Residential Care and Assisted Living Compendium: 2007. Florida

11/30/2007

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

Citation

Assisted living facilities: Florida Statutes Chapter 400 Part 3; Florida Administrative Code Chapter 58A-5 et seq.

General Approach and Recent Developments

Licensed facilities are being encouraged to register on the Agency’s Emergency Status System which contains information that can be used before, during and after a disaster. The state provides for several types of ALF licensing: standard, ECC, LNS, and limited mental health services. Training requirements were updated in 2005 and elopement standards were added in 2006. In July 2003, responsibility for training administrators and service staff was transferred from the Department of Elder Affairs to private organizations.

Adult Foster Care

Adult family care homes are licensed separately. The licensee must live in the home and may be licensed to care for no more than five individuals. Rules are available at: http://www.floridaaffordableassistedliving.org/documents/392258A.pdf.

Web Address Content
https://www.flrules.org/gateway/ChapterHome.asp?Chapter=58A-5 Rules
http://elderaffairs.state.fl.us/english/LMD/alf.html Consumer
http://www.floridaaffordableassistedliving.org/ Provider, consumer
http://ahca.myflorida.com/MCHQ/Long_Term_Care/Assisted_living/alf.shtml   Provider, rules, forms  

 

Supply
Category 2007 2004 2002
  Facilities   Units   Facilities   Units   Facilities   Units
Assisted living facilities   2,400   75,450   2,250   74,762   2,328   78,348  

Definition

Assisted living facility means any building or buildings, section or distinct part of a building, private home, boarding home, home for the aged, or other residential facility, whether operated for profit or not, which undertakes through its ownership or management to provide housing, meals, and one or more personal services for a period exceeding 24 hours to one or more adults who are not relatives of the owner or administrator.

Standard. A facility licensed to provide housing, meals, and one or more personal care services for a period exceeding 24 hours. Personal services include direct physical assistance with or supervision of a resident’s ADLs and the self-administration of medication and similar services. The facility may employ or contract with a person licensed under Chapter 464, F.S., to administer medication and perform other tasks as specified in §400.4255, F.S., such as take vital signs, manage individual weekly pill organizers for residents who self-administer medication, give prepackaged enemas ordered by the physician, observe residents, and document in the resident’s record.

Limited nursing services. A facility licensed to provide any of the services under a standard license and those services specified in §58A-5.031(1)(a)-(m). Those services include: conducting passive range of motion exercises; applying ice caps or collars; applying heat; cutting toenails of diabetic residents or residents with a documented circulatory problem if the written approval of the resident’s health care provider has been obtained; performing ear and eye irrigations; conducting a urine dipstick test; replacing established self-maintained in-dwelling catheter or performing intermittent urinary catheterizations; performing digital stool removal therapies; applying and changing routine dressings that do not require packing or irrigation, but are for abrasions, skin tears, and closed surgical wounds; caring for Stage II pressure sores; caring for casts, braces, and splints; conducting nursing assessments if conducted by, or under the direct supervision of, a RN; and for hospice patients, providing any nursing service permitted within the scope of the nurse’s license, including 24-hour supervision.

Extended congregate care. A facility licensed to provide any of the services under a standard license and LNS license, including any nursing service permitted within the scope of the nurse’s license consistent with ALF residency requirements and the facility’s written policy and procedures. A facility with this type of license enables residents to age in place in a residential environment despite mental or physical limitations that might otherwise disqualify them from residency under a standard or LNS license. This definition creates a higher LOC in assisted living which requires an additional license. Facilities with an ECC license must develop policies which allow residents to age in place and which maximize independence, dignity, choice, and decision making; specify the personal and supportive services that will be provided; specify the nursing services to be provided; and describe the procedures to ensure that unscheduled service needs are met.

Limited mental health license. An ALF that is licensed to serve three or more mental health residents. A mental health resident is an individual who receives Social Security Disability Insurance (SSDI) or SSI due to a mental disorder as defined by the Social Security Administration and receives optional state supplementation (OSS). The facility, mental health resident, and case manager must complete a community living support plan that includes the needs of the resident that must be met in order to enable the resident to live in an ALF and the community. The mental health provider and the facility must execute a cooperative agreement with each mental health resident which provides procedures and directions for accessing emergency and after-hours care.

Unit Requirements

Facilities licensed to provide ECC must provide private rooms or apartments, or semi-private room or apartment shared with a roommate of choice, with a lockable entry door. Facilities that offer rooms rather than apartments must have bathrooms shared by no more than four residents. Private rooms must be 80 square feet and shared rooms 60 square feet per resident.

