Residential Care and Assisted Living Compendium: 2007. Alabama

11/30/2007

[A PDF [http://aspe.hhs.gov/daltcp/reports/2007/07alcomAL.pdf] of only this state's summary also available]

Citation

Assisted Living: Chapter 420-5-4, Alabama Department of Public Health
Specialty Care Assisted Living Facilities: Chapter 420-5-20

General Approach and Recent Developments

Sections of the regulations governing building requirements for ALFs and specialty care facilities were revised in July 2003. Revisions to incident investigations were effective in 2004. Other minor changes were made in 2005, 2006 and 2007. The regulations license three categories of facilities:

  • Congregate ALFs serve 17 or more adults;
  • Group ALFs serve 4-16 adults; and
  • Family ALFs serve 2-3 adults.

Specialty care facilities must receive a separate certification from the Board of Health.

The state implemented a system for rating facilities in 2004. Using survey findings, facilities are rated green if they have minor deficiencies; yellow if they have a problem that could pose a substantial risk to residents; or red if the survey found serious risk to residents. Facilities rated red receive full surveys. About 10% of the facilities receive a “green” rating; 30% receive a “red” rating and require further action and the rest are rated “yellow.” Shorter surveys are conducted for facilities rated green or yellow. See sample at the end of the summary. General survey findings and a profile score are posted on the licensing agency’s website.

The Department of Health is evaluating whether the regulations adequately address safety related issues (e.g., if residents have recurring problems with falls) should the rules limit admission/retention or should the staffing and training requirements be changed. The Department, Board of Nursing and Legislature are considering proposals to allow unlicensed staff to administer medications either through nurse delegation or creation of medication technician category.

Adult Foster Care

The Department of Human Resources, Adult Protective Services unit sets policy, standards and oversight for adult foster homes that serve one resident.

Web Address Content
http://www.adph.org/providers/ Rules, list, application form  
http://adphnotes.state.al.us/hcfweb.nsf   Survey findings

 

Supply
Category 2007 2004 2002
  Facilities   Units   Facilities   Units   Facilities   Units
Assisted living facilities   219   7,021   241   7,260   302   9,140  
Specialty care facilities 88 2,488 94 2,616 25 598

Definition

“Assisted living facility” means an individual, individuals, corporation, partnership, limited partnership, a limited liability company or any other entity that provides or offers to provide residence and personal care to two or more individuals who are in need of assistance with ADLs. Exceptions to this definition are: Individuals who provide residential and personal care services solely to persons to whom they are personally related, shall not be deemed to be an ALF. This exception is only for individuals, and does not apply to corporations, partnerships, limited partnerships, limited liability companies, or any other organized entity or business.

Building requirements vary for congregate ALFs (17 or more), group assisted living facilities (4-16) and family ALFs (2-3 adults).

Specialty Care Assisted Living Facility means a facility that meets the definition of ALF but which is specially licensed and staffed to permit it to care for residents with a degree of cognitive impairment that would ordinarily make them ineligible for admission or continued stay in an ALF.

Unit Requirements

The regulations do not require separate living and sleeping quarters. Private bedrooms without sitting areas must provide 80 square feet, and double rooms 130 square feet. If sitting areas are included, private rooms must be 160 square feet and double rooms 200 square feet. Bathtubs or showers must be available for every eight beds; lavatories and toilets for every six beds. Lockable doors are permitted. No more than two people may share a room.

Admission/Retention Policy1

An ALF shall not admit nor once admitted shall it retain a resident who requires medical or skilled nursing care for an acute condition or exacerbation of a chronic condition which is expected to exceed 90 days unless:

  1. The individual is capable of performing and does perform all tasks related to his or her own care.

  2. The individual is incapable of performing some or all tasks related to his or her own care due to limitations of mobility or dexterity but the individual has sufficient cognitive ability to direct his or her own care and the individual is able to direct others and does direct others to provide the physical assistance needed to complete such tasks, and the facility staff is capable of providing such assistance and does provide such assistance.

Facilities may not serve individuals with acute infectious pulmonary disease, such as influenza or active tuberculosis, or other communicable diseases, and individuals with infected draining wounds until the wound is sufficiently healed.

Nursing Home Admission Policy

A physician must certify the need for continuing stay. Nursing care is required on a daily basis that as a practical matter can only be provided in a nursing facility on an in-patient basis. Residents must need two of the following services on a regular basis:

  • Administration of a potent and dangerous injectable medication and IV medications and solutions on a daily basis or administration of routine oral medications, eye drops, or ointment.

