State Assisted Living Policy: 1998. Arizona

06/01/1998

Citation

Assisted living facilities. Comprehensive administrative rules and regulations §R9-10-701 et seq.

General Approach

Rapid growth in the number and types of home and community based settings serving elderly and adults with physical disabilities, ranging from private homes to facilities providing specialized care to large retirement complexes, has outpaced the regulations developed to guide this development. In the Spring of 1997, the Arizona Department of Health Services' Office of Home and Community Based Licensure established a 28 member task force to help consolidate five of the existing six licensing classifications (adult care homes, supported residential living centers, supervisory care homes, unclassified homes and adult family care) into a single assisted living category. Rules have been issued which are expected to be effective in November, 1998.

The new assisted living facility category has requirements based on the size of the facility and supplemental requirements depending on the level of service provided. The core requirements address facilities serving 10 or fewer residents, eleven or more residents and adult foster homes which serve 1-6 residents. Facilities will be licensed to provide one of three levels of care supervisory care services, personal care services, and directed care services and must meet supplemental requirements.

The directed care level will serve people with Alzheimer's disease or dementia who cannot self-direct their care, eg., cannot recognize danger, summon assistance, express need or make basic decisions. Requirements for specialized training, activities, physical plant and services will be established.

The goal of the task force was to develop regulations that are consistent and ensure minimum standards for health, safety and welfare. Regulations will be based on the resident's level of need and promote dignity, independence, self-determination, privacy and choice. Legislation was approved in 1998 authorizing the new category.

AHCCCS, which administers the state's Medicaid managed care program, will retain higher standards (eg., private living units), for providers interested in serving Medicaid beneficiaries.

Pilot program expanded statewide Chapter 163 (1993) authorized a three year supportive residential living centers (SRLC) pilot project, which is the same as assisted living, to test the feasibility of developing additional cost effective alternatives to nursing homes for participants in the Arizona Long Term Care Systems (ALTCS). The pilot was implemented in Maricopa County by the Maricopa Managed Care Systems, a county based HMO which contracts with the state Medicaid agency, AHCCCS, to operate the ALTCS system. In 1996, the legislature approved the statewide expansion of the program and provided funding for 700 ALTCS members and no restrictions on the number of private pay residents. After 1997, there is no limit on the number of members who can be served through Supportive Residential Living Centers (to be renamed assisted living facilities).

As required by legislation, Maricopa Managed Care Systems issued a report in December 1995. The report recommended a statewide expansion of the program based on three primary findings: cost effectiveness, high satisfaction level among participants and the ability to meet resident needs in a less restricting environment.1 The study found annual savings of $2 million based on the continuous enrollment of 100 participants.

The evaluation collected data on resident satisfaction, number of residents, length of stay, level of care, emergency room utilization, urgent care visits, number of days of hospitalization and cost, average daily cost of supportive residential living, service levels, demographic information, functional information, and medical information. The study identified three areas for further study: building codes, public versus private pay criteria and level of care.

The following information is based on the new proposed regulations.

Definition

Assisted living facility means a residential care institution, including adult foster care, that provides or contracts to provide supervisory care services, personal care services or directed care services on a continuing basis.

Supervisory care services mean general supervision, including daily awareness or resident functioning and continuing needs, the ability to intervene in a crisis and assistance in the self-administration of prescribed medications.

Personal care services mean assistance with activities of daily living that can be performed by persons without professional skills or professional training and include the coordination or provision of intermittent nursing services and the administration of medication and treatments by a nurse who is licensed pursuant to Title 32, Chapter 15 or as otherwise provided by law.

Directed care services means programs and services, including personal care services, provided to persons who are incapable of recognizing danger, summoning assistance, expressing need or making basic care decisions.

The ALTCS program will contract with assisted living homes (10 or less) and assisted living centers but only centers that offer residential units (apartments).

Unit Requirements

Assisted living centers (11+ residents) may provide residential units or bedrooms. Residential units must have at least 220 square feet of floor space, excluding bathroom and closet for one person with an additional 100 square feet for a second person. Units must have a keyed entry, bathroom, resident controlled thermostat and a kitchen area with sink, refrigerator, cooking appliance that may be removed or disconnected and space for food preparation.