Facilities that do not have the ECC license and were licensed after October 1999 may offer shared rooms (maximum of two per room), a bathroom for every six residents, and bathing facilities for every eight residents. Facilities licensed prior to October 1999 may allow four people to share a room.

Admission/Retention Policy

Admission. The regulations for “admissions” to all ALFs are specific (see matrix below).

Continued residency. Additional criteria affect continued residency. In standard ALFs, people who are bedridden more than seven days or develop a need for 24-hour nursing supervision may not be retained. Residents with Stage II pressure sores may remain if the facility has a limited nursing license or the resident contracts with a home health agency or RN.

In ECC facilities, residents may not be retained if they are bedridden for more than 14 days. Terminally ill residents may continue to reside in any ALF if a licensed hospice agency coordinates services, an interdisciplinary care plan is developed, all parties agree to the continued residency, and all documentation requirements are maintained in the resident’s file.

To receive services under the Assisted Living for the Elderly (ALE) Medicaid waiver, which covers assisted living services, case management services, and incontinence supplies, tenants must be 60 years of age or older and meet the following requirements:

  1. Medicaid eligible.

  2. Determined disabled according to Social Security standards if under 65 years of age.

  3. Deemed appropriate for ALF placement by the facility administrator.

  4. Moving out of a nursing facility or other institutional program, be an ALF resident needing additional services in order to remain in the ALF, or be living at home and determined at risk of nursing facility placement and desiring to move into an ALF.

  5. Have a case manager employed by a waiver enrolled case management agency.

  6. Meet one or more functional criteria listed below:
    • Require assistance with four or more ADLs or three ADLs plus supervision or administration of medications;
    • Require total help with one or more ADLs;
    • Have a diagnosis of Alzheimer’s disease or another type of dementia and require assistance with two or more ADLs;
    • Have a diagnosed degenerative or chronic medical condition requiring nursing services that cannot be provided in a standard ALF but are available in an ALF licensed for LNS or ECC; and
    • Be a Medicaid-eligible recipient who meets ALF criteria, awaiting discharge from a nursing home but cannot return to a private residence because of a need for supervision, personal care, periodic nursing services, or a combination of the three.

Only facilities with an ECC or LNS and semi-private rooms and bathrooms are allowed to participate in the ALE waiver program.

Nursing Home Admission Policy

Eligibility for the waiver is higher than the nursing home criteria. Waiver eligibility is limited to the following conditions as determined by using the Comprehensive Client Assessment:

  • Requires assistance with four or more ADLs or three ADLs plus assistance with administration of medication.

  • Requires total help with one or more ADLs.

  • Has a diagnosis of Alzheimer’s disease or another type of dementia and requires assistance with two or more ADLs.

  • Has a diagnosed degenerative or chronic medical condition requiring nursing services that cannot be provided in a standard licensed ALF but are available for an ALF that is licensed to provide LNS or ECC services.

  • Is a Medicaid-eligible resident awaiting discharge from a nursing home who cannot return to a private residence because of the need for supervision, personal care services, periodic nursing services, or a combination of the three.

  • Is receiving case management and is in need of assisted living services as determined by the community case manager and meets eligibility criteria as determined by the state’s Comprehensive Assessment and Review for Long-Term Care Services (CARES) program.

Services

Four licensure types are available: standard, LNS, limited mental health, and ECC. Standard facilities provide personal care services, and may provide administration of medications if offered by the facility. Facilities with an ECC license may provide a higher level of service and must make available the following additional services if required by the resident’s service plan: total help with bathing, dressing, grooming and toileting; nursing assessments conducted more frequently than monthly; measurement and recording of basic vital functions and weight; dietary management including provision of special diets, monitoring nutrition, and observing the resident’s food and fluid intake and output; assistance with self-administered medications; or the administration of medications and treatments pursuant to a health care provider’s order. If the individual needs assistance with self-administration the facility must inform the resident of the qualifications of staff who will be providing this assistance, and if unlicensed staff will be providing such assistance, obtain the resident’s or the resident’s surrogate, guardian, or attorney-in-fact’s informed consent to provide such assistance; supervision of residents with dementia and cognitive impairments; health education and counseling and the implementation of health-promoting programs and preventive regimes; provision or arrangement for rehabilitation services; and provision of escort services to health-related appointments.

Other supportive services that may be provided include social service needs, counseling, emotional support, networking, assistance securing social and leisure services, shopping, escort, companionship, family support, information and referral, transportation, and assistance developing and implementing self-directed activities. In addition, facilities provide on-going medical and social evaluation, dietary management, and medication administration.

