Residential Care and Assisted Living Compendium: 2007. Ohio

11/30/2007

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

Citation

Residential care facilities, Ohio Revised Code Annotated §3721 et seq.; Ohio administrative code §3701-17-50 et seq.
Adult care facilities, Ohio Revised Code Annotated 3722 et seq.; Ohio Administrative Code Chapter 3701-20-01 et seq.

General Approach and Recent Developments

Changes to the RCF rules were effective in 2007 that establish new requirements for facilities serving special populations, admission/retention, staffing, training, dietary standards and fire safety. Adult care facility rules were updated in 2006. Legislation authorizing a Medicaid HCBS waiver to cover services in assisted living was passed and implemented in 2006.

Residential care facilities provide supervision, personal care services, and may administer medications, supervise special diets, and perform dressing changes. RCF residents may also receive up to 120 days of nursing services on a part-time intermittent basis.

Adult care facilities provide supervision and personal care services. Adult care facilities are prohibited from administering medications, supervising special diets, or performing dressing changes. However, adult care facility residents with short-term illnesses may receive up to 100 days of these and other needed nursing services.

Adult Foster Care

Adult foster homes are regulated by the Department on Aging and are defined as a residence, other than a residence certified or licensed by the Ohio Department of Mental Health, in which accommodations and personal care services are provided to one or two adults who are unrelated to the owner of the residence. Rules are available at: http://goldenbuckeye.com/_pdf/rltcop/afhrules.pdf.

Web Address Content
http://www.odh.ohio.gov/rules/final/f3701-17.aspx   Residential care rules
http://www.odh.ohio.gov/rules/final/f3701-20.aspx Adult care facility rules  
http://pubapps.odh.ohio.gov/EID/Default.aspx List
http://www.goldenbuckeye.com/families/al.html Consumer

 

Supply
Category 2007 2004 2002
  Facilities   Units   Facilities   Units   Facilities   Units
Adult care facilities 658 5,213 712 5,666 805 5,783
Residential care facilities   547   38,792   510   36,255   462   31,937  

Definition

Residential care facility means a home that provides either of the following:

Accommodations for 17 or more unrelated individuals and supervision and personal care services for three or more of those individuals who are dependent on the services of others by reason of age or physical or mental impairment.

Accommodations for three or more unrelated individuals, supervision, and personal care services for at least three of those individuals who are dependent on the services of others by reason of age or physical or mental impairment, and provides to at least one of those individuals any of the skilled nursing care authorized by section 3721.011 of the Revised Code.

Any entity that meets this definition must be licensed.

Adult care facility means an AFH or an AGH. An AFH is a residence or facility that provides accommodations to 3-5 unrelated adults, and supervision and personal care services to at least three of those adults. AGHs provide accommodations to 6-16 unrelated adults, and supervision and personal care to at least three of the unrelated adults.

Unit Requirements

Residential care facilities must offer 100 square feet for single occupancy rooms and 80 square feet per person in multiple occupancy rooms. No more than four people may share a room. A toilet, sink, tub/shower is required for every eight residents. If there are more than four persons of one sex to be accommodated in one bathroom on a floor, a bathroom must be provided on that floor for each sex residing on that floor.

Adult care facilities must offer 80 square feet for single occupancy rooms and 60 square feet per person in multiple occupancy rooms. Beginning December 2006, no more than two people may share a room. Existing rooms occupied by more than two residents are grandfathered but residents who move cannot be replaced if they exceed the maximum. A toilet, sink, tub/shower is required for every eight residents.

Admission/Retention Policy

Residential care facilities. Except for residents receiving hospice care, no RCF shall admit or retain an individual who: requires skilled nursing care that is not authorized by Section 3721.011 of the Revised Code or is beyond that which the specific facility can provide; requires medical or skilled nursing care at least eight hours per day or 40 hours per week; requires chemical or physical restraints as defined in paragraph (L) of Rule 3701-17-59 of the Administrative Code; is bedridden with limited potential for improvement; has Stage III or IV pressure ulcers; or has a medical condition that is so medically complex or changes so rapidly that it requires constant monitoring and adjustment of treatment regimen on an on-going basis.

Adult care facilities may not provide but may admit and retain individuals who need part-time, intermittent nursing care to treat a short-term illness.

Nursing Home Admission Policy

For the skilled LOC, individuals must require at least one skilled nursing service at least seven days a week, or a skilled rehabilitation service at least five days a week. For intermediate care, an individual must need hands-on assistance with at least two ADLs; or assistance with one ADL and is unable to perform self-administration of medications and requires assistance with administration; or requires one or more skilled services at less than a skilled care level (seven days per week); or the person requires the supervision of another person 24-hours-a-day due to dementia.

