Residential Care and Assisted Living Compendium: 2007. California

11/30/2007

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

Citation

Residential care facilities for the elderly (RCFEs): Title 22, Division 6, Chapter 87100-87730

General Approach and Recent Developments

AB 609 was enacted into law in 2006 and requires additional training on assistance with self-administration of medications that will take effect in 2008. A series of changes are being implemented following passage of several bills by the legislature. The changes replace the exceptions requirements for facilities serving people with health conditions with requirements for documentation, staff training and oversight, add requirements for special care facilities, and admissions agreements.

The Department of Health Services implemented a pilot program to test two models for covering assisted living services under a Medicaid HCBS waiver. One model covers services in licensed RCFEs and the second delivers services in elderly housing settings.

The Community Care Licensing Division plans to revise and post technical guides on their website. The website includes a manual that interprets regulations and gives guidance to facilities about how to apply the rules.

Adult Foster Care

No requirements were reported.

Web Address   Content  
http:/www.dss.cahwnet.gov/ord/CCRTitle22_715.htm Rules
http://www.ccld.ca.gov/docs/ccld_search/ccld_search.aspx   List
http://www.ccld.ca.gov/PG832.htm Provider

 

Supply
Category 2007 2004 2002
  Facilities   Units   Facilities   Units   Facilities   Units
Residential care facilities for the elderly   7,471   161,586   6,543   154,830   6,207   147,580  

Definition

Residential Care Facility for the Elderly means a housing arrangement chosen voluntarily by the resident, the resident's guardian, conservator or other responsible person; where 75% of the residents are 60 years of age or older and where varying levels of care and supervision are provided, as agreed to at time of admission or as determined necessary at subsequent times of reappraisal. Any younger residents must have needs compatible with other residents.

Unit Requirements

Occupancy is limited to two residents per bedroom, which must be large enough to accommodate easy passage between beds, required furniture, and assistant devices such as wheelchairs or walkers. One toilet and sink is required for every six residents and a bathtub or shower for every ten residents.

Admission/Retention Policy

Facilities may admit or retain residents who are capable of administering their own medications; receive medical care and treatment outside the facility or from a visiting nurse; repeat persons who because of forgetfulness or physical limitations need only be reminded or to be assisted to take medication usually prescribed for self-administration; persons with problems including, but not limited to, forgetfulness, wandering, confusion, irritability, and inability to manage money; and people with mild dementia or mild temporary emotional disturbance resulting from personal loss or change in living arrangement.

Facilities may not admit or retain anyone with a communicable disease; anyone who requires 24-hour skilled nursing or intermediate care or residents whose primary need for care and supervision results from either an on-going behavior, caused by a mental disorder, that would upset the general resident group; or dementia, unless certain requirements (Section 87724) are met or the resident is bedridden. The regulations allow residents with health conditions requiring incidental medical services which are specified in the rules (e.g., administration of oxygen, catheter care, colostomy/ileostomy care, contractures, diabetes, enemas, suppositories, and/or fecal impaction removal, incontinence of bowel and/or bladder, injections, intermittent positive pressure breathing machine, and Stage I and II dermal ulcers) to be admitted and retained if the resident can perform the care or a licensed professional provides care. Facilities may not serve people who require care for Stage III and IV dermal ulcers, gastrostomy care, naso-gastric tubes, tracheostomies, staph infection or other serious infection, and/or who depend on others to perform all ADLs.

Residents who will be bedridden more than 14 days may be retained if the facility notifies the Department of Social Services that the condition is temporary.

Nursing Home Admission Policy

Beneficiaries must have a medical condition that requires an out-of-home protective living arrangement with 24-hour supervision and skilled nursing care or observation on an on-going intermittent basis to abate health deterioration.

Services

Services are divided into: (1) basic services; and (2) care and supervision. Basic services include safe and healthful living accommodations; personal assistance and care; observation and supervision; planned activities; food service; and arrangements for obtaining incidental medical and dental care. Care and supervision covers assistance with ADLs and assumption of varying degrees of responsibility for the safety and well-being of residents. Tasks include assistance with dressing, grooming, bathing, and other personal hygiene; assistance with self-administered medications; and central storing and distribution of medications.

Legislation enacted a few years ago requires that RCFEs inform residents that they have the right to have an advance directive. A brochure explaining advance directives was developed for care providers to give residents.

Legislation enacted in 1994 allows hospice care provided the resident contracts individually with a hospice agency. Facilities must request a waiver to allow hospice care and be able to meet the resident’s needs when the hospice agency is not present. If the resident shares a room, the other party needs to agree to allow hospice care in the shared living space.