  • Restorative nursing procedures (such as gait training and bowel and bladder training) in the case of residents who are determined to have restorative potential and can benefit from the training on a daily basis.

  • Nasopharyngeal aspiration required for the maintenance of a clear airway.

  • Maintenance of tracheostomy, gastrostomy, colostomy, ileostomy, and other tubes indwelling in body cavities as an adjunct to active treatment for rehabilitation of disease for which the stoma was created.

  • Administration of tube feedings by naso-gastric tube.

  • Care of extensive decubitus ulcers or other widespread skin disorders.

  • Observation of unstable medical conditions required on a regular and continuing basis that can only be provided by or under the direction of a RN.

  • Use of oxygen on a regular or continuing basis.

  • Application of dressing involving prescription medications and aseptic techniques and/or changing of dressing in non-infected, post-operative, or chronic conditions.

  • Comatose patient receiving routine medical treatment.

Services

ALFs must provide personal care for bathing, oral hygiene, hair and nail care, shaving, laundry services, personal safety and assistance making and keeping appointments. Facilities may provide for general observation and health supervision and may arrange for or assist residents in obtaining medical attention or nursing services when needed. Home health may be provided by a certified agency as long as residents do not require hospital or nursing home care. A written plan of care is required at the time of admission based on the medical examination, diagnoses, and recommendations of the resident’s treating physician. It shall document the personal care and services required from the facility. Plans of care are kept current and reviewed and updated at least annually by the attending physician.

Dietary

Menus must be planned and posted one week in advance. Alternate food selections must be available for residents on medically prescribed diets, including hypertension, diabetes, hyperlipdemia, and modified consistency diets. A dietician is available for residents who need special diets. Congregate ALFs must be under the direction and supervision of a full or part-time professionally qualified dietician or a consulting dietician.

Agreements

Agreements must be signed prior to or at the time of admission and include: basic charges (room, board, laundry, personal care, and services); period covered; services for which there are special charges; refund policy and termination provisions; bed hold policy and process; documentation that the resident and sponsor understand that the facility is not staffed and not authorized to perform skilled nursing services nor to care for residents with severe cognitive impairment and that the resident and sponsor agree that if the resident should need skilled nursing services or care for a severe cognitive impairment as a result of a condition that is expected to last for more than 90 days, that the resident will be discharged by the facility after prior written notice; and a reminder to the resident or sponsor that the local ombudsman may be able to provide assistance if the facility and the resident or family member are unable to resolve a dispute about payment of fees or monies owed.

Provisions for Serving People with Dementia

The state has separate rules for specialty care facilities. No facility may serve anyone with Alzheimer’s disease or dementia unless they have a specialty care facility license. Facilities are allowed to serve residents who do not have dementia if they have readily available egress from the facility. Specialty care facilities must have a medical director, at least one RN who is responsible for staff training, resident assessment, and plans of care and medication. Minimum ratios of awake staff are specified: two staff for less than 16 residents; one staff for every eight residents for facilities with 16 or more residents from 7 a.m. to 9 p.m.; three staff from 9 p.m. to 7 a.m. for facilities with 17-24 residents; and three staff plus one for every 16 residents for facilities serving 25 or more residents. Activity programs are required. Residents must have a Physical Self Maintenance Scale score of 23 or less and may not have unmanageable behavior problems.

Continuing Education. All staff members of a specialty care ALF shall have at least six hours of continuing education annually. All direct care staff, including the administrator, shall have initial training and refresher training as necessary. An RN shall identify staff refresher training needs and shall provide or arrange for needed training. Prior to providing any resident care, all staff shall complete the Dementia Education and Training Act Brain Series Training developed by the Alabama Department of Mental Health and Mental Retardation or equivalent training approved by the state Health Officer. In addition to the training areas for staff in ALFs, special care staff members must receive training on: resident fire and environmental safety; specialty care ALFs Chapter 420-5-20; understanding the aging mind; basic brain function; common neuropsychiatric disorders in the elderly; basic evaluation of the dementia patient; cognitive symptoms of dementia; psychiatric symptoms of dementia; behavioral problems associated with dementia; end of life issues in dementia; dementia other than Alzheimer’s; research and dementia; nutrition and hydration needs of the resident with dementia to include feeding techniques; and safety needs of residents with dementia.

Medication Administration

Assistance with medications is limited to reminders, reading container labels to the resident, checking the dosage, and opening containers. Licensed nurses are allowed to administer medications for residents who are not aware of their medications.