Services

Residential care facilities may provide supervision, personal care, laundry, activities, meals, and nursing services that include supervision of special diets, application of dressings, and administration of medication, and may also provide other nursing services on a part-time, intermittent basis for a total of not more than 120 days in any 12-month period. Part-time, intermittent is defined as less than eight hours a day or less than 40 hours a week. The skilled nursing services may be provided by the RCF, a licensed hospice agency, or a certified home health agency. RCFs may not administer parenteral nutrition. In adult care facilities, part-time, intermittent nursing services may be provided for up to 120 days in any 12 month period by either a licensed hospice, a certified home health agency, licensed nursing home, or mental health agency to residents with short-term illnesses. Short-term illness means either a medical condition for which recovery can be expected to occur with not more than 35 consecutive days of skilled nursing care or a medical condition requiring skilled, nursing care provided on a periodic, scheduled basis.

A health assessment covering specific areas must be performed within 48 hours of admission and at least annually unless required sooner. The updated assessment must include change in health status. Risk agreements may be used, and are valid only if they are in writing.

In adult care facilities, a health assessment must be conducted by a physician or other licensed professional. The purpose of the assessment is to ensure that a resident is not being admitted with needs beyond the facility’s capacity to provide care. The assessment must be completed within 14 days of admission. Annual assessment are required or upon significant change in condition.

Facilities may enter into a risk agreement with a resident or the resident’s sponsor through which the resident or sponsor and the facility agree to share responsibility for making and implementing decisions affecting the scope and quantity of services provided by the facility to the resident. The facility also agrees to identify the risks inherent in a decision made by a resident or sponsor not to receive a service provided by the facility.

Dietary

Residential care facility. Facilities may choose not to provide meals, or they may provide one, two, or three meals; preparation of simple diets and one, two, or three meals; preparation and supervision of simple diets and three meals; preparation and supervision of calculated diets and three meals. Meals must provide the recommended daily allowances of the Food and Nutrition Board and be based on a standard meal planning guide from a diet manual published by a dietician or registered dietician or approved by a dietician. Serving sizes and content are described in the regulations. Facilities providing special diets must monitor staff that prepare or serve the food and monitor residents. Facilities must have policies and procedures that assure that special diets are prepared and offered as ordered. Facilities that do not provide meals must ensure that each resident unit is appropriately and safely equipped with food storage and preparation appliances which the facility maintains in safe operating condition or ensure that each resident has access to such meal preparation and storage appliances.

Adult care facility. These facilities must make three meals available that provide for the recommended dietary allowances of the Food and Nutrition Board and snacks. Special diets shall be prepared in accordance with orders from a physician or a licensed dietician.

Agreements

Adult care facility and residential care facility agreements cover all charges including security deposits; a statement that all charges, fines, or penalties that shall be assessed are included in the agreement; a statement that the basic rate will not change without 30-days’ notice; refund policy; an explanation of the services offered and the type of skilled nursing care provided and allowed; and any limitations on the type and duration of skilled nursing and the extent and types of services that will be provided and who is responsible for payment. RCFs must explain their policy on smoking, resident’s rights, care for persons with Alzheimer’s disease, dementia, or a related disorder by means of an ASCU, ability to accommodate handicapped residents, and advance directives and issue a statement concerning discharge when the resident’s skilled nursing needs exceed their capacity.

Provisions for Serving People with Dementia

Changes in 2007 require that applications from facilities that serve special population a written description of the special care provided that includes: a statement of mission or philosophy that reflects the needs of the special population; admission criteria to the RCF, or part thereof, including screening criteria transfer and discharge criteria and procedures; a weekly staffing plan for the facility or part thereof; a description of activities offered, including frequency and type, and how the activities meet the needs of the type of residents; specialized staff training and continuing education practices; the process used for assessment and the provision of services, including the method for altering services based on changes in condition; if necessary, how the facility addresses the behavioral health care needs of residents; the physical environment and design features to support the functioning of residents in the facility or part thereof; the involvement of families and the availability of family support programs for residents in the facility.