ECC facilities may not provide oral or nasopharyngeal suctioning, assistance with nasogastric tube feeding, monitoring of blood gasses, intermittent positive pressure breathing therapy, skilled rehabilitative services; or treatment of surgical incisions, unless the surgical incision and the condition which caused it have been stabilized and a plan of care developed.

ECC facilities are allowed to use managed risk agreements which is defined as “the process by which the facility staff discuss the service plan and the needs of the resident with the resident and, if applicable, the resident’s representative or designee or the resident’s surrogate, guardian, or attorney in fact, in such a way that the consequences of a decision, including any inherent risk, are explained to all parties and reviewed periodically in conjunction with the service plan, taking into account changes in the resident’s status and the ability of the facility to respond accordingly.”

“Shared responsibility” means exploring the options available to a resident within a facility and the risks involved with each option when making decisions pertaining to the resident’s abilities, preferences, and service needs, thereby enabling the resident and, if applicable, the resident’s representative or designee, or the resident’s surrogate, guardian, or attorney in fact, and the facility to develop a service plan which best meets the resident’s needs and seeks to improve the resident’s quality of life.

Dietary

The state’s tenth edition of the recommended dietary allowances is the standard used to evaluate meals. The rules specify the servings of protein, vegetables, fruits, bread and starches, milk, fats, and water that must be served. All special diets must be reviewed annually by a registered dietician, licensed dietician/nutritionist, or a dietetic technician supervised by a register dietician or nutritionist. Therapeutic diets must be prepared as ordered by a health professional. The person responsible for food service must obtain two hours of continuing education in nutrition and food service. Staff who prepare or serve food must receive a minimum of one hour in-service training in safe food handling practices within 30 days of employment.

Agreements

The resident contract must contain: a list of specific services, supplies and accommodations to be provided; the daily, weekly or monthly rate; additional services available and charges; 30 day notice of rate increases; rights, duties and obligations of the resident; refund policy; bed hold policy; statement of the organization’s religious affiliation if any; and the process for making transfer arrangements.

Facilities with an ECC license must describe the additional personal, supportive, and nursing services provided; the costs; and any limitations on where residents must reside.

Resident contracts must include a list of specific services, supplies and accommodations provided, including LNS and ECC services; the basic daily, weekly, or monthly rate; a list of any additional services available and their charges; a provision giving at least a 30-day notice of rate changes; rights, duties, and obligations of residents; purpose of advance payments or deposits and refund policy; bed hold policy; a statement of any religious affiliation; and a notice of transfer if the facility is not able to serve the resident.

Provisions for Serving People with Dementia

Facilities may admit and retain residents with dementia. Training requirements have been increased for facilities advertising themselves as providing special care for persons with Alzheimer’s disease or related dementia. Facilities must provide supervision for all residents.

In addition to assisted living core training, staff must receive four hours of initial training covering understanding Alzheimer’s disease; characteristics of the disease; communicating with resident; family issues; resident environment; and ethical issues. Direct caregivers must obtain an additional four hours of training within nine months of employment covering: behavior management; assistance with ADLs; activities for residents; stress management for the caregiver; and medical information. Direct caregivers must receive annually four hours of training on topics specified by the Department of Elder Affairs.

State law (Chapter 429.177) requires that facilities that provide special care for persons who have Alzheimer’s disease or other related disorders must disclose in its advertisements or in a separate document those services that distinguish the care as being especially applicable to, or suitable for, such persons. Facilities with 17 or more resident must have an awake staff member on duty at night. Facilities with less than 17 residents may have staff on duty or mechanisms to monitor and ensure safety. Activities designed for people with dementia must be offered.

Medication Administration

Unlicensed staff who meet training requirements may assist with self-administration of medications. Assistance includes taking previously dispensed, properly labeled containers from where they are stored and bringing it to the resident; reading the label, opening the container, removing a prescribed amount of medication, and closing the container; placing an oral dosage in the resident’s hand or in another container and helping the resident lift the container to his or her mouth; applying topical medications; returning the medication container to proper storage; and keeping a record of when a resident receives assistance with self-administration. Licensed nursing staff may administer medications.

Public Financing

Services are in residential settings are reimbursed for low income residents through SSI, SSDI, OSS, an OSS to the federal SSI payment, Medicaid ACS, which is a Medicaid state plan service, and two Medicaid programs: an ALE waiver and the Nursing Home Diversion program.