Residents who are aware of their medications may self-administer medications. A licensed nurse may administer medication to a resident who is capable of self-administration. Facility staff may assist with the self-administration of medication. Assistance includes reminding, physically assisting by opening or helping to open a container holding oral medications, offering liquids, physically bringing a container of oral medications. Assistance with medications by staff does not include giving injections, administering eye drops, ear drops, nose drops (unless the resident is aware but has dexterity limitations), inhalers, suppositories, or enemas, telling or reminding a resident that it is time to take a PRN, or as needed medication crushing or splitting, placing medications in a feeding tube, or mixing medications with food or liquids.

Public Financing

A Medicaid waiver to cover people with dementia in assisted living was approved in 2003 but was not implemented due to budget limitations.

Staffing

An ALF shall employ sufficient staff and ensure sufficient staff are on duty to meet the care needs of all residents 24-hours-a-day, seven days a week. This means that an ALF must not only have a sufficiently large number of staff members to meet the care needs of all residents, it must also manage and direct the activities of staff members in a manner that results in adequate care being provided. An ALF shall likewise employ sufficient staff, ensure sufficient staff are on duty, and manage and direct staff activities in a manner that results in maintenance of a neat, clean, orderly, and safe environment at all times.

Training

Administrators. Legislation passed in 2001 creates a Board of Examiners for Assisted Living Administrators. All administrators must be licensed which includes passing an examination and meeting education and training requirements. Existing rules require that administrators have six hours of continuing education annually. Administrators who are licensed nursing facility administrators are exempt.

Staff. Administrators and direct care staff receive initial and refresher training on state law and rules on ALFs; identifying and reporting abuse, neglect and exploitation; special needs of the elderly, mentally ill, and mentally retarded; basic first aid; advance directives; protecting resident confidentiality; safety and nutritional needs of the elderly; resident fire and environmental safety; and identifying signs and symptoms of dementia.

Background Check

Not specified. Facilities may not hire an individual whose name appears on the nurse abuse registry.

Monitoring

Facilities are monitored through licensing review and periodic inspections by the Board of Health depending on funding for inspectors. Incidents are reported through a hotline. Written reports may be requested to determine the cause of an incident or if the facility acted appropriately. Facilities are currently inspected every 2-3 years. The oversight agency is seeking additional staff to permit annual inspections.

The Alabama scoring system arranges deficiencies into three categories: routine deficiencies that have limited potential for harm; systemic or substantial risk deficiencies that have a high potential for harm; and critical deficiencies that result in actual harm and lead to mandatory enforcement. Routine deficiencies present minimal risk to residents and receive a score only if more serious deficiencies are not present. Each deficiency reduces the facility’s score by one point each up to a maximum of ten points. Facilities with routine deficiencies receive a score between 90 and 100 and are coded green. Examples of deficiencies include: the facility exceeds its licensed capacity; the facility does not properly label drugs and medicines; the facility does not have sufficient staff to meet residents’ needs; the facility does not provide appropriate health observation and oversight; or the facility fails to provide appropriate assistance with self-administration of medications or uses non-licensed personnel to administer medications.

Substantial risk deficiencies are scored only when actual harm deficiencies are not present. The first substantial risk deficiency receives a score of 11 and additional substantial risk deficiencies add three additional points for up to a total of four deficiencies. Facilities that score between 80 and 90 receive a deficiency report with a yellow border.

Actual harm deficiencies are noted when residents have been injured or neglected due to inappropriate or inadequate care and mandatory enforcement is required. These deficiencies result in an enforcement action. The first actual harm deficiency reduces the facility’s score by 21 points. Scores are reduced by five points for each subsequent deficiency. Inspection reports that contain citations for actual harm are printed with a red border. Eight deficiencies are listed that lead to mandatory enforcement. An additional 44 deficiencies are included in the substantial risk group and may lead to mandatory enforcement if they result in actual harm.

Fees

Licensure fees for ALFs and specialty-care ALFs rising to the level of intermediate care are $200, plus $15 per bed.

Alabama Department of Public Health
Assisted Living Facility Inspection Report (Facsimile)
Facility Name:
City:
Administrator:
Date of Survey:
TOTAL SCORE
 
                    
 
90-100
Acceptable
A score of 90-100 indicates that the facility is generally well operated but may have one or more problems that must be corrected. A report with this score has a green border.
80-89
Caution
A score of 80-89 indicates that the facility has some significant problems that need correction but it does not have safety or patient care problems that pose an immediate risk threat to residents. A report with this score has a yellow border.
Less than 80
Referred for enforcement action
A score of LESS THAN 80 IS A FAILED SCORE and indicates that the facility has significant problems that have resulted in a referral of the facility for enforcement action. A report with this score has a red border.

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