[A PDF [http://aspe.hhs.gov/daltcp/reports/2007/07alcomIN.pdf] of only this state's summary also available]
Assisted living: 460 IAC 1-11-1 et seq.
Residential care facilities: 410 IAC 16.2 Rule 5
General Approach and Recent Developments
RCFs are licensed under the licensure category for health facilities. This licensure category also includes rules for comprehensive care facilities, commonly known as nursing homes. Senate Enrolled Act 333 (2007) requires that administrators be licensed and the development of education, experience and training requirements by the Board of Health facility administrators. Regulations were readopted in 2007. Rules for housing with services establishments were filed in 2005.
Adult Foster Care
AFC is a covered Medicaid HCBS waiver. Certification standards define AFC as “the family home in which consumer care is provided to three or fewer elderly individuals or adults with physical and/or cognitive disabilities who are not members of the provider’s or primary caregiver’s family. The care is provided in a home-like environment for compensation. For the purpose of these certification standards, the AFCH does not include any house, institution, hotel or other similar living situation that supplies room and/or board only, if no consumer thereof requires any element of care.”
|http://www.state.in.us/legislative/iac/title410.html||Rules (Article 16.2)|
|http://www.in.gov/legislative/iac/T04600/A00010.PDF?||Housing with services rules|
|http://www.in.gov/icpr/Webfile/formsdiv/48896.pdf||Alzheimer’s disclosure form|
|http://www.in.gov/icpr/webfile/formsdiv/49028.pdf||Housing with services disclosure|
|Residential care facilities||190||14,655||147||11,767||140||11,555|
|Housing with services establishments||271||18,658||300||NR||NR||NR|
Residential care facilities. A health facility that provides residential nursing care or administers medications prescribed by a physician must be licensed as a RCF. A facility that provides services such as room, meals, laundry, activities, housekeeping, and limited assistance in ADLs, without providing administration of medications or residential nursing care is not required to be licensed. The provision by a licensed home health agency of medication administration or residential nursing care in a facility which provides room, meals, a laundry, activities, housekeeping, and limited assistance in ADLs does not require the facility to be licensed, regardless of whether the facility and the home health agency have common ownership, provided, however, that the resident is given the opportunity to contract with other home health agencies at any time during the resident’s stay at the facility.
A housing with service establishment is defined as an establishment providing sleeping accommodations to at least five residents and offering or providing for a fee at least one regularly scheduled health-related service or at least two regularly scheduled supportive services, whether offered or provided directly by the establishment or by another person arranged for by the establishment. Health-related services mean home health services, attendant and personal care services, professional nursing services, and central storage and distribution of medications. Supportive services mean help with personal laundry, handling or assisting with personal funds, arranging for medical services, health-related services, or social services.
Residential care facilities. Rules require 100 square feet for single rooms and 80 square feet per bed for multiple occupancy rooms. For facilities licensed after 1984, no more than four people may share a room. One toilet and sink is required for every eight residents in facilities licensed after 1984.
Residential care facilities may not admit or retain individuals who require 24-hour comprehensive nursing care. Facilities that retain appropriate professional staff may provide comprehensive nursing care to residents needing care for a self-limiting condition. Residents must be discharged if the resident is a danger to self or others, requires 24-hours-a-day comprehensive nursing care or comprehensive nursing oversight; requires less than 24 hour per day comprehensive nursing care, comprehensive nursing oversight, or rehabilitative therapies and has not entered into a contract with an appropriately licensed provider of the resident’s choice to provide those therapies, is not medically stable or meets two of the following three criteria unless the resident is medically-stable and the facility can meet the resident’s needs: (1) requires total assistance with eating; (2) requires total assistance with toileting; and (3) requires total assistance with transferring.
Housing with services establishments. The establishment must, in the disclosure form, indicate when a resident must be transferred because the establishment and the resident are unable to develop a means for assuring that the resident is able to respond to an emergency in a manner that is consistent with local fire and safety requirements and when the establishment is unable to assure that the resident’s physical, mental, and psycho-social needs can be met. Except as stated in the contract, residency in the housing with services establishment may not be terminated due to a change in a resident’s health or care needs. Except where the resident’s health or safety or the health or safety of others are endangered, an operator shall provide at least thirty (30) days notice to the resident or the resident’s designated representative before terminating the resident’s residency.
