[A PDF [http://aspe.hhs.gov/daltcp/reports/2007/07alcomAZ.pdf] of only this state's summary also available]
Assisted living facilities: Comprehensive administrative rules and regulations §R9-10-701 et seq.
General Approach and Recent Developments
The Governor issued an Executive Order in January 2007 directing state agencies to develop a comprehensive three year strategy to improve quality of care in nursing homes, ALFs and community settings. Most of the focus is on nursing homes. The licensing rules, established in 1998, set requirements based on the size of the facility along with supplemental requirements depending on the level of service provided. A “rules committee” that includes stakeholders may be formed early in 2008 to review changes to the regulations that are still being developed. The core requirements address facilities serving ten or fewer residents, 11 or more residents, and adult foster homes which serve 1-4 residents. Facilities are licensed to provide one of three levels of care (supervisory care services, personal care services, and directed care services) and must meet supplemental requirements.
The directed care level serves people with Alzheimer’s disease or dementia who cannot self-direct their care (e.g., cannot recognize danger, summon assistance, express need, or make basic decisions). Legislation expanding the Department of Health Services’ enforcement authority for overseeing training programs passed in 2005 that allows the Department to grant, deny, suspend or revoke the approval of training programs and to impose civil penalties for violations of the training requirements.
Adult Foster Care
AFC is regulated under the assisted living rules.
|http://www.azdhs.gov/als/hcb/index.htm||Rules, guide, list, provider|
|Assisted living home: <10||1,951||27,000||1,509||24,500||1,077||8,616|
|Assisted living centers: 11+||196||14,384|
|Adult foster care: 1-4||251||1,041|
Assisted living facility means a residential care institution, including AFC, that provides or contracts to provide supervisory care services, personal care services, or directed care services on a continuing basis.
Supervisory care services mean general supervision, including daily awareness of resident functioning and continuing needs, the ability to intervene in a crisis, and assistance in the self-administration of prescribed medications.
Personal care services mean assistance with ADLs that can be performed by persons without professional skills or professional training and include the coordination or provision of intermittent nursing services and the administration of medication and treatments by a nurse who is licensed pursuant to Title 32, Chapter 15, or as otherwise provided by law.
Directed care services mean programs and services, including personal care services, provided to persons who are incapable of recognizing danger, summoning assistance, expressing need, or making basic care decisions.
Assisted living homes serve ten or fewer residents and assisted living centers serve 11 or more residents. The Arizona Long-Term Care Systems (ALTCS) Program contracts with AFC (four or fewer in which the provider lives in the home), assisted living homes (ten or fewer, owner is not a resident), and assisted living centers.
Assisted living centers (11+ residents) may provide residential units or bedrooms. Residential units must have at least 220 square feet of floor space (excluding bathroom and closet) for one person, with an additional 100 square feet for a second person. Units must have a keyed entry, bathroom, resident controlled thermostat, and a kitchen area with sink, refrigerator, cooking appliance that may be removed or disconnected, and space for food preparation.
Assisted living centers and homes providing bedrooms must have 80 square feet in single rooms and 60 square feet per resident in double rooms. No more than two residents may share a room. Rooms occupied by residents receiving personal care services or directed care services must have a bell, intercom, or other mechanical means to contact staff. At least one toilet, sink, and shower is required for every eight residents.
ALFs providing supervisory care services may serve residents who need health or health-related services if these services are provided by a licensed home health or hospice agency.
ALFs 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; residents with a Stage III or IV pressure sore, or someone who 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.
ALFs licensed to provide directed care services may admit residents who are bedbound, need continuous nursing services, or have a Stage III or IV pressure sore if the requirements for facilities providing personal care services are met.
A copy of the resident agreement, resident rights, and consumer resources must be provided to residents upon move-in.
Nursing Home Admission Policy
Assessment information in three categories is scored: functional, emotional and cognitive, and medical. Functional areas include ADLs (i.e., bathing, dressing, grooming, eating, mobility, transferring, and toileting), communication and sensory skills, and continence. Emotional and cognitive information is obtained on orientation and behavior (i.e., wandering, self-injurious behavior, aggression, suicidal behavior, and disruptive behavior). Medical information is collected on conditions and their impact on ADLs, conditions requiring medical or nursing services and treatment, medication, special services and treatments needed, and physical measurements, history, and ventilator dependency.