Assisted living centers and homes providing bedrooms must have 80 square feet in single rooms and 60 square feet per resident in double rooms. No more than two residents may share a room. Rooms occupied by residents receiving personal care services or directed care services must have a bell, intercom or other mechanical means to contact staff. At least one toilet, sink and shower is required for every eight residents

Tenant Policy

ALFs providing supervisory care services may serve residents who need health or health related services if these services are provided by a licensed home health or hospice agency.

ALFs with a personal care service license may not accept or retain any resident who is unable to direct self-care; requires continuous nursing services unless the nursing services are provided by a licensed hospice agency or a private duty nurse; residents with a stage III or IV pressure sore or someone who is bed bound due to a short illness unless the primary care physician approves, the resident signs a statement and the resident is under the care of a nurse, a licensed home health agency, or a licensed hospice agency.

ALFs licensed to provide direct care services may admit residents who are bedbound, need continuous nursing services or have a stage III or IV pressure sore if the requirements for facilities providing personal care services are met.

Services

Residents must receive an assessment and a service plan within 14 days of acceptance. Plans must be reviewed every 12 months for residents receiving supervisory care services, every six months for residents receiving personal care services and every three months for residents receiving directed care services. Services must meet scheduled and unscheduled needs. Facilities must provide general supervision; promote resident independence, autonomy, dignity, choice, self-determination and the resident's highest physical, cognitive and functional capacity; help utilizing community resources; encouragement to preserve outside supports; individual attention and social interaction and activities.

Facilities providing personal care services also provide skin maintenance, sufficient fluids to maintain hydration, incontinence care, an assessment by a primary care provider for residents needing medication administration or nursing services.

Facilities providing directed care must provide cognitive stimulation and activities to maximize functioning; encouragement to eat meals and snacks; and an assessment by a primary care provider.

ALTCS Services are grouped into three types: hotel services, personal care services and nursing care services. Hotel services include meals, linen and personal laundry, housekeeping and social and recreational services. Personal care includes assistance with ADLs, managing functional and behavior problems, assisting with medication and oversight. Nursing services cover observation and assessment, routine nursing tasks, intermittent nursing care and terminal care delivered by hospice providers.

Prior to move in, an interdisciplinary team (manager, staff, RN if nursing services are provided, resident and/or representative and case manager if applicable) conducts an assessment. A plan of care is developed with the resident or their representative that identifies the services needed, the person responsible for providing the service, method and frequency of services, measurable resident goals and the person responsible for assisting the resident in an emergency.

Financing

Assisted living facilities can contract with ALTCS program contractors to serve beneficiaries meeting the nursing home criteria. Program administrators used rates set for adult foster care, nursing facilities, the Oregon assisted living program and the Arizona HCBS program as guidelines in setting the rates paid to what were formerly called Supportive Residential Living Centers. (ALTCS will use the new terms contained in the assisted living regulations.) Administrators also consider the package of services provided and ask each Center to submit a budget. Three classes of rates are negotiated based on the level of care: low, intermediate and high skilled. The rates include room and board which is paid by the resident. The monthly room and board amount is the resident's "alternative share of cost" (spend down) or 85% of the current SSI payment, whichever is greater. For residents who receive SSI, the payment rate is $470 a month of which $403.10 is paid to the residence to cover room and board charges and $66.90 is retained by the resident.

ARIZONA RATES BY PROGRAM CONTRACTOR

 

  Class I  

  Class II  

  Class III  

APIPA

  $46.67  

  $56.67  

  $66.67  

Ventana  

$50.00

$56.67

 

MMCS

$47.33

$60.42

$73.88

Pima

$46.45

$59.30

$72.51

An evaluation of the SLRC program found that the average cost of SRL was 58.7% of the cost of a nursing facility in FY 95 - $1567 a month compared to $2669 for nursing facility residents, for a savings of $1102 a month. Ancillary health costs (inpatient, physician, transportation, emergency rooms etc.) were 30% lower for SRL participants than nursing home residents.