Earlier rule changes establish disclosure requirements for RCFs that serve people with dementia. The disclosure includes the form of treatment; philosophy and mission; the process and criteria for placement, transfer, and discharge; assessment and treatment process; staff training and continuing education practices; the physical environment and design features; frequency and type of activities; involvement of families and availability of family support programs; and the cost of specialized services and additional fees. Staff in special care facilities who plan activities for residents with special need must have training in appropriate activities for individuals with cognitive impairments or serious mental illness. Staff in facilities that admit or retain residents with late-stage cognitive impairment with significant on-going daily living assistance needs, or cognitive impairments with increased emotional needs or presenting behaviors that cause problems for the resident or other residents, or both, shall have, within 14 days of the first day of work, two hours of training in Alzheimer's and/or dementia care. Staff members shall receive four hours of continuing education in Alzheimer's disease, dementia or related disorders annually.

Medication Administration

Medications may be administered in RCFs by RNs, LPNs that have completed an approved training program and under direction from an RN, and physicians. No medications may be administered to a resident unless ordered by a physician or individual authorized under state law to prescribe medications. Trained non-licensed staff of both RCFs and adult care facilities may assist with self-administration. Assisting with self-administration requires the resident to be mentally alert and able to participate in the medication process and includes reminders, observing, handing medications to the resident, verifying the resident's name on the label, and, for physically impaired residents, removing oral or topical medications from containers, applying medication upon request, and placing containers with medication to the mouth of the resident. Medications may be administered by a licensed hospice agency, certified home health agency, or a member of the RCF’s staff who is qualified to do so. Adult care facility staff may not administer medications. However, medications may be administered by a home health agency, hospice care program or nursing home staff.

Public Financing

Medicaid waiver coverage was implemented in 2006 for individuals who receive services under a HCBS waiver who would move to a nursing home in the absence of the ALP or who live in a nursing home and relocate to an ALR (RCF). This limitation which was included in statute has limited provider participation. Legislation to allow other individuals to be covered passed in 2007. The Department of Aging website -- http://www.goldenbuckeye.com/providers/al.html -- includes information on conditions of participation; the statutory definition of assisted living services; transition services that may be covered for beneficiaries moving from to assisted living; and questions and answers about provider certification.

The program served 235 beneficiaries in 60 ALFs in July 2007. Family supplementation is not permitted. Individuals on the assisted living waiver receive a PNA of $50.00. Room and board charges are limited to $573. A three tiered payment methodology was implemented (see table below). Tiers are assigned based on three levels of service and four categories (i.e., cognitive impairments, physical impairments, nursing, and medication management) and the amount and type of service(s) the assisted living provider is responsible for delivering to the consumer.

  • The cognitive impairment category tier assignment is based on the frequency of intervention required ensure the consumer’s health and safety needs are met.

  • The physical impairment category tier assignment is based on the amount of time required to assist the consumer with ADLs/IADLS as a result of a physical limitation(s). Examples of a condition/diagnosis that may result in the need for assistance with ADLs/IADLS include: Parkinson’s disease, chronic obstructive pulmonary disease (COPD), amputee secondary to diabetes, cerebrovascular accident (CVA).

  • The nursing category tier assignment is based on the frequency of individualized, hands-on nursing care provided by the facility.

  • The medication management category tier assignment is based on the type of intervention required by the consumer provided by the facility.

Medicaid Payment Rates (2007)
Category Tier 1 Tier 2 Tier 3
Rate $49.98 per day $60.00 per day $69.98 per day
Cognitive Impairments Occasional prompts Daily cuing and Prompts On-going cuing, prompts, and redirection
Medication Administration Independent with Medications (requires no staff involvement) Supervision/Assistance with Medication Management (staff involvement with procurement, storage, and reminders) Medication Administration by qualified staff
Nursing No individualized, scheduled, hands-on care provided by a licensed nurse Weekly and/or Monthly individualized, hands-on care provided by a licensed nurse. Daily nursing care due to an unstable medical condition or intermittent skilled nursing care provided by the facility
Physical Impairments Individuals who require up to 2.75 hours of service per day Individuals who require more than 2.75 hours and less than 3.35 hours of service per day Individuals who require more than 3.35 hours of service per day
NOTE: The category with the highest tier assignment determines the tier that will be assigned. Example: if a client meets Tier 2 for cognitive impairments and Tier 3 for Medication Management, Tier 3 will be the assignment.

The SSI payment standard, with the state supplement, is $850 and the PNA is $50. However, the supplement is only available to non-waiver participants. The state is considering increasing the PNA and expanding coverage to include RCFs.

Staffing

Residential care facilities must have an administrator on staff at least half-time per week.

