[A PDF [http://aspe.hhs.gov/daltcp/reports/2007/07alcomWY.pdf] of only this state's summary also available]
Assisted living licensure: Chapter 4
Assisted living program administration: Chapter 12
General Approach and Recent Developments
Rules for ALFs were revised in June 2001. A Medicaid waiver was implemented in 2001. Chapter 219 (2007) expanded funding for Medicaid assisted living waiver slots from 146 to 168. Program administration rules are being revised to include new requirements for secure dementia units. A hearing was held in June and final rules are expected to be issued in 2007.
The rules for program administration outline a philosophy for assisted living which references the desire of the state to develop reasonable and enforceable rules for the placement of individuals with disabilities in community settings such as ALFs in lieu of unnecessary institutionalization. These rules are designed not only to support the philosophy of community placement but to also protect the health, welfare, and safety of residents in ALFs.
Adult Foster Care
AFCH means a home where care is provided for up to five adults who are not related to the provider by blood, marriage or adoption, except in special circumstances, in need of long-term care in a home like atmosphere. Clients in the home shall have private rooms which may be shared with spouses and shall have individual handicapped accessible bathrooms.
Chapter 219 (2007) authorized an AFCH pilot in three sites.
|http://soswy.state.wy.us/RULES/4450.pdf||Rules (program administration)|
|Assisted living facilities||20||1,150||15||970||14||1,005|
Assisted living means “a non-institutional dwelling operated by a person, firm or corporation engaged in providing limited nursing care, personal care and boarding home care, but not habilitative care, for persons not related to the owner of the facility.”
Boarding home care means “a non-institutional dwelling or rooming house operated by any person, firm or corporation engaged in the business of operating a home for the purpose of letting rooms for rent and providing meals and personal daily living care, but not habilitative or nursing care, for persons not related to the owner.”
Rooms must provide 120 square feet for single-bed rooms and 80 square feet per bed in multiple-bed rooms, exclusive of toilets, closets, wardrobes, alcoves, and vestibules, in both cases. No more than two people may share a bedroom. One flush toilet, lavatory and mirror is required for every two residents. One tub and shower is required for every ten residents. One-half of licensed beds must be private rooms.
The regulations allow residents who need LNS to be served. Residents who need continuous assistance with transfer and mobility, are unable to feed themselves, need total assistance with bathing and dressing, require catheter care, continuous oxygen and monitoring, wander excessively, need wound care requiring sterile dressings, have Stage II skin care and beyond, exhibit inappropriate social behavior, and demonstrate chemical abuse that puts residents at risk cannot be cared for by ALF staff members.
Residents may not be asked to leave without 14 days written notice, unless the resident poses an imminent danger to self and/or others. Residents may be asked to leave only for the following reasons: the facility has had its license revoked, not renewed, or voluntarily surrendered; the resident’s LOC exceeds the LOC that can be provided by an ALF; the facility cannot meet the resident’s needs; the resident or responsible person has a documented established pattern, in the facility, of not abiding by agreements necessary for assisted living; non-payment of charges; or the resident engages in behavior which poses an imminent danger to self and/or to others.
Nursing Home Admission Policy
Individuals scoring 13 or more points on ten assessment items are eligible. Those items include eating, meal preparation, diet; medication management; skin care and dressing treatment; speech, vision and hearing; dressing and personal grooming; bathing; continence; mobility; behavior/motivation; and socialization. Nursing home placement is allowed for individuals who need care but for whom services are not available, who lack a support system, are intermittently confused and/or agitated and need a structured environment, who wander extensively; or who have total confusion or apathy.
ALF core services include meals, housekeeping, personal and other laundry services; a safe and clean environment; assistance with transportation; assistance with obtaining medical, dental, and optometric care, and social services; assistance in adjusting to group living activities; maintenance of a personal fund account, if requested by the resident or resident’s responsible party, showing any and all deposits, withdrawals, and transactions of the account; provision of appropriate recreational activities in/out of the ALF; partial assistance with personal care (e.g., bathing, shampoos); limited assistance with dressing; minor non-sterile dressing changes; Stage I skin care -- skin integrity intact; infrequent assistance with mobility (the resident may use an assistive device, such as wheelchair, walker, or cane); cuing guidance with ADLs for the visually impaired resident, or the intermittently confused and/or agitated resident requiring occasional reminders to time, place and person; care of the resident who can independently manage his own catheter or ostomy (e.g., resident who can change his own catheter bags, able to clean and care for his ostomy); care of the resident incontinent of bowel or bladder if he/she can manage his condition independently; RN assessments; RN medication review every two months or 62 days or whenever new medication is prescribed or the resident’s medication is changed; 24-hour monitoring of each resident; and provision of mechanically altered diets and dietary supplements (e.g., Ensure allowed, if they are required by the individual resident).
An activities program must be available to all residents and must be designed to enhance each resident’s sense of physical, psycho-social, and spiritual well-being.
