Residential Care and Assisted Living Compendium: 2007. Oklahoma

11/30/2007

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

Citation

Residential care homes: 63 Oklahoma statute §1-819 et. seq.; Oklahoma rules, §310:680:1:1 et seq.
Continuum of care and assisted living: 63 O.S. Supp. 1997, Section 1-890.1. et seq.; Oklahoma rules, Chapter 310:663:1 et. seq.

General Approach and Recent Developments

Rules for assisted living centers were updated in 2007. The changes affected requirements covering medication administration, staffing of special care facilities, the complaint procedures, incident reports, plans of correction, termination of placement, and other provisions. The revisions were based on survey experience, history of complaint allegations and investigations, and public meetings held by the Long-Term Care Facility Advisory Board. The Continuum of Care and Assisted Living Act authorized two types of health care or residential settings: the continuum of care facility and the assisted living center. The continuum of care facility provides more services than are available in a typical nursing facility. The assisted living center offers a level of services between current nursing facilities and RCHs.

An amendment is being prepared to cover services in affordable assisted living centers under Medicaid. Changes in 2004 require the physical plant to be designed and constructed in conformity with requirements for accessibility to physically disabled persons as established by the IBC. Rules prohibiting smoking except in a designated area were issued in 2002. An Alzheimer’s Disease Special Care Disclosure Act passed in 1999.

Adult Foster Care

Facilities serving three or fewer residents are covered by separate sections of the RCH rules.

Web Address Content
http://www.health.state.ok.us/PROGRAM/condiv/continuum.html Rules assisted living
http://www.health.state.ok.us/program/condiv/res.html Rules residential care
http://www.health.state.ok.us/PROGRAM/condiv/hrsd/okdir~1.asp?pageID=14&sort=1    List
http://www.health.state.ok.us/PROGRAM/condiv/alzdisclose.html Special care rules, disclosure  

 

Supply
Category 2007 2004 2002
  Facilities   Units   Facilities   Units   Facilities   Units
Residential care homes   91   2,809   103   3,358   210   8,620  
Assisted living centers 115 6,493 115 6,308 8 1,253

Definition

An assisted living center means any home or establishment offering, coordinating, or providing services to two or more persons who:

  • Are domiciled therein;
  • Are unrelated to the operator;
  • By choice or functional impairments, need assistance with personal care or nursing supervision;
  • May need intermittent or unscheduled nursing care;
  • May need medication assistance;
  • May need assistance with transfer and/or ambulation; and
  • Intermittent nursing care and home health aide services may be provided by a home health agency.

No facilities may call themselves an assisted living center or a continuum of care facility unless they are licensed. The law allows assisted living centers to be licensed as a component of a nursing facility.

A continuum of care facility means a home, establishment, or institution providing nursing facility services and at least one of the following: assisted living center services or ADC center services.

Residential care home means any establishment or institution other than a hotel, motel, fraternity or sorority house, or college or university dormitory which offers or provides residential accommodations, food services, and supportive assistance to any of its residents or houses any resident requiring supportive assistance who is not related to the owner or administrator of the home by blood or marriage. Said residents shall be ambulatory and essentially capable of managing their own affairs and do not routinely require skilled nursing care or intermediate care.

Unit Requirements

Assisted living centers. No more than two residents may share a bedroom. Each center shall ensure privacy and independence by requiring lockable doors except in the case of documented contraindication, have individually-controlled temperature controls, and the right to use personal furnishings. No more than four residents may share bathing and toilet facilities. Shower and bathing facilities shall be occupied by no more than one resident at a time. The assisted living portion of continuum of care facilities must be physically separate from the nursing home.

Residential care home. Single rooms must have 80 square feet and multiple occupancy rooms 60 square feet per bed. The regulations do not limit the number of residents who may share a bedroom. Toilet facilities must be provided for every six residents and a tub/shower for every ten residents.