Each score is weighted and totaled. The weighted functional score (ADLs and cognition) can range from 0-15 on each item, and the maximum total is 141. Applicants are grouped into two medical groups based on their conditions. Applicants in either medical group with a total score of 60 or over and those in groups 1 and 2, whose total scores are less than 60 but exceed a specified numerical threshold in each component, are eligible.
Residents must receive an assessment and a service plan within 14 days of acceptance. Plans must be reviewed every 12 months for residents receiving supervisory care services, every six months for residents receiving personal care services, and every three months for residents receiving directed care services. Services must meet scheduled and unscheduled needs. Facilities must provide general supervision; promote resident independence; autonomy; dignity; choice; self-determination; and the resident’s highest physical, cognitive, and functional capacity; help utilize community resources; encourage residents to preserve outside supports; and offer individual attention and social interaction and activities.
Facilities providing personal care services also provide skin maintenance, sufficient fluids to maintain hydration, incontinence care, and an assessment by a primary care provider for residents needing medication administration or nursing services.
Facilities providing directed care must provide cognitive stimulation and activities to maximize functioning; encouragement to eat meals and snacks; and an assessment by a primary care provider.
Hospice care may be provided by a licensed hospice agency.
Arizona Long-Term Care Systems (ALTCS)
An interdisciplinary team (manager, staff, RN [if nursing services are provided], resident and/or representative, and case manager, if applicable) conducts an assessment within 12 days of enrollment and every 90 days, or as needed, thereafter. A plan of care is developed with the resident or their representative that identifies the services needed, the person responsible for providing the service, the method and frequency of services, the measurable resident goals, and the person responsible for assisting the resident in an emergency.
Facilities must provide three meals a day and one snack to meet nutritional needs based on resident health and age. Menus must be based on the Food Guide Pyramid, USDA Center for Nutrition Policy and Promotion, Home and Garden Bulletin Number 252. If therapeutic diets are offered, a manual must be available for use by employees. Diets must be consistent with physicians’ orders or as prescribed by law. Provisions for the storing and preparation of food are included. Nutrition, hydration, food preparation, service, and storage are part of the orientation and training requirements.
Resident agreements that include the following must be signed upon move-in: terms of occupancy; services to be provided; amount and purpose of fees, charges, and deposit (including fees/charges for days the resident is absent); services available for additional charges; refund policy; responsibility to provide 30 days notice of any fee changes (unless there is a change in acuity); policy and procedures for termination of residency; and the grievance procedure.
Provisions for Serving People with Dementia
The rules contain specific provisions for facilities serving people with dementia. A minimum of four hours of training in dementia care must be provided to staff each year. Direct supervision must be available and facilities must provide cognitive stimulation and activities to maximize functioning. Facilities must have egress controls and access to secure outside areas for residents who wander.
Facilities must have policies and procedures governing the procurement, administration, storing, and disposal of medications. Trained caregivers may supervise self-administration by opening bottle caps, reading labels, checking the dosage, and observing the resident taking the medication. Medications which cannot be self-administered must be administered by an RN or “as otherwise permitted.” The phrase as otherwise permitted was included to accommodate any future statutory changes in the state’s Nurse Practice Act. Medication organizers can be prepared a month in advance by an RN or family member. Rules governing assistance with medications are contained in the licensing rules.
Services in ALFs are covered through the ALTCS program which operates under a §1115 waiver. Program administrators originally used rates set for AFC, nursing facilities, the Oregon ALP, and the Arizona HCBS program as guidelines in setting the rates. Three classes of rates are negotiated based on the LOC: low, intermediate, and high skilled. The rates include room and board which is paid by the resident. The monthly room and board amount is the resident’s “alternative share of cost” (spend-down) or 85% of the current SSI payment, whichever is greater. For residents who receive SSI, the payment rate is $623.00 a month of which $512.55 is paid to the residence to cover room and board charges and $90.45 is retained by the resident as a PNA. Rates are presented in the table below. The weighted average reflects participation among the program contractors by level.