Nursing Home Admission Policy
Individuals are eligible if they have an unstable medical condition or three or more of 14 substantial medical conditions or ADL impairments. The list includes: supervision and direct assistance on a daily basis to ensure that prescribed medication is taken correctly; 24-hour supervision and/or direct assistance due to confusion; disorientation not related to a mental illness; inability to eat, transfer from bed or chair, change clothes, bathe, manage bladder and/or bowel functions or ambulate or use a wheelchair without direct assistance. The criteria allow a person with three ADLs, or two ADLs and the need for medication assistance to receive waiver services.
Residential care facilities. Services offered to a resident must be appropriate to the scope, frequency, need and preference of the resident. Services must be reviewed and revised as appropriate and discussed with the resident as his or her needs change. If administration of medications and/or the provision of residential nursing services are needed, a licensed nurse must be involved in the determination and documentation of needed services. The administration of medications and the provision of residential nursing services must be ordered by a physician and supervised by a licensed nurse on the premises or on call.
The facility must provide activities programs appropriate to the ability and interests of the residents. Scheduled transportation must be provided or coordinated to community-based activities.
Each facility must determine whether it will administer medications or provide residential nursing services. This must be clearly stated in the admission agreement.
Residential nursing care may include, but is not limited to: identifying human responses to actual or potential health conditions, deriving a nursing diagnosis, executing a minor regimen based upon a nursing diagnosis or as prescribed by a physician, physician’s assistant, chiropractor, dentist, optometrist, podiatrist, or nurse practitioner, or administering, supervising, delegating, and evaluating nursing activities.
A minor regimen may include, but is not limited to: assistance with self-maintained ex-dwelling or indwelling catheter care for a chronic condition; prophylactic and palliative skin care; routine dressing that does not require packaging or irrigation; general maintenance care of ostomy; restorative nursing assistance; toileting care; routine blood glucose testing; enema and digital stool removal therapies; general maintenance care in connection with braces, splints, and plaster casts; observation of self-maintained prosthetic devices; administration of subcutaneous and intramuscular injections; metered dose inhalers, nebulizer/aerosol treatments self-administered by a resident, and routine administration of medical gases after a therapy regimen has been established.
Housing with services establishments. Except as stated in the contract and identified in the disclosure document, an operator may not restrict the ability of a resident to use a home health agency, home health provider, or case management service of the resident’s choice or require a resident to use home health services.
Residential care facilities. Facilities must make available three meals a day, seven days a week that provide a balanced distribution of the daily nutritional requirements. Facilities must meet daily dietary requirements and requests, with consideration of food allergies, reasonable religious, ethnic, and personal preferences, and temporary need for meals to be delivered to the resident’s room. All modified diets must be prescribed by a physician.
Housing with services establishments. Not specified.
Residential care facilities. Some of the provisions typically included in resident agreements are contained in the section on resident rights. They include the right to receive (at the time of admission) a written notice of the basic daily or monthly rate; all facility services (including those offered on a need basis); information on related charges; and admission, readmission, and discharge policies. A 30-day notice of changes in rates or services is required.
An evaluation of the individual needs of each resident must be initiated before admission and must be updated at least semiannually or upon a significant change in condition. Subsequent evaluations must be used to compare against the baseline evaluation to assure that the care a resident requires is within the range of personal care and supervision provided by the facility. At a minimum the evaluation must include information on the resident’s physical and mental status, independence in ADLs, weight, and ability to self-administer medications.
Housing with services establishments. Contracts include the name, street and mailing address of the establishment, the owner and managing entity, if any; a statement describing the disclosure document and licensure status; term of the contract; services to be provided in the base rate; additional services available and their cost; process for changing the contract; complaint resolution process; the resident’s designated representative, if any; the establishment’s referral procedures if the contract is terminated; the criteria used by the establishment to determine who may continue to reside in the establishment; a description of the process for assuring that the resident’s needs are assessed on admission and periodically thereafter in conjunction with the resident and the resident’s representative and for assuring that the resident’s physical, mental, and psycho-social needs are met within the terms of the contract criteria for residence; the billing and payment procedures and requirements; that an establishment’s contract must state that: except as stated in the contract, residency in the establishment may not be terminated due to a change in the resident’s health or care needs; the ability of a resident to engage in activities away from the establishment regardless of time, duration, and distance of the activities may not be restricted; except to protect the rights and activities of other residents, the establishment may not restrict the ability of a resident to have visitors and to receive family members and guests; and except as stated in the contract and identified in the disclosure document, the operator may not: restrict the ability of a resident to use a home health agency, home health provider, hospice, home health attendant, or case management service of the resident’s choice; or require a resident to use home health services; that except where a resident’s health or safety or the health and safety of others are endangered, an operator shall provide at least 30 days notice to the resident or the resident’s designated representative before terminating the resident’s residency.