Dietary

The total daily diet must meet the recommended dietary allowances of the Food and Nutrition Board of the National Research Council. At least three meals and snacks must be provided in facilities that have responsibility for all food arrangements. Meals must include an appropriate variety of foods, planned in consideration of cultural and religious backgrounds and resident preferences. Modified diets prescribed by physicians are provided. Facilities with 16-49 residents must designate one person with appropriate training to be responsible for food planning, service, and preparation. Staff must have training or related experience on the assigned job tasks.

Agreements

Admission agreements must be signed within seven days of admission and include provisions for: the basic services available; optional services; payment provisions (i.e., basic rate, optional service rate, payer, due date, funding source); process for changing the requirements and a 60-day notice; and refund; that the Department or licensing agency has the authority to examine residents' records as a part of their evaluation of the facility; general facility policies which are for the purpose of making it possible for residents to live together; actions, circumstances, or conditions which may result in the resident's eviction from the facility; the facility's policy concerning family visits and other communication with residents; and other conditions under which the agreement may be terminated.

Provisions for Serving People with Dementia

RCFEs that serve people with dementia must have adequate staff to support each resident’s physical, social, emotional, safety and health care needs. Staff must have additional training on dementia care (knowledge about hydration, skin care, communication, therapeutic activities, behavioral challenges, the environment and assisting with ADLs); recognizing symptoms that create or aggravate dementia behaviors; and recognizing the effects of dementia.

RCFEs that market themselves as special care facilities must include in their plan of operation a description of the philosophy of the program, preadmission assessment, admission information (areas where special care is provided, services available, and procedures to review the plan of operation), assessment, activity programs, staff qualifications and staff training, the physical environment, procedures to follow when there is a change in a resident’s condition and procedures to review the program’s effectiveness. Staff training includes six hours of orientation and eight hours in-service training on topics related to serving people with dementia. At least two of the following topics must be covered each year and all within three years: the effects of medication on the behavior of residents; common problems (wandering, aggression, and inappropriate sexual behavior); positive therapeutic interventions; communication skills; promoting resident dignity, independence, privacy and choices; and end of life issues.

Medication Administration

Facility staff may assist with self-administration of medications and, if authorized by law, administer injections. Medications may also be administered by licensed home health agency personnel. Beginning January 2008, the new law requires direct care staff in RCFEs, excluding licensed medical professionals, to meet specified training requirements, including passing an examination, in order to be able to assist residents with the self-administration of medications. It does not authorize unlicensed personnel to directly administer medications. This law requires 16 hours of initial training on specified topics relating to medications (including eight hours of hands-on shadowing and eight hours of other training or instruction) for staff who assist residents with the self-administration of medications in facilities licensed with a capacity of 16 or more residents, and six hours (including two hours of hands-on shadowing and four hours of other training or instruction) for staff in facilities with a licensed capacity of 15 or fewer residents. The training material and exam for all RCFEs must be developed by, or in consultation with, a licensed nurse, pharmacist or physician. Each employee who received the initial training and passed the required exam, and who continues to assist with the self-administration of medications, must also complete four hours of in-service training on medication-related issues in each succeeding 12-month period.

Public Financing

The California Department of Health Services developed an Assisted Living Waiver Pilot Project (ALWPP) in three counties: Sacramento, San Joaquin and Los Angeles, and serve 1,000 people over three years in two different settings -- licensed RCFEs and conventional elderly housing sites. The legislature wanted to test ALPs as an effective alternative to long-term placement in a nursing home. In RCFEs, services are delivered to participants by staff and in elderly housing sites, services are delivered by home health agency staff. In the summer of 2007, there were 20 licensed ALFs participating in the pilot program serving 205 participants.

The pilot requires private occupancy, with shared occupancy only by residents’ choice. Units will have a kitchen area equipped with a refrigerator, a cooking appliance (microwave is acceptable), and storage space for utensils and supplies.

The project developed a four-tiered payment methodology based on the tiers used in Arkansas. The bundled rate includes payment for the following services: 24-hour awake staff to provide oversight and meet the scheduled and unscheduled needs of residents; provision and oversight personnel and supportive services (assistance with ADLs and IADLs); health-related services (e.g., medication management services); social services; recreational activities; meals; housekeeping and laundry; and transportation. The SSI/SSP standard in licensed facilities is $1,035 a month with a PNA of $119. The SSP is $412. The payment standard includes the following components: room and board, $444; care and supervision, $472; and up to $916 for basic services.