Arizona allows third-party supplementation for room upgrades that are not part of the Medicaid payment. A family member could pay the difference in the rate if someone wanted their parent to live in a one-bedroom unit of an assisted living center rather than the standard efficiency type unit. Level III rates can vary greatly because they can include specialty care services (e.g., behavioral management).
|Medicaid Payment Rates by Program Contractor (Daily)|
|Level I||Level II||Level III|
|AFC||AL Homes||AL Centers||AFC||AL Homes||AL Centers||AFC||AL Homes||AL Centers|
Facilities are required to ensure that sufficient staff are available to provide: services consistent with the LOC for which the facility is licensed; services established in a service plan; services to meet resident needs for scheduled and unscheduled needs; general supervision and intervention in a crisis 24-hours a day; food services; environmental services; safe evacuations; and on-going social and recreational services.
Managers must be 21 years old, certified, and have a minimum of 12 months of health-related experience.
Staff must complete an orientation that includes the characteristics and needs of residents; the facility’s philosophy and goals; promotion of resident dignity, independence, self-determination, privacy, choice and resident rights; the significance and location of service plans and how to read and implement a service plan; facility rules, policies, and procedures; confidentiality of resident records; infection control; food preparation, service, and storage if applicable; abuse, neglect, and exploitation; accident, incident, and injury reporting; and fire, safety, and emergency procedures.
Managers and staff must complete 12 hours of on-going training annually covering the promotion of resident dignity; independence; self-determination; privacy; choice; resident rights; fire, safety, and emergency procedures; infection control; and abuse, neglect, and exploitation. Staff in facilities licensed to provide directed care services must also receive a minimum of four hours of training in providing services to residents.
In addition to the above topics, training may include providing services to residents; nutrition, hydration, and sanitation; behavioral health or gerontology; social, recreational, or rehabilitative services; personnel management, if applicable; common medical conditions, medication procedures, medical terminology, and personal hygiene; service plan development, implementation, or review; and other needs identified by the facility.
Staff must also maintain current CPR certification and complete six hours of continuing education annually pursuant to §36-448.11(D). Nurses aides in good standing may be deemed to meet the initial training requirements.
Certificate of training. Caregiving staff must obtain a certificate of training. Facilities may develop their own training and certificate program with approval from the department. Department approved training programs have requirements for instructors and the method of instruction. The competency-based approach sets standards for supervisory care services, personal care services, directed care services, and manager training.
Supervisory care services. 20 hours or the amount of time needed to verify a person demonstrates skills and knowledge in assisted living principles; communication; managing personal stress; preventing abuse, neglect, and exploitation; controlling the spread of disease and infection; documentation and record keeping; implementing service plans; nutrition, hydration, and food services; assisting with self-administration of medications; providing social, recreational, and rehabilitative activities; and fire, safety, and emergency procedures.
Personal care services. 30 hours (50 total) or the amount of time needed to verify a person demonstrates skills and knowledge in additional skills areas such as the aging process, common medical conditions associated with aging or physical disabilities, and medications; assisting with ADLs; and taking vital signs.
Directed care services. 12 hours (62 total) or the amount of time needed to verify a person demonstrates skills and knowledge of Alzheimer’s disease and related dementia; communicating with residents who are unable to direct care; providing services including problem solving, maximizing functioning, and life skills training for those unable to direct care; managing difficult behaviors; and developing and providing social, recreational, and rehabilitative activities for such persons. Four hours per year of on-going training is required.
Managers and staff must comply with fingerprint requirements under A.R.S. 36-411.
The licensing agency conducts annual renewal inspections. Licenses may be renewed for two years for facilities that are free of deficiencies. Penalties for violations may include civil money penalties, provisional licensing, and restricted admissions.
Facilities that contract with ALTCS are monitored by ALTCS program contractors and the Department of Health Services. During the pilot phase of the waiver, program contractors monitored resident care on a quarterly basis, provided technical assistance, and conducted meetings of providers to obtain feedback on the program. With statewide expansion, participants are visited at least quarterly by their ALTCS case manager. Annual operating and financial reviews of ALTCS contractors (health maintenance organizations) are conducted annually by the Arizona Health Care Cost Containment System (AHCCCS). The reviews also include case management and provider records and claims data. AHCCCS also reviews a random sample of residents, including assisted living residents, to evaluate the appropriateness and quality of care. The review found no unmet needs or quality of care problems.
There is a $50 application fee. Facilities with 1-59 beds pay an additional fee of $100 plus $10 per bed; 60-99 beds: $200 plus $10 per bed; 100-149: $300 plus $10 per bed; 150+: $500 plus $10 per bed.
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