Facilities that administer medication must employ a RN; a LPN that has successfully completed a course in medication administration who administers medication only at the direction of a RN or physician; a physician; or a person authorized by law to administer medication. Facilities that provide for the application of dressings must have sufficient nursing staff to provide the service and facilities offering skilled nursing care using staff must have sufficient nursing staff to provide the skilled nursing care. If the RCF elects to provide enteral tube feedings on a part-time intermittent basis the facility shall provide or arrange for a dietitian and provide sufficient nursing staff with appropriate experience and training in enteral tube feedings.

At least one staff member must be on-site at all times. During the evening, the staff member on-site may be on call if the facility meets the call signal requirements established in rule. When only one staff member is on duty in the facility, the facility must designate another person who meets the same qualifications to be on call. Staff may be shared with other licensed facilities in the same building or in the same lot as long as staffing requirements for all facilities are met.

Adult care facilities, which include some semi-independent living homes, must have one staff member on-site whenever a resident who requires on-going supervision; assistance with walking, moving, bathing, toileting dressing, eating, evacuation; or PRN medications is present. When only one staff person is on duty, the facility must designate another staff person to be available immediately in case of emergency.

In addition, for both RCFs and adult care facilities, sufficient additional staff must be available to meet, in a timely manner, the residents’ care, supervisory, and emotional needs and reasonable requests for service, including on-going supervision of residents with increased emotional needs or presenting behaviors that cause problems for the resident or other residents and to properly provide dietary, housekeeping, laundry, and facility maintenance services and recreational activities.

Training

Residential care facility administrators must be a licensed nursing home administrator or have 2,000 hours of operational responsibility in related facilities, must have successfully completed 100 credit hours of post-high school education in gerontology, be a licensed health professional, or hold a baccalaureate degree. RCF administrators also must receive annually nine hours continuing education in gerontology, health care, business administration, or RCF operation.

Adult care facility managers are required to have six hours of basic orientation and training applicable to job duties including cleanliness/sanitary conditions; conflict resolution; documentation; financial management: provider and resident; resident screening and referral procedures; role and responsibilities of adult care facilities; and role and responsibilities of ombudspersons, other governmental systems and resources and six hours of continuing education annually on the above topics plus the following: implementation and interpretation of adult care facility administrative rules and statute; personal care service protocols; and policy and procedure updates.

Staff. Staff members who provide personal care services in a RCF must successfully complete training or continuing education that covers the following: the correct techniques of providing personal care services as required by the staff member's job responsibilities; observational skills such as recognizing changes in residents' normal status and the facility's procedures for reporting changes; and communication and interpersonal skills. The training or continuing education shall be provided by a RN or a LPN under the direction of a RN, and be sufficient to ensure that the staff member receiving the training can demonstrate an ability to provide the personal care services. The facility may utilize other health care professionals acting within the scope of the professional's practice as part of the training or continuing education; or successfully completed the training and competency evaluation program and competency evaluation program approved or conducted by the director; or successfully completed the training or testing requirements in accordance with the Medicare condition of participation of home health aide services.

Both adult care facilities and RCFs must provide orientation and training for all staff in job responsibilities, facility procedures, securing emergency assistance, and resident rights.

Adult care facility and RCF staff who provide personal care must have currently valid documentation of a successfully completed first aid course before they have contact with residents.

The manager and each staff member providing personal care services shall annually receive a minimum of six hours of training in topics relevant to persons diagnosed with mental illness who are residing in the facility. Each adult care facility staff member shall have training in the facility's fire control and evacuation procedures and training in how to secure emergency assistance in the event of suspected fire, medical emergency, or other crisis. Adult care facility staff that provide personal care must successfully complete training or continuing education that covers the correct techniques of providing personal care services to others.

Background Check

Criminal background checks are required for any individual used by an adult care facility or RCF in a position that provides direct care to older adults. Staff providing direct care services must also provide fingerprint impressions.

Monitoring

Residential care facilities must be inspected at least once prior to the issuance of a license and one unannounced visit every 15 months by the Department of Health and the fire marshal. State or local adult care facilities must be inspected annually by the Department. These visits must be unannounced and with additional unannounced visits made as deemed necessary. AGHs must also undergo an annual fire inspection.

Inspections are compliance-based, and do not incorporate a consultative or collaborative component.

Fees

Residential care facility: licensing and renewal fee of $105 for every 50 persons, or part thereof of licensed capacity.

Adult group home: license fee is $50.

Adult family home: license fee is $25.

AGHs and AFHs must also pay an inspection fee of $20 for each licensed bed.

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