Admission/Retention Policy

Assisted living centers must describe the population to be served based on the population’s need for personal care, nursing supervision, intermittent or unscheduled nursing care, medication administration, assistance with cognitive orientation and care or service for Alzheimer’s disease, and assistance with transfer or ambulation. Each center’s admission criteria must be included in the application for licensing.

The center must use a comprehensive screening instrument to determine the appropriateness of the resident’s placement in the facility. Centers may not serve anyone whose needs are inconsistent with the services provided by the facility, whose physician determines that restraints are needed, who is a threat or danger to self or others, or whose needs for privacy and dignity cannot be met by the facility.

Residential care home. The regulations do not contain a section on admission/retention criteria. The definition states that residents may not need services provided in a skilled care facility or ICF. Residents must be ambulatory and essentially capable of managing their own affairs. A home shall not involuntary transfer or discharge a resident except for medical reasons, for the resident’s safety, or for the safety of other residents, or for non-payment for the resident’s stay.

Nursing Home Admission Policy

Eligibility for nursing home admissionis based on the physician’s recommendation, an assessment by a department nurse, and professional judgment. The minimum criteria are high risk range on ADLs or mental state questionnaire (MSQ) scores; or a combination (2) of moderate ADL scores, moderate MSQscores, and high risk nutrition score. Other factors include moderate risk client support score, high risk environment or moderate risk environment, and high risk social resources.

The assessment measures eight ADLs: bathing, eating, dressing, grooming, transferring, mobility, toileting, and bladder/bowel control. High risk range ADL scores means some help with four ADLs or a person cannot perform two ADLs and needs helps with one additional ADL. Moderate risk range means needs help with three ADLs; total help with two ADLs, or total help with one ADL and help with two ADLs.

Services

Assisted living centers shall not care for any resident needing care in excess of the level that the assisted living center is licensed to provide or capable of providing. The center must ensure that routines of care provision and service delivery are directed by the resident to the maximum extent possible. The center must describe the services to be provided or arranged including: personal care, meals, housekeeping, laundry, intermittent or unscheduled nursing care, nursing supervision, medication administration, assistance with cognitive orientation, specialized services for people with Alzheimer’s disease, assistance with transfer or ambulation, planned programs for socialization, and activities and exercise. Nurses are allowed to delegate tasks that are within the scope of their license to perform. Intermittent nursing care and home health aide services may be provided in an ALF by a home health agency.

If a resident’s preference or decision places the resident or others at risk or is likely to lead to an adverse consequence, the assisted living center shall advise the resident and the resident’s representative of such risk or consequences. The assisted living center shall specify the cause for concern, discuss the concern with the resident and representative, if any, and attempt to negotiate a written agreement that minimizes risk and adverse consequences and offers alternatives while respecting resident preferences.

Continuum of care facilities must provide, coordinate or arrange care appropriate to the needs and capabilities of its residents, including the availability of care appropriate to a nursing facility or specialized facility. A facility may not care for residents needing care in excess of the LOC that the facility is licensed to provide.

An admission assessment specified by the state must be implemented 30 days before or at admission, and a comprehensive assessment specified by the state must be completed within 14 days after admission and updated at least annually thereafter or whenever a significant change occurs. The rules describe the content of the assessment. Assessments must be completed by the appropriate participation of health professionals trained in assessment, and coordinated and signed by a RN or the resident’s physician. The assessment is used to determine the appropriateness of placement and to develop a plan of care.

A managed risk process is required when resident preferences or decisions create risk or are likely to lead to adverse consequences. The center identifies the cause for concern, attempts to negotiate an agreement that minimizes risk, and offers alternatives. Any lack of agreement must be documented. Managed risk procedures are required when needed.

Nurses remain responsible for all nursing care that a person receives under their direction. Nurses may use their professional judgment in determining which tasks may be delegated. Tasks which may not be delegated include those which require nursing assessment, judgment, evaluation, and teaching during implementation such as physical, psychological, and social assessments which require nursing judgment, intervention, referral or follow-up; require formulation of a plan of nursing care and evaluation of responses to the care; or administration of medications except as authorized by regulations.