Provisions for Serving People with Dementia
Residential care facilities. Facilities that offer special care must complete a disclosure statement that includes: the facility's mission or philosophy statement concerning the needs of residents with Alzheimer's disease, a related disorder, or dementia; the process and criteria the health facility uses to determine placement, transfer, or discharge from Alzheimer's and dementia special care; the process for the assessment, establishment, and implementation of a plan of Alzheimer's and dementia special care, including how and when changes are made to a plan of care; the following information concerning the staff of the Alzheimer's and dementia SCU. The disclosure statement must also include: the staff-to-patient ratio for each shift; the positions and classifications of staff; the initial training or special education requirements of the staff; and the qualities and amount of continuing education and in-service training required for staff; a description of the Alzheimer's and dementia SCU and the unit's design features; the frequency and types of activities for the residents of the facility who have Alzheimer's disease, a related disorder, or dementia; the extent that the health facility's Alzheimer's and dementia SCU and program offers family support programs and solicits input from family members; guidelines for using physical and chemical restraints in providing Alzheimer's and dementia special care; an itemization of the health facility's charges and fees for Alzheimer's and dementia special care and related services; and any other features, services, or characteristics that the health facility believes distinguishes the health facility from Alzheimer's and dementia.
Facilities that are required to submit an Alzheimer's and dementia SCU disclosure form must designate a director. The director must have a degree from an educational institution in a health care, mental health, or social service profession or be a licensed health facility administrator. The director shall have a minimum of one year work experience with dementia or Alzheimer's residents, or both, within the past five years. Persons serving as a director for an existing Alzheimer's and dementia SCU at the time of adoption of this rule are exempt from the degree and experience requirements. The director shall have a minimum of 12 hours of dementia-specific training within three months of initial employment as the director of the Alzheimer's and dementia SCU and six hours annually thereafter to meet the needs or preferences, or both, of cognitively impaired residents and to gain understanding of the current standards of care for residents with dementia.
Staff caring for residents in dementia-specific units must have a minimum of six hours of dementia-specific training within six months and three hours annually thereafter.
Housing with services establishments. Not specified.
Residential care facilities. Medications may be administered under physician’s order by licensed nursing personnel or qualified medication aides. Other treatments may be given by nurse aides upon delegation by licensed nursing personnel except for injectable medications which may be given only by licensed staff. The resident must be observed for effects of medications and documentation of undesirable effects is required, followed by notification of the resident’s physician.
Residents who self-medicate may keep and use prescription and non-prescription medications in their unit as long as they are kept secure.
Assisted living. Services are covered under an HCBS waiver. Assisted living is a comprehensive, residential service provided through the Aged and Disabled Medicaid Waiver and the Assisted Living Medicaid Waiver. Individuals who receive this service reside in an independent setting, provided by a licensed residential care provider. It is a bundle of services, which may include, but is not limited to, the following: personal care, homemaker, attendant care, medication oversight, social and recreational programming. The individual lives independently, or with a roommate if he/she so chooses. Personalized care must be furnished to clients who reside in their own living units. The apartment-like setting includes an area for a kitchenette, living area, bedroom area, and bathroom. Meals and/or nutritious snacks are also available and must meet the dietary reference intake (DRI) for adults. There is 24-hour on-site response staff, and an on-call nurse available. Regulations governing participation in the waiver are available at http://www.in.gov/legislative/iac/T04600/A00080.PDF.
In 2004, 14 facilities were approved for the waiver program and 71 beneficiaries were served. The number of participating facilities grew to 43 in the summer of 2007 after rates were increased. The number of participants was not reported. Licensed facilities must meet additional requirements for private bedrooms and baths, and a number of additional service requirements. Existing unlicensed ALFs that have submitted a disclosure form and are considered housing with services establishments and meet the waiver program requirements have not expressed an interest in becoming waiver providers because they would need to become licensed, and would need to serve a much higher acuity population than desired.