The OSS payment standard is $647.40 a month including a PNA of $54.

Coverage of ACS under the state plan was implemented in September 2001 in all ALFs and in AFHs in January 2002. ACS includes health support; assistance with ADLs; assistance with IADLs and assistance with self-administration of medication. This Medicaid program is optional state plan service for individuals in ALFs, AFCHs, and RTFs. The payment rate is $9.28 for each day the recipient was receiving services in the facility.

ALE waiver services are available in ALFs licensed for ECC and/or LNS. Providers receive $32.20 a day ($966 per 30-day month) for services. Payments are calculated to maintain a total provider reimbursement rate of $1,556 per 30-day month. The payment for case managements is $100 a month and incontinence supplies are reimbursed $125 a month.

To be eligible for the waiver program, ALE recipients must be 60 years of age or older, require a nursing home LOC, receive SSI or have income under 300% of the federal SSI benefit, or have income under 88% of the federal poverty level.

Only facilities with an ECC or LNS license may participate in the waiver program. The State allows and caps the amount of supplemental income that may be received. ALE waiver beneficiaries must be offered a private room or apartment or a unit that is shared with the approval of the beneficiary. Additionally, to be eligible for participation, a facility may not have had a Class I or Class II violation during the past five years, nor have had uncorrected Class III violations during the past two years.

Services reimbursed include: attendant call system; attendant care; behavior management; personal care services; chore and homemaker services; medication administration; intermittent nursing care services; occupational therapy; physical therapy; speech therapy; therapeutic social and recreational services; specialized medical equipment; and incontinence supplies.

Facilities may receive payment for both waiver services and ACS. Recipients eligible for both ACS and ALE waiver assistance must have a service plan in which services that are considered ACS are shown and identified separately from those provided under the waiver.

Medicaid Participation
  2007 2004 2002
  Facilities     Participation     Facilities     Participation     Facilities     Participation  
Assisted living for the elderly   478 3,623 581 4,167 299 2,681
Assistive care services NR 7,766 1,527 14,188 1,565 9,990

Staffing

Every ALF must be under the supervision of an administrator who is responsible for the operation and maintenance of the facility including the management of all staff and the provision of adequate care to all residents.

LNS facilities must employ or contract with a nurse(s) who must be available to provide nursing services as needed by residents. The LNS facility shall maintain documentation of the qualifications of nurses providing LNS in the facility’s personnel files.

ECC facilities must provide, as staff or by contract, the services of a nurse who must be available to provide nursing services as needed by ECC residents, participate in the development of resident service plans, and perform monthly nursing assessments. An ECC staff member must serve as the ECC supervisor if the administrator does not perform this function. The ECC supervisor is responsible for the general supervision of the day-to-day management of an ECC program and ECC resident service planning.

Rules require that facilities must employ sufficient staff in accordance with required ratios (staff hours/week) and based on the physical and mental condition of residents, size and layout of the facility, capabilities of trained staff, and compliance with all minimum standards (up to five residents, 168 staff hours per week; 6-15 residents, 212 hours; 16-25 residents, 253 hours). Staff must be employed that are able to assure the safety and proper care of individual residents and implement the evacuation and emergency management plan. At least one staff must be awake in facilities with 17 or more residents.

Training

Administrators must be at least 21 years old, have received a high school diploma or GED, or have been an administrator for one of the last three years of a licensed Florida ALF that met minimum standards. Effective July 1997, administrators must complete a competency exam following completion of ALF core training. Administrators must undergo Federal Bureau of Investigation (FBI) and Florida Department of Law Enforcement (FDLE) background screening.

Administrators and direct care staff must successfully complete a 26-hour ALF core training program and a competency test. The 26-hour core educational requirement must cover at least the following topics:

  • State law and rules on ALFs;
  • Resident rights and identifying and reporting abuse, neglect, and exploitation;
  • Special needs of elderly persons, persons with mental illness, and persons with developmental disabilities and how to meet those needs;
  • Nutrition and food service, including acceptable sanitation practices for preparing, storing, and serving food;
  • Medication management, recordkeeping, and proper techniques for assisting residents with self-administered medication;
  • Fire safety requirements, including fire evacuation; and other emergency procedures; and
  • Care for persons with Alzheimer’s disease and related disorders.

Nutrition and food service. The administrator or person responsible for the facility’s food service and day-to-day supervision of food services staff shall participate in continuing education a minimum of two hours annually.

