[A PDF [http://aspe.hhs.gov/daltcp/reports/2007/07alcomNV.pdf] of only this state's summary also available]
Residential Facilities for Groups: Nevada Revised Statutes §449.017 et seq.; Nevada administrative code §449.156-2766
General Approach and Recent Developments
Revisions to the regulations were adopted in 2005 and 2006. The rules set requirements for facilities seeking to provide assisted living services based on legislation that requires licensed facilities to obtain an endorsement on its license authorizing it to operate as a residential facility which provides “assisted living services.” Facilities may not market themselves as providing assisted living services unless they obtain an endorsement from the licensing agency. Facilities will provide to any potential resident a full written disclosure describing what personalized care services will be available and the amount charged for those services. Physical plant standards require independent units to contain toilet facilities and a sleeping area or bedroom. In facilities with 11 or more residents, units will be able to be shared by consent only. New core principles are described including the promotion of resident quality of life, individualized needs, and personal choice; creative and innovative service provision; resident autonomy; fostering a community atmosphere; and facility operations that minimize the need for residents to move out of the facility as resident needs change over time. Application fees will be $200. Revised minimum staff training requirements for residential facilities which provide services to persons with Alzheimer’s disease are being proposed.
In January 2004, Nevada amended their HCBS waiver for the Elderly in Group Care Homes to include an assisted living service.
Adult Foster Care
A home for individual residential care is a home in which a natural person furnishes food, shelter, assistance and limited supervision, for compensation, to not more than two persons who are aged, infirm, mentally retarded or handicapped, unless the persons receiving those services are related within the third degree of consanguinity or affinity to the person providing those services. Regulations are available at: http://leg.state.nv.us/nac/NAC-449.html#NAC449Sec15511.
|Residential care facilities for groups||258||3,941||300||4,021||372||NR|
Residential facility for groups means an establishment that furnishes food, shelter, assistance and limited supervision to an aged, infirm, mentally retarded or handicapped person. The term includes, without limitation, an ALF. The term does not include an establishment which provides care only during the day, persons providing care for no more than two persons in their home, persons providing care for one or more persons related within the third degree of consanguinity or affinity, a halfway house for recovering alcohol and drug abusers, or facilities funded by a division or program of the Department of Human Resources.
Residential facilities for groups may specialize in care for different groups: elderly and disabled, mentally ill, Alzheimer’s and related dementia, hospice care, mentally retarded adults, and persons with chronic illnesses. In order to specialize in care for different groups, a facility must obtain an endorsement on its license authorizing it to operate as a residential facility which provides care to a specific population (e.g., persons with Alzheimer’s disease).
A residential facility for elderly or disabled persons means a residential facility which provides care to persons requiring assistance and protective supervision due to infirmity or disability.
A residential facility which cares for persons with Alzheimer’s disease means a residential facility which provides care and protective supervision for persons with Alzheimer’s disease or a related disease, including, without limitation, senile dementia, organic brain syndrome, or other cognitive impairment.
To provide assisted living services, facilities must make a full written disclosure to the person regarding what services of personalized care will be available to the person and the amount that will be charged for those services throughout the resident’s stay at the facility. The residents of the facility reside in their own living units which contain toilet facilities, a sleeping area or bedroom, and are shared with another occupant only upon consent of both occupants.
Facilities provide personalized care to the residents of the facility and the general approach to operating the facility incorporates these core principles:
- The facility is designed to create a residential environment that actively supports and promotes each resident’s quality of life and right to privacy;
- The facility is committed to offering high-quality supportive services that are developed by the facility in collaboration with the resident to meet the resident’s individual needs;
- The facility provides a variety of creative and innovative services that emphasize the particular needs of each individual resident and his personal choice of lifestyle;
- The operation of the facility and its interaction with its residents supports, to the maximum extent possible, each resident’s need for autonomy and the right to make decisions regarding his own life;
- The operation of the facility is designed to foster a social climate that allows the resident to develop and maintain personal relationships with fellow residents and with persons in the general community;
- The facility is designed to minimize and is operated in a manner which minimizes the need for its residents to move out of the facility as their respective physical and mental conditions change over time; and
- The facility is operated in such a manner as to foster a culture that provides a high-quality environment for the residents, their families, the staff, any volunteers and the community at large.
