[A PDF [http://aspe.hhs.gov/daltcp/reports/2007/07alcomIA.pdf] of only this state's summary also available]
Assisted living programs: Iowa Code 231C and 321 IAC Chapter 25, 26, and 27; IAC 6615.626 Assisted Living Housing (Life Safety)
Residential care facilities: IAC Chapter 57 and Chapter 60
Related codes that affect but do not specifically reference assisted living: 655 IAC Chapter 6-Nurse Practice; 645 IAC Chapter 63-Salons; Iowa Code Chapter 155A-Pharmacy; 481 IAC Chapters 30 & 32-Food Service Establishments
General Approach and Recent Developments
Responsibility for promulgating regulations was transferred to the Department of Inspections and Appeals from the Department of Elder Affairs in 2007 (SF 601) following the transfer of oversight in 2004. Revisions to the regulations were effective April 14, 2004. During the past few years, the LOC provided has received increased attention.
Legislation passed in 2005 (HF 617) directed the Department of Human Services to prepare a Medicaid HCBS waiver application to cover assisted living. ALPs currently provide attendant care services to waiver participants.
Adult Foster Care
Elder group homes are licensed as a single-family residence that is operated by a person who is providing room, board, and personal care and may provide health-related services to three through five elders who are not related to the person providing the service, and which is staffed by an on-site manager 24 hours per day, seven days per week. Rules are available at: http://www.legis.state.ia.us/ACO/IAChtml/321.htm#agency_321.
|https://dia-hfd.iowa.gov/DIA_HFD/Process.doc||List, application, provider*|
|* List = entities book; application -- documents (scroll down)|
|Assisted living programs||209||10,332||184||8,246||154||6,199|
|Assisted living programs for people with dementia||39||2,740||NR||NR||NR||NR|
“Assisted living means provision of housing with services which may include, but are not limited to, health-related care, personal care and assistance with IADLs to six or more tenants in a physical structure which provides a home-like environment. Assisted living also includes encouragement of family involvement, tenant self-direction, and tenant participation in decisions that emphasize choice, dignity, privacy, individuality, shared risk, and independence. Assisted living includes the provision of housing and assistance with IADLs only if personal care or health-related care is also included” (96 Acts, Chapter 1192). SF 2193 modified the definition by including housing and IADLs only if personal care and health-related services are included.
A dementia-specific ALP means an ALP that either serves five or more tenants with dementia or cognitive disorder at Stage IV or above on the Global Deterioration Scale or holds itself out as providing special care for persons with cognitive disorder or dementia, such as Alzheimer’s disease, in a dedicated setting.
ALPs may have private dwelling units with lockable doors and individual cooking facilities. In facilities built before July 2001, units must have at least one room with not less than 120 square feet of floor area. Other habitable rooms must have at least 70 square feet. Each single occupancy dwelling unit in buildings built after July 2001 must have at least 240 square feet of floor area, excluding bathrooms. Units used for double occupancy must have at least 340 square feet, excluding bathrooms. The space requirements are lower for dementia units.
Programs may not admit or retain tenants who are bedbound, require two person assistance with standing, transfer or evacuation; pose a danger to self or others; are in an acute stage of alcoholism, drug addiction or uncontrolled mental illness; are under age 18; require more than part-time or intermittent health-related care (21 days); on a routine basis have unmanageable incontinence; or meet the program’s transfer criteria. Part-time or intermittent nursing care includes licensed nursing care for unstable conditions, daily medication injections (except stable diabetes), daily assessment or treatment of conditions such as an open wound or pressure ulcer, total care for unmanageable incontinence, or routine two-person assistance with standing, transfer, or evacuation. Managed risk statements must be used. The facility’s policy is stated in the application for certification.
Exceptions to the limit on part-time or intermittent health care may be requested for residents who need hospice care or temporarily need more than part-time or intermittent health care for more than 21 days. Approvals may be given for limited time periods if the resident makes an informed choice to remain, the program has the staff to meet the extended needs, and the health and welfare of other tenants is not jeopardized.
Nursing Home Admission Policy
Intermediate LOC can be approved if the individual requires daily supervision with dressing and personal hygiene in conjunction with one of the following: cognitive functions; mobility; skin; pulmonary status; continence; physical functioning -- eating, medications, communication/hearing/vision patterns; or prior living circumstances -- psycho-social.
Intermediate LOC can also be approved if the individual requires physical assistance by one or more persons to perform dressing and personal hygiene.
The certification application includes the process for assessing tenants’ health status, functional and cognitive ability and a copy of each assessment tool. Individualized service plans (ISPs) are required. Programs must provide some personal care or health-related services and at least one meal a day. Health-related services mean less than daily skilled nursing services and professional therapies for temporary but not indefinite periods of time of up to 21 days a month. Skilled services and therapies combined with personal care and nurse delegated activities may not total more than eight hours a day. Service plans must be developed for each tenant, and plans for tenants needing personal care or health-related services must be developed with a multidisciplinary team (including a health professional and human services professional) and the tenant.
The rules allow a managed risk statement which includes the tenant’s or responsible person’s signed acknowledgment of the shared responsibility for identifying and meeting needs and the process for managing risk and upholding tenant autonomy when tenant decision making may result in poor outcomes for the tenant or others.