Administrators must also receive 12 hours of continuing education every two years. The administrator of an ECC facility and the ECC supervisor must complete six hours of initial training on the physical, psychological, or social needs of frail elders or persons with Alzheimer’s disease and adults with disabilities, and six hours of continuing training every two years.

Staff. In addition to the core training, new staff must complete one hour of training in each of the following areas: infection control, including universal precautions and sanitation procedures. A minimum of one hour must cover reporting major incidents and emergency procedures. A minimum of one hour must also cover resident rights and recognizing/reporting abuse, neglect, or exploitation. Three hours is required on resident behavior and needs and providing assistance with ADLs. Staff who prepare or serve food must receive a minimum of one hour in-service training in safe food handling practices. HIV/AIDS training is required biennially. Staff that assist with self-administration of medications must receive four hours of training prior to assuming these responsibilities.

Two hours of in-service training that addresses ECC, concepts, statutory and rule requirements and delivery of personal care and supportive services is required for ECC direct care staff.

Facilities which advertise that it provides special care for persons with Alzheimer’s disease or other related disorders or who maintain secured areas are required to ensure that staff who have regular contact with or provide direct care to residents with Alzheimer’s disease and related disorders receive four hours of initial training within three months of employment in understanding the disease, characteristics of Alzheimer’s disease, communication with residents with Alzheimer’s disease, family issues, resident environment, and ethical issues. An additional four hours is required for direct care staff within nine months covering behavior management, assistance with ADLs, activities, stress management for caregivers, and medical information. Direct care staff must participate in four hours of continuing education each year.

Core training and Alzheimer’s disease training may be obtained from persons approved by the Department of Elder Affairs, or designee. The Department maintains a website listing approved trainers. Competency evaluations are conducted by the University of South Florida.

Background Check

Florida law requires ALF owners (if individuals), administrators, and financial officers to be screened by the FBI and FDLE. ALF owners or administrators must screen all employees who provide personal services to residents through FDLE. An FBI and FDLE screening must also be conducted on an officer or board member of a firm, corporation, partnership, or association, or any person owning 5% or more of the facility if the agency has probable cause to believe that such person has been convicted of any offense in Section 435.04, F.S., Employment Screening.

Monitoring

A RN or appropriate designee representing the licensing agency must visit ECC facilities quarterly to monitor residents and to determine facility compliance. An RN representing the agency must also visit LNS facilities twice a year to monitor residents who are receiving LNS and to determine facility compliance.

Rules adopted in 2001 allow facilities to voluntarily adopt an internal risk management and quality assurance program. Facilities are required to file preliminary and full adverse incident reports within one and 15 days respectively. The reports are confidential as provided by law and cannot be used in civil or administrative actions, except in disciplinary proceedings by the Florida Agency for Health Care Administration or appropriate regulatory board. Facilities must also report monthly liability claims filed. The quality assurance program is intended to assess care practices, incident reports, deficiencies, and resident grievances and develop plans of action in response to findings.

Fees

The base biennial fee for a standard ALF license is $335 per license plus $56 per private bed. Total fees for a standard license do not exceed $12,325. Facilities providing ECC services pay a fee of $467, plus $10 per bed. Facilities with a limited nursing license pay $276, plus $10 per bed.

Admission Requirements
Basic Assisted Living, Limited Nursing
Service, Limited Mental Health
Extended Congregate Care
18 years of age;

Be able to perform ADLs with supervision or assistance (but not total assistance);

Be free of signs and symptoms of communicable diseases;

Able to transfer with assistance, if necessary;

Able to take own medications with assistance from staff if needed;

Not be a danger to self or others;

Not require licensed professional mental health services on a 24-hour-a-day basis;

Be able to meet special dietary needs;

Not be bedridden;

Not require: oral or nasopharyngeal suctioning, assistance with tube feeding, monitoring of blood gases, intermittent positive pressure breathing therapy, skilled rehabilitation services, or treatment of unstable surgical incisions;

Not require 24-hour nursing supervision; and

Not have any Stage III or IV pressure ulcers (residents with Stage II ulcers may be served if the facility has a LNS license or resident contracts for care with a home health agency or nurse).

18 years of age;

Free of signs and symptoms of communicable disease;

Able to transfer, with assistance, if necessary;

Not be a danger to self or others;

Not be bedridden;

Not require: oral or nasopharyngeal suctioning, nasogastric tube feeding, monitoring of blood gases, intermittent positive breathing pressure, skilled rehabilitative services, or treatment of unstable surgical incisions;

Not require 24-hour nursing supervision; and

Not have Stage III or IV pressure sores.

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