Residential Care and Assisted Living Compendium: 2007. Services

11/30/2007

One of the attractive philosophical tenets of assisted living is that it allows aging-in-place -- meaning that as individuals age and become more disabled, additional services can be provided so that they will not have to move to another residential care setting or to a nursing home.

States seeking to facilitate aging-in-place and to offer consumers a full range of long-term care options allow more extensive services to be provided in residential care facilities, just as they can be provided in an individual’s home through home health agencies and in-home service programs.

However, facilities vary in the extent to which aging-in-place is possible, because states generally specify the range of allowable services and a minimum that must be provided, but do not require facilities to provide the full range of allowable services. Facilities are usually authorized to determine which services they will provide within state parameters. Facilities may offer very limited, moderate, or extensive services. Thus, both state regulations and facility policy govern the type, amount, frequency and duration of services provided, and, hence, the ability to age in place.

Thus, although state regulations frequently state their support for aging-in-place, they may also allow facilities to discharge individuals with higher levels of need. A key determinant of the ability to age in place is the extent to which states permit residential care facilities to address residents’ nursing and health-related needs.

Some experts contend that residential care settings cannot and should not be expected to meet the needs of persons with a high level of disability and/or medically complex conditions. Others agree, believing that residential care should be a social care model and that having nurses on staff is not only unnecessary but undesirable. However, other regulators, particularly in states that allow nurses to delegate specified nursing tasks, believe that residential care settings, like a person’s own home or apartment, are appropriate settings for people with severe disabilities and/or health needs. But some observers have expressed concern about direct care staff’s ability to recognize and address health problems in medically fragile residents when they are not trained nursing assistants. Many states do allow residential care facilities to provide skilled nursing care, as indicated in the following examples.

  • Illinois allows health services such as medication administration, dressing changes, catheter care, and therapies, if provided on an intermittent basis.

  • Florida allows the provision of nursing services under two types of licensure: LNS and ECC. A license for LNS allows facilities to provide nursing services including medication administration and supervision of self-administration, heat and ice cap application, passive range of motion exercises, urine tests, routine dressing changes that do not require packing or irrigation, and intermittent nursing services (e.g., change of colostomy bag and related care, catheter care, administration of oxygen, routine care of an amputation or fracture, prophylactic, and palliative skin care). A license for ECC permits a facility to provide nursing services in addition to those provided under the LNS license.

    However, the state also specifies certain nursing services that may not be provided under either type of license, including oral or nasopharyngeal suctioning, assistance with tube feeding, monitoring of blood gasses, intensive rehabilitation services for a stroke or fracture or treatment of surgical incisions that are not clean and infection-free, and any treatment requiring 24-hour nursing supervision.

  • Washington’s regulations specify which skilled services may and may not be delivered by licensed nurses and unlicensed staff in residential care settings. RNs or licensed practical nurses (LPNs) may insert catheters, provide nursing assessments, and glucometer readings. Unlicensed staff under the supervision of a licensed nurse may provide Stage I skin care, routine ostomy care, enemas, catheter care, and wound care. Statutory changes in the Nurse Practice Act that would allow greater delegation are pending in the legislature.

  • New Jersey allows residential care facilities to provide skilled nursing procedures that are specifically barred in many states, for example, care of Stage III or IV pressure sores, ostomy care, and 24-hour nursing supervision.

  • Missouri allows residential care facilities to provide certain nursing procedures that they call “advanced personal care services.” They include catheter and ostomy care, bowel or bladder routines, range of motion exercises, assistance applying prescriptions or ointments and other tasks requiring a highly trained aide.

  • Maine allows residential care facilities and congregate housing programs to provide skilled nursing services.

Several states limit the provision of skilled nursing services in residential care settings by restricting their frequency and duration. Others prohibit facilities from providing these services directly, but allow them -- and/or residents -- to arrange for their provision through a home health agency. Some states use a combination of approaches, all of which are illustrated in the following examples.

  • Massachusetts -- like many states -- does not allow residential care facilities to serve residents who need nursing services available 24-hours-a-day. Skilled services may only be provided by a certified home health agency on a part-time or intermittent basis to persons whose medical conditions require services periodically on a scheduled basis.

    In addition, the state allows residents to “engage or contract with any licensed health care professional and providers to obtain necessary health care services...to the same extent available to persons residing in private homes.” Because the Massachusetts statute allows skilled nursing services to be provided only by a certified home health agency, RNs hired by an ALF are not allowed to deliver skilled care. An initial draft of new state regulations did not allow the provision of skilled services for more than 90 days in a 1-year period. When the state attorney general’s office determined that such limits may conflict with fair housing rules, the state removed the 90-day limit.

  • Ohio limits the provision of skilled services in residential care facilities to 120 days in a 12-month period with exceptions for special diets, dressing changes, and medication administration.

  • Iowa allows facilities to provide health-related care (i.e., services provided by a RN, a LPN, or home care aide), and services provided by other licensed professionals as defined in regulations. Health-related and personal care services can be provided on an intermittent and part-time basis, which is defined as up to 35 hours a week on a less than daily basis, or up to eight hours provided seven days a week for temporary periods not exceeding 21 days.

  • Kentucky allows residents to arrange for additional services under direct contract or arrangement with an outside agent, professional, provider, or other individual designated by the client if permitted by facility policy.

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