Medications

Facilities must have policies and procedures governing the procurement, administration, storing and disposal of medications. Staff may supervise self-administration by opening bottle caps, reading labels, checking the dosage and observing the resident taking the medication. Medications which cannot be self-administered must be administered by an RN or "as otherwise permitted." The phrase as otherwise permitted was included to accommodate any future statutory changes in the state's nurse practice act. Medication organizers can be prepared a month in advance by an RN or family member.

Staffing

Facilities are required to ensure that sufficient staff are available to provide services consistent with the level of care for which the facility is licensed, services established in a care plan, service to meet resident needs for scheduled and unscheduled needs, general supervision and intervention in a crisis 24-hours a day, food services, environmental services, safe evacuations and ongoing social and recreational services.

Training

Managers must be 21, certified and have a minimum of 12 months of health related experience.

Staff must complete an orientation that includes the characteristics and needs of residents; the facility's philosophy and goals; promotion of resident dignity, independence, self-determination, privacy, choice and resident rights; the significance and location of service plans and how to read and implement a service plan; facility rules, policies and procedures; confidentiality of resident records; infection control; food preparation, service and storage if applicable; abuse, neglect and exploitation; accident, incident and injury reporting; and fire, safety and emergency procedures.

Managers and staff must complete 12 hours of ongoing training annually covering promoting resident dignity, independence, self-determination, privacy, choice, and resident rights/fire, safety and emergency procedures; infection control; abuse, neglect and exploitation. Staff in facilities licensed to provide directed care services must receive a minimum of four hours of training in providing services to residents.

In addition to the above topics, training may include providing services to residents; nutrition, hydration and sanitation; behavioral health or gerontology; social, recreational or rehabilitative services; personnel management, if applicable; common medical conditions, medication procedures, medical terminology and personal hygiene; service plan development, implementation or review and other needs identified by the facility.

Staff must also maintain current CPR certification and complete six hours of continuing education annually pursuant to §36-448.11(D). Nurses aides in good standing are deemed to meet the initial training requirements.

Certificate of training Staff must obtain a certificate of training. Facilities may develop their own training and certificate program with approval from the department. Department approved training programs have requirements for instructors and the method of instruction. The competency based approach sets standards for supervisory care services, personal care services, directed care services, and manager training.

Supervisory care services: 20 hours or the amount of time needed to verify a person demonstrates skills and knowledge in assisted living principles; communication; managing personal stress; preventing abuse, neglect and exploitation; controlling the spread of disease and infection; documentation and record keeping; implementing service plans; nutrition, hydration and food services; assisting with self-administration of medications; providing social, recreational and rehabilitative activities; and fire, safety and emergency procedures.

Personal care services: 30 hours (50 total) or the amount of time needed to verify a person demonstrates skills and knowledge in additional skills areas such as the aging process, common medical conditions associated with aging or physical disabilities and medications; assisting with ADLs and taking vital signs.

Directed care services: 12 hours (75 total) or the amount of time needed to verify a person demonstrates skills and knowledge of Alzheimer's disease and related dementia; communicating with residents with residents w ho are unable to direct care; providing services including problem solving, maximizing functioning and life skills training for those unable to direct care; managing difficult behaviors; and developing and providing social, recreational and rehabilitative activities for such persons.

Background Check

Staff must comply with fingerprint requirements under A.R.S. 36-411. Legislation requiring federal criminal background checks is likely to be passed and implemented in 1998.

Monitoring

The licensing agency conducts annual renewal inspections. Licenses may be renewed for two years for facilities that are free of deficiencies.

Facilities are monitored by ALTCS program contractors and the Arizona Department of Health Services. Sites are recertified annually by the Department of Health Services. During the pilot phase, MMCS monitored resident care on a quarterly basis, provided technical assistance and conducted meetings of providers to obtain feedback on the program. With statewide expansion, participants are visited at least quarterly by their ALTCS case manager. Annual operating and financial reviews of ALTCS contractors (HMOs) are conducted annually by AHCCCS. The reviews also include case management and provider records and claims data. AHCCCS also reviews a random sample of residents, including assisted living residents, to evaluate the appropriateness and quality of care. The review found no unmet needs or quality of care problems.

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  1. Supportive Residential Living Pilot Project. A Report on the SRL Pilot Status of ALTCS members. Maricopa Managed Care Systems. Phoenix, Arizona. December 1995.

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