Residential care homes provide assistance with personal care; medications; three meals a day; and supportive assistance which includes housekeeping, assistance in the preparation of meals, and storage, distribution, and assistance with medications.

Dietary

Each assisted living center must use a licensed dietician or qualified nutritionist to develop the center’s diet plan and address the needs of individuals with special diets.

Residential care homes must have available a minimum of three meals per day that constitute a palatable, nutritionally adequate general diet and should include the four basic food groups in the recommended amounts. Homes with residents requiring special diets prescribed by a physician must contract with a consulting licensed/registered dietician. All special diet menus must be approved by a licensed/registered dietician.

Agreements

Assisted living centers. Each assisted living center must provide a complete and understandable contract to each resident. All rights, privileges, and assurances in the regulations are considered part of the contract. Other provisions require a clear statement and the center’s name and address; admission criteria; services provided; discharge criteria; dispute resolution and grievance procedure; the term, renewal, and cancellation provisions; conformity with state law; and in the event the resident’s condition merits transfer, the transfer shall be initiated within five days and progress noted in the resident’s record. The written contract constitutes the entire agreement between the center and the resident “not excluding the marketing materials and the requirements of this chapter.” Assisted living centers are required to provide all the services specified in the resident’s contract.

Residential care homes. A written contract must be executed within 120 days of admission, or when the source of resident funds changes from private to public or from public to private funds, or when the terms of the contract have changed. The contract must specify the contract terms; the services that may be provided to supplement the contract and the charges for those services; sources liable for payment; amount of deposit paid; the rights, duties and obligations of the resident; and the name of the resident’s designated representative, if any.

Provisions for Serving People with Dementia

Facilities providing specialized care in special units to persons with Alzheimer’s disease and related dementias must complete an Alzheimer’s Disease Specialized Care Disclosure Form. This form includes the philosophy of care, the process and criteria for placement and discharge, the assessment and care planning process, staff ratios, staff training and continuing education, the physical environment and design features, types and frequency of activities, the involvement of families in care planning, and the fees charged.

Adequate trained staff shall be on duty, awake, and present at all times, 24-hours-a-day, seven days a week, to meet the needs of residents and to carry out all the processes listed in the assisted living center’s, written emergency and disaster preparedness plan for fires and other natural disasters.

Centers with only one direct care staff member awake at night have to disclose the staffing arrangement and have an approved plan to deal with urgent or emergency situations. Centers must have a minimum of two staff members on duty and awake on all shifts if an assisted living center has a unit or program designed to prevent or limit resident access to areas outside the designated unit or program. A minimum of one direct care staff is required to be on duty and awake at all times within the unit or program designed to prevent or limit resident access to areas outside the designated unit or program.

Medication Administration

Assisted living centers. Each center must provide or arrange for staff to administer medications only under physician’s orders. The person responsible for administering medications prepares the dose, observes the swallowing or oral medications and records the medication. . Unlicensed personnel administering medications must complete a training program approved by the relevant department. Medications must be reviewed monthly by a RN and quarterly by a pharmacist.

Residential care homes may administer medications and assist with self-administration of medications. All direct care staff responsible for the administration of medication are required to begin training in the administration of medication within 90 days of employment, and complete 15 hours of training in the administration of medications within the first year of employment. Residents who have been deemed capable of self-administration of medications may retain the medications in a safe location in the resident’s room.

Public Financing

An amendment to cover assisted living under a Medicaid HCBS waiver is being prepared in 2007. A three tiered payment system is anticipated. Room and board would be limited to the SSI benefit. The maintenance allowance for individuals eligible under the 300% of SSI option would be set at 150% of the SSI benefit. Additional standards for waiver providers are being discussed with the Department of Health.

The SSI payment is $623, and the PNA is $50. Family supplementation is allowed for residents who may reside in residential settings.