Single occupant rooms must have 80 square feet of floor space and multiple resident rooms must have 60 square feet of floor space per resident. No more than three residents may share a room. One toilet and lavatory is required for every four residents. A tub or shower is required for every six residents. However, new legislation provides that units may be shared “with another occupant only upon consent of both occupants and all units must include toilet facilities. Doors of bedrooms may be equipped with locks for use by residents if the doors may be unlocked from the corridor and keys are readily available. Provisions must be made for privacy in all bathrooms and for all toilets located in bedrooms for use by more than one resident.
Facilities serving people with Alzheimer’s disease must be have sprinklers and have 24-hour awake staff. Exit doors must have alarms or time-delay locks. Local audible alarming units must be installed. Facilities serving people with Alzheimer’s disease must have a secure yard, completely fenced and gated with locking devices.
Residents are considered Care Category 1 (ambulatory) and Care Category 2 (non-ambulatory). Ambulatory residents are physically and mentally capable of moving unassisted from an unsafe area to an area of safety within four minutes. Non-ambulatory residents require the assistance of at least one other person to move to a safe area within four minutes. Facilities licensed prior to January 1, 1997, are not required to meet requirements for installing automatic sprinkler systems unless they seek to serve Category 2 residents. Sprinklers must be installed prior to a change of ownership, an increase in licensed beds, or admission of non-ambulatory residents. Requirements for hard-wired smoke detectors with battery back up are also waived for small homes unless the above changes are proposed.
People who are bedfast, require restraints, 24-hour skilled nursing or medical supervision, and/or require restraints or confinement in locked quarters may not be admitted. The rules do not allow facilities to admit or retain residents with a lengthy list of health conditions with some exceptions. Residents with (or needing) catheters, colostomies or ileostomies, contractures, pressure ulcers, diabetes, unmanageable incontinence, enemas/suppositories, oxygen, injections, protective supervision, or wound care may not be admitted or retained unless the resident is physically and mentally capable of performing the required care or if the care is provided or supervised by an appropriately skilled medical professional. Residents needing gastronomy care, naso-gastric tubes, or have staph or other serious infections or tracheotomies cannot be admitted or retained unless a written request is submitted by the administrator documenting the resident’s condition and how care can be provided and the request is approved by the licensing agency. A resident who is suffering from an illness or injury from which the resident is expected to recover within 14 days after the onset of the illness or the time of the injury may be cared for in the facility. A resident may reject medical care. This rejection must be recorded and signed by the resident.
Nursing Home Admission Policy
Individuals are nursing home eligible if the individual’s condition requires the level of services provided by either a skilled nursing facility or ICF with at least three deficits identified in the following areas: (1) self-administration of medications; (2) treatments/special needs such as oxygen, tracheostomy, suctioning, ventilator dependent, IV, central line, feeding tube, wound care, glucose monitoring, insulin coverage, as examples; (3) ADLs; (4) need for supervision; and (5) IADLs.
Services provided include personal care; at least ten hours of activities a week; three meals a day; protective supervision; laundry; and assistance with access to dental, optical, social, and related services as needed by residents. Assistance with medical needs described in the Admission/Retention Policy section may be provided through a contract with a community agency or directly by staff hired by the facility. Assessments are completed by a physician.
Three meals a day and snacks that meet the recommended dietary allowance of the Food and Nutrition Board must be provided. Meals must be nutritious, served in an appropriate manner, suitable for the residents and prepared with regard for individual preferences and religious requirements. At least three meals a day must be served at regular intervals. The times at which meals will be served must be posted. Not more than 14 hours may elapse between the meal in the evening and breakfast the next day. Snacks must be made available in between meals for the residents who are not prohibited by their physicians from eating between meals. A resident must be served meals in his bedroom for not more than 14 consecutive days if he is temporarily unable to eat in the dining room because of an injury or illness. The facility may serve meals to other residents in their rooms upon request. Special diets may be provided if ordered by a physician or dietician. Facilities with more than ten residents must consult at least quarterly with a registered dietician concerning development and review of weekly menus, training for kitchen employees, compliance with nutritional program of the facility, and other observations regarding preparation and serving of meals.