Medicaid contracting requirements provide for private apartments, shared only by choice, square footage, meal preparation, temperature controls, and door locks that differ from the licensing rules. A three-tiered payment system has been developed based on points from the assessment process. Rates have increased since 2004 (see table below). The rates do not include room and board. The SSI payment maximum is currently $623 (less a $52 PNA). The state has not issued a policy on family supplementation. The waiver uses the definition and covered services included in the HCBS waiver preprinted format: case management, RN oversight, personal care, homemaker, chore, attendant care, companion, medication oversight, and therapeutic and recreational programming.
The Residential Care Assistance Program is a state-funded program that covers limited services for residents who are aged, blind, mentally ill or disabled, low income, and/or cannot live alone but do not qualify for nursing home care. Payments are based on a flat rate. County home (housing with services establishments) rates are $27 per day for room, board, laundry, housekeeping, and limited oversight. Private RCF rates are $39.35 per day. Nineteen county homes and 42 RCFs served 418 county home residents and 1,121 people in private RCFs respectively as of March 2004.
|Medicaid Payment Rates (July 1, 2007)|
|Level 1: (<36 points)||$62.74|
|Level 2: (36–60 points)||$71.85|
|Level 3: (61–75 points)||$80.93|
Residential care facilities. Each facility must have one administrator who is responsible for the overall administration of the facility. Staff shall be sufficient in number, qualifications and training to meet the 24-hour scheduled and unscheduled needs of the residents and services provided. A minimum of one awake staff person, with CPR and first aid certificates, must be on duty at all times. If 50 or more residents require nursing services and/or administration of medication, at least one nursing staff person must be on staff at all times. For facilities with 100 or more residents requiring nursing services and/or administration of medication, at least one awake staff person must be on duty at all times, with an additional staff person required for every additional 50 residents. Employees providing more than limited assistance with the ADLs must be either a CNA or a home health aide.
A consultant pharmacist must be employed or under contract. The facility must designate an activities director who is a recreational therapist, an occupational therapist or a certified occupational therapist assistant, or someone who will complete, within one year, an activities director training course approved by the State. Facilities may employ dining assistants who may only residents who do not have complicated eating problems, which include, but are not limited to, the following: difficulty swallowing, recurrent lung aspirations or tube or parenteral/IV feedings.
Housing with services establishments. Not specified.
Residential care facilities. Administrators must be licensed.
Staff (residential care facilities). Prior to working independently, each employee shall be given an orientation of the facility by the supervisor. Orientation of all employees shall include:
- Instructions on the needs of the specialized populations served in the facility;
- A review of the facility’s policy manual and applicable procedures including organizational chart, personnel policies, appearance and grooming, and resident rights;
- Instructions in first aid, emergency procedures, and fire and disaster preparedness, including evacuation procedures;
- A detailed review of the appropriate job description, including a demonstration of equipment and procedures required of the specific position to which the employee will be assigned;
- Review of ethical considerations and confidentiality in resident care and records;
- For direct care staff, personal introduction to and instruction in the particular needs of each resident to whom the employee will be providing care; and
- Documentation of orientation in the employee’s personnel record.
On-going training must include resident’s rights, prevention and control of infection, fire prevention, safety, and accident prevention, the needs of specialized populations served, medication administration, and nursing care. For nursing personnel, training must include at least eight hours of in-service per calendar year and four hours of training for non-nursing personnel.
Any unlicensed employee providing more than limited assistance with ADLs must be either a CNA or home health aide. Dining assistants must complete a 16 hour training program that has been approved by the department.
Residential care facilities. Annual surveys are conducted by the Department of Health.
Housing with services establishments. The state may impose financial penalties for violations of the disclosure requirement. A housing with services establishment may request a review of the penalty. If the state determines that an establishment has had substantial and repeated violations, the state may prohibit an establishment from using the term “assisted living” to describe the establishment’s services and operations to the public. If the state determines that the establishment has made intentional violations of the disclosure requirement or has made fraudulent and material misrepresentatives to a resident, the state may request the attorney general to investigate and take appropriate action against the operator or administrator.
Licensure fees are collected annually: $200 for the first 50 beds and each additional bed is $10.
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