Medicaid Payment Rates -- Waiver Pilot Services (2007)
Assisted living services
     Tier 1
     Tier 2
     Tier 3
     Tier 4
 
$52 per day
$62 per day
$71 per day
$82 per day
Care coordination   $200 per month  
Nursing home transition coordination $1,000
Consumer education -- up to 10 hours in 1st year   $22 an hour
Interpretation/translation -- 4 hours per year $59 an hour

Staffing

Administrators of facilities with 16-49 beds must have 15 college credits and in facilities with 50 or more units, two years of college or three years of experience or equivalent education and experience. Administrators who do not have a license must complete a certification program and 12 hours of classroom training.

Sufficient staffmust be employed to deliver services required by residents. On-the-job training or experience is required in the principles of nutrition, food storage and preparation, housekeeping, and sanitation standards; skill and knowledge to provide necessary care and supervision; assistance with medications; knowledge to recognize early signs of illness; and knowledge of community resources.

Requirements for awake staff vary by the size of the facility. For 16 or fewer, staff must be available in the facility; 16-100, at least one awake staff; 101-200, one on call and one awake, with an additional awake staff for each additional 100 residents.

Training

Administrators.  Individuals shall complete an approved certification program prior to being employed as an administrator. The program must include 40 hours of classroom training which covers laws, rights, regulations, and policies (eight hours); business operations (three hours); management and supervision (three hours); psycho-social needs of the elderly (five hours); physical needs of the elderly (five hours); community and support services (two hours); use, misuse, and interaction of drugs (five hours); admission, retention, and assessment procedures (five hours) and four hours in the care of residents with Alzheimer’s Disease and other dementias. All administrators shall be required to complete at least 20 clock hours of continuing education per year in areas related to aging and/or administration.

Staff. All personnel must be given on-the-job training or have related experience in: the principles of good nutrition, good food preparation and storage and menu planning; housekeeping and sanitation procedures; skill and knowledge required to provide necessary resident care and supervision including the ability to communicate with residents; knowledge required to safely assist with prescribed medications which are self-administered; knowledge necessary in order to recognize early signs of illness and the need for professional help; and knowledge of community services and resources. All RCFE staff who assist residents with personal ADLs shall receive at least ten hours of initial training within the first four weeks of employment and at least four hours annually. The training shall include, but not be limited to, the following: the aging process and physical limitations and special needs of the elderly; the importance and techniques of personal care services, including but not limited to, bathing, grooming, dressing, feeding, toileting, and universal precautions (at least three of the required ten hours shall cover this subject; residents’ rights; policies and procedures regarding medications (at least two of the required ten hours shall cover this subject); psycho-social needs of the elderly, such as recreation, companionship, independence, etc.; and recognizing signs and symptoms of dementia in individuals.

Facilities licensed for 16 or more must have a planned on-the-job training program in the above areas including orientation, skill training, and continuing education.

Background Check

The licensing agency conducts a criminal background check of officers of the organization, staff responsible for administration and direct supervision, persons providing direct care, and employees having frequent contact with residents and others and may approve or deny a license or employment based on its findings. A fingerprint clearance shall be received by the licensing agency on all persons subject to criminal record review prior to issuing a license. All facility staff must be fingerprint cleared prior to their physical presence in the facility.

Monitoring

Facilities are inspected on a rotating basis. Facilities are inspected on a random sample basis, but at least once every five years. Facilities that require “targeted visits” will be visited on an annual basis. These consist of facilities that need closer attention because of their compliance histories. Three levels of penalties are allowed for violations with an: (A) immediate, (B) potential, and (C) technical impact. Fifty dollars per day civil penalties are allowed for A and B violations increasing to $100 per day if the same violation is repeated three times in a 12-month period. Consultation is provided for Type C violations. The licensing agency is mandated to conduct an investigation within ten days on any complaint received against a facility.

Fees

Licensing fees required at initial licensure and annually thereafter are adjusted by facility size.

Licensing Fees (June 2005)
  Capacity     Application     Annual  
1-3 $375 $375
4-6 $750 $375
7-15 $1,126 $563
16-30 $1,500 $750
31-49 $1,876 $938
50-74 $2,252 $1,126
75-100 $2,628 $1,314
101-150 $3,004 $1,502
151-200 $3,502 $1,751
201-250 $4,000 $2,000
251-300 $4,500 $2,250
301-350 $5,000 $2,500
351-400 $5,500 $2,750
401-500 $6,500 $3,250
501-600 $7,500 $3,750
601-700 $8,500 $4,250
701+ $10,000 $5,000

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