Administrators must make the following information available upon request: the basic rate and the services included, schedule of payment, charges for optional services, and the refund policy.
Provisions for Serving People with Dementia
Facilities serving people with Alzheimer’s disease must obtain an endorsement on its license to do so. Administrators must have three years’ experience caring for residents with Alzheimer’s disease or a combination of education and training. The facility’s policies and procedures must include a description of the basic services, activities, the manner in which behavioral problems will be addressed, medication management, steps to encourage family involvement, criteria for admission and discharge, and steps that have been developed to prevent and respond to wandering. Facilities must offer activities related to gross motor skills, social activities, sensory enhancement activities, and outdoor activities. At least one awake staff must be on duty at all times. Within a week of employment, staff must receive at least two hours of training in providing care, including emergency care, to a resident with any form of dementia, including, without limitation, Alzheimer’s disease, and providing support for the members of the resident’s family. Within three months of employment, staff must complete eight hours of training in providing care to residents with Alzheimer’s disease and providing support to family members. Exits must have warning devices. The grounds must be secure.
Facility staff may administer medication and assist with self-administration of medications when the resident’s condition is stable and following a predictable course, the amount of medication is at a maintenance level and does not require daily assessment, and a written plan of care has been prepared by a physician or RN. The staff assisting with self-administration must complete a training program in medications.
Amendments effective January 2004 to the HCBS Waiver changed the name from Elderly in Group Care Homes to the “Waiver for the Elderly in Adult Residential Care” (WEARC). An assisted living waiver was also approved in 2006 to provide augmented personal care and case management to a maximum of 54 participants. Participants must meet the criteria for placement in a group care home or ALF and meet the 300% SSI eligibility criteria. To participate in this waiver, individuals must be placed from a nursing facility, hospital, or have been a participant in one of three other waivers serving the Frail Elderly, People with Physical Disabilities, and Persons with Mental Retardation and Related Conditions. There is one ALF that opened in Las Vegas. There are plans to open a second facility with the projected opening date of March 2009.
|Waiver for the Elderly in Adult Residential Care||73||330||52||222||66||121|
|Adult Residential Care Levels of Service (2007)|| Daily
|Assisted Living Level 1||Supervision to minimal assistance with an ADL and a score a 3 on the Total LOC Score line.||Personal Care Level 1||Supervision to minimal assistance with an ADL and a score a 3 on the Total LOC Score line.||$20.00|
|Assisted Living Level 2||Moderate assistance with both critical ADLs* or moderate assistance with any 4 ADLs or dependent with 1-2 ADLs or score of 2 in at least 1 critical behavior.**||Personal Care Level 2||Moderate assistance with both critical ADLs* or moderate assistance with any 4 ADLs or dependent with 1-2 ADLs or score of 2 in at least 1 critical behavior.** Minimal physical assistance with ADLs, with some self-care tasks requiring moderate levels of assistance.||$45.00|
|Assisted Living Level 3||Maximum assistance to dependent with both critical ADLs or maximum assistance with any 4 ADLs or dependent for 3 or more ADLs or score of 3 in at least one critical behavior area.||Personal Care Level 3||Maximum assistance to dependent with both critical ADLs or maximum assist with any 4 ADLs or dependent for 3 or more ADLs or score of 3 in at least one critical behavior area. Moderate physical assistance with ADLs, with some self-care tasks requiring maximal levels of assistance.||$60.00|
|* Critical ADLs include eating/feeding, bladder and bowel continence
** Critical behaviors include wandering, resists care, self-abusive behavior, abusive to others, and memory/cognition
The new assisted living waiver provides a greater level of choice than WEARC and provides for care in a more individual apartment/studio setting that includes a kitchenette, a sleeping/living room, and private bath. Rooms may be shared with another person only by choice. Both waivers have three levels of service based upon the recipient’s functional need, determined through a comprehensive assessment process by a RN or licensed social worker. Assessments are completed annually or upon a significant change in condition. A plan of care is developed from the comprehensive assessment by a social worker or a case manager, and must include the input of the recipient or the recipient’s representative.