Staffing

Assisted living centers. Staffing shall be available based on the needs of residents. Nursing staff shall be provided or arranged to supervise skilled interventions, document the resident’s physician of choice, and document the resident’s living will or DNR order. Centers must have a dietary consultant, pharmacy consultant, and nurse consultant if there are no nurses on staff.

Residential care homes shall employ sufficient personnel appropriately qualified and trained to provide the essential services of the home. Homes must have a minimum of three-fourths hour of personnel per day per resident based on the average daily census. All homes must have a signed, written agreement with a RN to act as a consultant.

Training

Assisted living center administrators must either hold a state nursing home administrator’s license, a RCH administrator’s certification from an institution of higher learning approved by the Department, or a national recognized assisted living certificate of training and competency reviewed and approved by the Department.

Assisted living center staff providing socialization, activity, and exercise services must be qualified by training. Centers offering specialized units must ensure that staff are trained to meet the specialized needs of residents, and all direct care staff must be trained in first aid and CPR.

Residential care home administrators must receive a minimum of 50 hours of training including at least 15 hours of training in administration, supervision, reporting, record keeping, the administration of medication, IADLs and ADLs, leisure skills and recreation, and public relations. Sixteen hours of annual continuing education is required of all administrators, not counting first aid and CPR training.

Residential care home staff. All employees must be currently certified in first aid. All direct care staff must receive eight hours of in-service training within 90 days of employment. Staff responsible for administering or monitoring medications must receive eight hours of training annually in the following areas: patient reporting and observation; record keeping; independent or daily living skills; leisure skills and recreation; human relations; and such other training that is relevant to residential care program and operations.

New employee orientation programs must include: policies and procedures on abuse and neglect, resident rights, confidentiality, handling emergencies, and job descriptions.

Background Check

Assisted living center. All employees are subject to requirements for criminal arrest checks applicable to nurses aides under 63 O.S. Supp. 1997, §1-1950.1 and other regulations governing registered sex offenders or violent crime offenders, §1-1946. Employers must pay a fee of $10 to the Bureau of Investigation for checks. Reports are provided for felonies and misdemeanors for crimes against a person, public indecency or morality, domestic abuse, controlled substances, and crimes against property. Employees may not be hired if they have been convicted of crimes listed in the statute.

Residential care homes. Same provisions.

Monitoring

Assisted living centers. The state must inspect each continuum of care facility and assisted living center through unannounced inspections at least once every 15 months, with a statewide average of 12 months. If a violation is found, the state must provide written notice of all violations. The facility has ten business days to respond with a written plan of correction. The state will review and provide the facility with its response. If an assisted living center provides or arranges skilled nursing care, the state must assess the quality of that care against applicable national standards of practice adopted by the American Nurses Association and Specialty Nursing Organizations.

Each center must have a quality assurance committee that meets at least quarterly to monitor trends, monitor customer satisfaction, and document quality assurance efforts and outcomes. The committee must include an RN or physician, the administrator, a direct care staff member, or person responsible for administering medications and a pharmacist consultant if a medication problem is to be monitored or investigated. The Department may inspect centers whenever it deems it necessary.

Residential care homes. Inspections are performed at least three times a year to determine compliance with licensure rules. At least one inspection, investigation, survey, or evaluation shall be unannounced. Any individual who discloses the planned unannounced visit may be convicted of a misdemeanor. The state shall invite one person from a statewide organization of the elderly to act as a citizen observer in any inspection. The results of all inspections are made available to the public. This report is updated monthly. The state must make at least one annual report on each home in the state. The report must include all conditions and practices not in compliance with the provisions of the Residential Care Act or rules, if a violation is corrected, or is subject to an approved plan of correction. A local or state ombudsman or case manager is authorized to accompany the state on its inspections. The state must give written notice of any violations. A RCH may request a hearing, and submit a plan of correction within ten business days.

Fees

Assisted living centers. There is a $10 per bed application fee, with a $1,000 cap, to establish a facility and an initial licensing fee of $10 per bed.

Residential care homes. $50 per application. Annual renewal fees are $50.

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