Services that may not be provided in assisted living include continuous assistance with transfer and mobility; care for residents who cannot feed themselves independently; total assistance with bathing or dressing; provision of catheter or ostomy care; care of residents who are on continuous oxygen if monitoring is required; care of residents whose wandering jeopardizes the health and safety of residents or residents who exhibit inappropriate social behavior such as frequent aggression, abuse, or disruptive behavior; care of residents demonstrating chemical abuse that places himself or others at risk; or care for residents needing Stage II skin care and beyond; wound care requiring sterile dressing changes; therapeutic diets that are highly restrictive (e.g., renal diets, and incontinence care). However, care beyond what the facility provides may be delivered by an outside agency.
Assessments using the required Long-Term Care 102 Form must be completed by RNs no earlier than one week prior to admission and, at a minimum, annually or upon a significant change in condition. The results of the assessment are used to develop, review, and revise the resident’s individualized assistance plan. The assistance plan must include who will provide the care/services; what care/services will be provided; when care/services will be provided; how the care/services will be provided; and the expected outcome. The resident must be included in the development of the assistance plan to the best of his or her abilities, and a relative or other interested party may participate. The plan must reflect assessed needs and resident decisions (including resident’s level of involvement); support principles of dignity, privacy, choice, individuality, independence, and home-like environment and must include significant others who participate in the delivery of services.
A minimum of three balanced, palatable, properly prepared, and attractively served meals must be offered that meet the recommended dietary allowances. Special diets may be ordered by a physician or a registered dietician.
An assistance plan is required that specifies the type, frequency, and duration of services and the expected outcome. A resident agreement is not required. Management is responsible for developing policies and procedures that are available to residents and staff dealing with resident rights, disciplinary procedures concerning substantiated cases of resident abuse, admission/transfer/bed holds, medication management, emergency care, fire/disaster plans, departure and return, smoking, visiting hours, activities, notification of changes in conditions, personnel policies, grievance procedure, per diem rate/charges/fees and what is included, incident reports, notification of changes in fees, outside contractual responsibilities, and identification of changes in the resident’s condition.
Provisions for Serving People with Dementia
Facilities are required to provide cuing with guidance for people who are intermittently confused and/or agitated and who require occasional reminders to time, place, and person. Facilities cannot care for residents who wander to the point that it jeopardizes the health and safety of the resident. Training requirements will be included in the revised regulations.
RNs provide medication reviews every two months or whenever new medications are ordered. A RN is responsible for the supervision and management of all medication administration as required by the Wyoming Nurse Practice Act, and the Wyoming Board of Nursing Rules and Regulations.
Medications may be administered by a RN or LPN. The regulations allow assistance with self-administration by nurse aides which includes but is not limited to reminders, removing medication from containers, assistance with removing caps, and observation of the resident taking the medication. Residents capable of self-administration are allowed to keep prescription medications in their rooms, as long as it is deemed safe and appropriate by the RN. For residents who share a room and self-medicate, an assessment will be made of each resident and his or her ability to safely have medications in the room. If safety is a factor, the medications must be kept in a locked container.
Since July 2001, Medicaid HCBS waiver coverage is available for individuals residing in ALFs when the resident requires a service that can be provided by both the long-term care and the HCBS waiver provider and the ALF, but the resident cannot afford to pay the ALF for the service. The waiver case manager will ensure that the required service is provided.
Twelve facilities currently participate in the Medicaid waiver program serving 130 participants. Funding was approved in 2007 to serve 168 participants. A three tiered rate system reimburses providers $42-$50 per day. The payment level is based on a score derived from the Long-Term Care 101 Form, the required screening tool as defined by the Program Division and performed by a RN. Room and board is not capped and is negotiated between the resident and the facility.
|Medicaid Payment Rates (2007)|
|Level I -- 13-14 points||$42|
|Level II -- 15-16 points||$46|
|Level III -- 17+ points||$50|
Staff shall be sufficient to meet the needs of residents. There must be at least one RN, LPN, or CNA on duty every shift. At least one awake staff is required for all facilities serving eight or more residents.
Administrators. Managers must meet one or more of the following requirements: complete at least 48 semester hours or 72 quarter hours of post-secondary education in health care, elderly care, health case management, facility management or related field; be a CNA; have at least two years experience working with elderly or disabled individuals; or demonstrate knowledge, skills, and abilities in the administration of a facility. The rules outline the expectations for knowledge and experience.
Staff. Management shall provide to new employees an orientation, education regarding resident rights, evacuation and emergency procedures, and training and competent supervision designed to improve resident care.
Central registry checks are required.
Facilities are surveyed no less than annually. The state has a contracted employee who performs monitoring of facilities. The contract is paid by the ALFs. The survey division must provide a list of deficiencies to the facility within ten working days of the survey. The facility has ten calendar days to provide a plan of correction for each of the cited deficiencies. If the facility fails to provide a plan of correction, licensure revocation proceedings may ensue. Each facility must have an active QI program that is re-evaluated at least annually to ensure effective utilization and delivery of services. The program must have a written description, problem areas identified, monitor identification, frequency of monitoring, a provision requiring the facility to complete annually a self-assessment survey of compliance with regulations, and a satisfaction survey must be provided to the resident, resident’s family, or resident’s responsible party at least annually. The state is responsible for receiving and investigating complaints.
- 1-50 beds ($100 per facility);
- 51-100 beds ($200 per facility);
- 101-150 beds ($300 per facility);
- 151-200 beds ($400 per facility); and
- More than 200 beds ($500 per facility).
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