Facilities must have the capacity to provide hot or other appropriate meals at least once a day or to coordinate with other community providers to make arrangements for the availability of meals. Therapeutic diets may be provided.
Each tenant signs an occupancy agreement and managed risk statement prior to admission. The agreement includes a shared responsibility/managed risk policy, all fees, charges, and rates describing tenancy and basic services covered, any additional and optional services and their cost. It also includes a statement regarding the impact of the fee structure on third-party payments and whether they will be accepted by the program; procedure for non-payment of fees; identification of the person responsible for making payment; guarantee of a 30-day written notice of any changes in the agreement unless the tenant’s health status or behavior creates a substantial threat to health and safety; occupancy and transfer criteria; grievance policies; emergency response policy; the staffing policy including whether or not staff are available 24-hours a day, whether delegation will be used and how staffing will be adapted to meet changing needs. Additional provisions are added for programs serving people with dementia; refund policy; statement regarding billing, telephone number to make a complaint; a copy of the tenant’s rights provisions; and a statement that tenant landlord law applies to ALPs.
Provisions for Serving People with Dementia
Units built in a neighborhood design offer 150 square feet of floor excluding bathroom for single occupancy and 250 square feet for double occupancy. The difference in square footage must be added to the common areas. Facilities must have an operating door alarm system. Visual or audible alarms may be disconnected if it is disruptive to a tenant. The tenant agreement must include a description of the services and programming. Dementia-specific ALPs must have one or more staff persons who monitor tenants as indicated in each tenant’s service plan. The staff shall be awake and on duty 24-hours-a-day in the proximate area, and check on tenants as indicated in the tenants’ service plans.
Programs must have a system, program, or staff procedure that responds to emergency needs in lieu of a personal emergency response system. Training for all employees includes six hours on specified topics that include: explanation of the disease; philosophy and program; skills for communicating with residents and family; family issues; importance of planned and spontaneous activities; providing ADL assistance; service planning and social history; working with challenging tenants; simplifying cuing and redirecting; and staff support and stress reduction.
Written medication plans are required. Nurse delegation rules allow administration and supervision of routine, oral medications by trained unlicensed personnel. RNs may delegate injections to licensed nursing staff. Delegation rules are issued by the Board of Nursing. RNs must monitor administration, ensure orders are current and are administered consistent with the orders. They must also document the resident’s health status and progress every 90 days.
Assisted living is covered through a Medicaid HCBS waiver, state service funds, and a state-funded rent supplement program.
Medicaid. Certified or accredited ALPs may be providers of Medicaid HCBS waiver including: assistive devices, chore, consumer directed attendant care, emergency response, home delivered meals, home health aide, homemaker, nursing, nutritional counseling, respite, senior companions, and transportation.
Services are reimbursed on a fee-for-services basis according to the care plan. There is a maximum cap of $1,083 per month on care plans.
The SSI payment standard is $623 and the PNA was increased from $30 to $50. The resident’s room and board payment is separate from the Medicaid service amount. The state uses the 300% special income level eligibility option. Residents may retain up to $1,869 a month of their income to cover room and board and other costs. Family supplementation of resident income for room and board costs is allowed up to the $1,869 limit.
State Supplementary Assistance. This state-funded program provides up to $26.50 a day for in-home health-related services that are not covered under other programs or for HCBS assisted living residents who need more care than is available under the service cap. Services may include nursing and personal care tasks when certified by a physician that the services can be provided in a person’s home, including assisted living.
State rental assistance program. This program works like HUD’s Section 8 program and pays rental expenses for low income beneficiaries who do are on a waiting list for a federal, state or local rent subsidy. Beneficiaries pay 30% of their income for rent. The program can pay the difference between the tenant’s payment and the fair market rent set by HUD. Participants must be eligible for waiver services. The average duration of the subsidy is 12 months and the average payment is $152 per month. In FY 2007, 1,635 Medicaid beneficiaries received subsidy payments.
Sufficient staffing must be available at all times to meet the needs of residents. Programs administering medications or providing health-related services must provide for a RN to monitor medications, ensure physician orders are current, and assess and monitor health status (90 days). Each program must provide access to a 24-hour emergency response system.
Administrators. The owner or sponsor of the ALP is responsible for ensuring that both management and direct service employees receive training appropriate to the task.
Staff. The ALP shall have a staffing and training plan on file and maintain documentation of training received by staff. All personnel of the ALP shall be able to implement the ALP’s accident, fire safety, and emergency procedures.
Prior to employment in an ALP, a candidate must first undergo a criminal history and dependent adult abuse records check if the individual will provide direct services to consumers. The Department of Human Services will perform an evaluation of any criminal history or founded dependent adult abuse to determine whether a prospective employee may be employed and, if so, in what capacity. [Iowa Code chapter 135C.33]
Monitoring staff hold community meetings with tenants during their site reviews. The meetings often identify concerns about quality and practice for the monitors. A protocol based on the certification requirements is used to guide the review. Tenants, program staff, and family members are interviewed. During the review, rules may be clarified and explained. Monitoring staff often participate in training meetings organized by three associations representing ALPs.
The regulations require a $900 fee for reviewing blue prints. The two year initial certification fee is $750. The recertification fee for a non-accredited program is $1,000 and $125 for an accredited program.
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