: supervisory care, personal care, and directed care. Residential care facilities providing supervisory care may serve residents who need health or health-related services if these services are provided by a licensed home health or hospice agency. Those with a personal care service license may not accept or retain any resident who is unable to direct self-care; requires continuous nursing services unless the nursing services are provided by a licensed hospice agency or a private duty nurse; has a Stage III or IV pressure sore; or is bed bound due to a short illness unless the primary care physician approves, the resident signs a statement and the resident is under the care of a nurse, a licensed home health agency, or a licensed hospice agency. Facilities licensed to provide directed care may serve residents who are bed bound, need continuous nursing services, or have a Stage III or IV pressure sore.
Arkansas licenses two levels of facilities. Level I ALFs cannot serve nursing home eligible residents or residents who need 24-hour nursing services; are bedridden; have transfer assistance needs that the facility cannot meet; present a danger to self or others; or require medication administration performed by the facility.
Level II ALFs can serve nursing home eligible residents and participate in a Medicaid HCBS waiver, but cannot serve residents who need 24-hour nursing services; are bedridden; have a temporary (no more than 14 consecutive days) or terminal condition unless a physician or advance practice nurse certifies the resident’s needs may be safely met; have transfer assistance needs, including but not limited to assistance to evacuate the facility in case of emergency, that the facility cannot meet with current staffing; present a danger to self or others; or engage in criminal activities. Facilities may be licensed for both levels of care in distinct parts or separate wings.
Florida licenses four types of facilities: basic ALFs, limited nursing services (LNS), limited mental health services, and ECC which is the highest LOC. ECC facilities serve residents with higher needs and provide more services than the other levels including total help with bathing; nursing assessment more frequently than monthly; measurement and recording of basic vital functions; dietary management; supervision of residents with dementia; health education and counseling; assistance with self-administration and administration of medications; provide or arrange rehabilitative services; and escort services to health appointments.
Utah licenses two levels of facilities. Level I facilities serve residents who are ambulatory, have stable health conditions, require limited assistance with ADLs and need regular or intermittent care or treatment from facility staff. Level II facilities serve residents who need substantial assistance with ADLs, offer separate living units, and enable residents to age in place as much as possible. Level II residents may not need in-patient or 24-hour continual nursing care for more than 15 days, or a two-person assist to evacuate the building. Both types of facilities may assist with or administer medications under supervision of a licensed nurse.
Nursing Home Level-of-Care Issues
States typically have two or more levels of nursing home care and not all persons served in nursing homes may be served in residential care. States distinguish among levels of care primarily for payment purposes. As noted in the discussion of admission and retention policies, above, states typically do not allow facilities to serve persons who require a skilled level of nursing care (as opposed to discrete skilled services, which many states allow in residential care on a limited basis).
Generally, individuals who meet a state’s minimum LOC criteria can be and are served in residential care settings. Only a few states do not allow residential care facilities to serve persons who meet the minimum or threshold nursing home LOC criteria (e.g., North Carolina). Because states’ minimum nursing home criteria vary markedly, individuals who meet the nursing home criteria in one state may not meet the criteria in another state. Thus, the statement that most states permit residential care settings to serve individuals who are “nursing home eligible” obscures sometimes significant differences in the type and LOC provided in these settings in different states.
States fall on a continuum from low to high thresholds for nursing home admission. Some states require a person to need assistance with only two ADLs, while others may require that a person be totally dependent in three or more ADLs. Some states require individuals to have a combination of medical conditions/needs and functional limitations; others require only certain medical needs. Of the 45 states whose criteria were reviewed for the 2004 Compendium, two used medical criteria only; 13 used medical and functional needs; eight used an assessment score based on a combination of medical and functional needs; and 22 used ADL thresholds. Section 3 provides information about each state’s nursing home LOC criteria.15 A few examples of states’ criteria follow.
Medical. Alabama requires an individual to need daily nursing or medical services that as a practical matter can only be provided in a nursing facility on an in-patient basis.
Medical and/or functional. Maine requires individuals to need skilled care on a daily basis (nursing or rehabilitation therapies); or extensive assistance with three of the following ADLs (bed mobility, transfer, locomotion, eating, and toileting); or one of several specifiedcombinations of nursing and functional needs.
ADL Threshold. New Hampshire requires individuals to either need assistance with two or more ADLs, or to need 24-hour care for at least one of the following: medical monitoring and nursing care; restorative nursing or rehabilitative care; or medication administration.
Combination of Factors. Illinois requires individuals to have a specific score on a standardized assessment. The score is derived from a score on the Mini-Mental State Examination (MMSE), and impairments in six ADLs and nine instrumental activities of daily living (IADLs) (including ability to perform routine health and special health tasks and ability to recognize and respond to danger when left alone).
Because Centers for Medicare and Medicaid Services (CMS) gives states considerable flexibility in setting minimum nursing home LOC criteria, states may choose to make the criteria more stringent in response to budget deficits. In states that cover Medicaid waiver services in residential care settings, if individuals become ineligible for nursing home care due to increases in the threshold LOC criteria -- for example, requiring three out of five ADL impairments rather than two out of five -- they will also be ineligible for waiver services in residential care settings.
If a state markedly increases the stringency of its minimum nursing home LOC criteria to control nursing home admissions, it would need to ensure that admission and retention criteria for residential care settings allow these settings to continue serving Medicaid waiver clients with the higher level of need required for Medicaid nursing home admission.
15. Some state summaries do not include this information because it was not readily available.