Medicaid payment is not available for room and board, items of comfort or convenience, or the costs of facility maintenance, upkeep and improvement. Family supplementation has been discussed but not implemented. The SSI and state supplement payment standard is $1,014 a month which includes a PNA of $102. Room and board fees are determined by the facility for WEARC participants. The Medicaid service payment in both waivers is $20, $45, or $60 a day (about $600, $1,350, or $1,800 a month) depending on the assessment of the level of service.
Facilities must maintain staffing patterns that are sufficient to meet the care needs of residents and to enable residents to achieve and maintain their functioning, self-care, and independence. Facilities with more than 20 residents must have at least one awake staff member and an additional person available within ten minutes. Staff of all facilities must receive annually eight hours of training that is directed toward meeting the needs of group-care residents. Facilities licensed for 20-49 residents must have one staff member designated to organize, conduct, and evaluate activities. Facilities with 50 or more beds must have a full-time person for activities. Volunteers may be used to supplement the services and programs of a residential facility, but may not be used to replace members of the staff of the facility.
Administrators must have the necessary skills to meet or direct staff to meet the needs of residents unless such skills are met by appropriately skilled medical professionals who are employed by or contract with the facility. Administrators must receive annually eight hours of training that is directed toward meeting the needs of group-care residents.
All staff must possess the necessary knowledge, skills and abilities to meet the needs of the residents in the residential facility with the exception of those needs/skills which are to be met in a contract with other service providers. Within 60 days after being employed by a residential facility for elderly or disabled persons, a caregiver must receive not less than four hours of training related to the care of those residents. Staff must receive annually eight hours of training that is directed toward meeting the needs of group-care residents. If a resident of a residential facility uses prosthetic devices or dental, vision or hearing aids, the caregivers employed by the facility must be knowledgeable of the use of those devices. Staff who assist residents with administration of any medication, must receive at least three hours of training in the management of medication. The caregiver must receive the training at least every three years and provide the residential facility with satisfactory evidence of the content of the training and his attendance at the training; and pass an examination every three years.
Within 30 days after an administrator or caregiver of a residential facility is employed at the facility, the administrator or caregiver must be trained in first aid and CPR. The advanced certificate in first aid and adult CPR issued by the American Red Cross or an equivalent certification will be accepted as proof of that training.
Caregivers must have no prior convictions or history of previous findings of abuse, neglect, or exploitation or other serious convictions relating to the ability to care for dependent persons. All other staff must not have any convictions or history of abuse, neglect, or exploitation. Reference checks may be used for documentation.
Facilities are subject to on-site inspections and complaint investigations. The licensing agency views the oversight process as less structured than nursing facility oversight, although the focus on compliance and quality of care is still paramount. They provide on-site education during the survey process, which has been more effective than a plan of correction-only approach.
Initial fees are $2,400 plus $184 per bed. Renewal fees are $1,182 plus $92 per bed. Residential facilities for groups with low income beds have an initial fee of $2,400 plus $100 per bed. Renewal fees are $1,182 plus $35 per bed. Residential facilities for groups with less than 11 beds have an initial fee of $1,085 plus $95 per bed and renewal fees of $35 per bed for low income beds. Residential facilities for groups with less than 11 beds that have 75% or more low income beds pay an initial fee of $500 plus $92 per bed, and renewal fees of $35 per bed for low income beds. Facilities that wish to increase their bed capacity must pay a flat fee of $250 and $184 for each additional bed. For beds that will serve the low income residents, the fee is $100.
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