Residential care facilities for the elderly Title 22, Division 6, Chapter 8.
California licenses 5,900 residential care facilities for the elderly with 123,238 residents. About 70% of the facilities serve fewer than six residents. These facilities account for between 25-30% of all residents. As in other states, nursing facilities are concentrating on providing specialty, subacute and rehabilitative care, many through contracts with HMOs. Nursing homes have not expressed interest in converting to assisted living facilities, however, many nursing homes are adding assisted living to free beds for higher need residents and to provide referrals as assisted living residents age.
At the direction of the state legislature, a study of state approaches to assisted living was conducted by the Department of Health and filed in 1997. Informal discussions among state agencies, assisted living providers and legislative staff were to discuss the definition of assisted living and where it fits or how it compares to the current residential care facilities for elderly model. The discussion has focused on if assisted living is different, what services should be allowed and whether assisted living should be considered a bundle of services that is provided without regard to the building. Other issues addressed included the definition, information needed by consumers, the scope of services to be covered and the needs of clients that can be met, the place of assisted living in the continuum of care and whether a new licensure category was needed or appropriate.
The 18 member group has discussed financing for low income elders but believes Medicaid waiver financing would lead to a medical model. The Department of Health has concerns about residents meeting the nursing home level of care criteria being served in settings that are not licensed. The aging community believes there are too many licensure categories already and new ones only serve providers seeking higher levels of reimbursement without really increasing the services provided.
During 1995, legislation (Chapter 550 of the Acts of 1995) was passed that allows RCFEs that serve people with Alzheimer's Disease to develop secure perimeters. Based on the results of a pilot project, the law allows facilities that meet specific additional requirements to secure exterior doors or perimeter fences, or to install delayed egress devices on exterior doors and perimeter fence gates. Resident supervision devices, wrist bracelets which activate a visual or auditory alarm when a resident leaves the facility may also be used. Facilities must provide interior and exterior space for residents to wander freely, receive approval from the local fire marshal and conduct quarterly fire drills. Facilities with delayed egress devices must be sprinklered and contain smoke detectors and the devices must deactivate when the sprinkler system or smoke detectors activate. The devices must also be able to be deactivated from a central location and deactivate when a force of 15 pounds is applied for more than two seconds to the panic bar. In addition facilities shall permit residents to leave who continue to indicate such a desire and staff must ensure continued safety. Reports must be submitted when residents wander away from the facility without staff. Delayed egress devices may not substitute for staff.
A voluntary disclosure process has been adopted under which facilities offering special services for people with Alzheimer's Disease disclose information concerning their program. A consumer's guide has been developed which alerts family members to several key questions that should be asked. The areas include the philosophy of the program and how it meets the needs of people with Alzheimer's, the pre-admission assessment process used by the facility, the transition to admission, the care and activities that will be provided, staffing patterns and the special training received by staff, the physical environment and indicators of success used by the facility.
Residential care facility for the elderly means a housing arrangement chosen voluntarily by the resident, or the resident's guardian, conservator or other responsible person, where 75% of the residents are 60 years of age or older, or, if younger, have needs compatible with other residents and where varying levels of care and supervision are provided, as agreed to at time of admission or as determined necessary at subsequent times of reappraisal.
Occupancy is limited to two residents per bedroom which must be large enough to accommodate easy passage between beds, required furniture and assistant devices such as wheelchairs or walkers. One toilet and sink is required for every six residents and a bath tub or shower for every 10 residents.
Facilities may admit or retain residents who are capable of administering their own medications; receive medical care and treatment outside the facility or from a visiting nurse; residents who need to be reminded to take medications; and people with mild dementia, or mild temporary emotional disturbance resulting from personal loss or change in living arrangement. Facilities may not admit or retain anyone with a communicable disease; anyone who requires 24-hour skilled nursing or intermediate care or is bedridden more than for more than 14 days including residents who are unable to transfer independently to and from bed and are unable to leave the building unassisted in an emergency. The regulations allows residents with health conditions requiring incidental medical services which are specified in the rules to be admitted and retained (eg., intermittent positive pressure breathing, indwelling catheter, management of incontinence, colostomy/ileostomoy, contractures, healing wounds). Residents who will be bedridden more than 14 days may be retained if the facility submits a physician's statement to the Department of Health stating that the condition is temporary and an estimated date upon which the resident will no longer be confined to bed is provided.
Alzheimer's projects Facilities may admit and retain people with Alzheimer's Disease who are not able to respond to verbal instructions to leave a building without assistance provided they have:
Submitted a waiver exception request that includes a plan of operation which specifically addresses the needs of Alzheimer's residents;
A training plan which ensures that facility staff can meet the needs of residents;
An activity program and resident assessment and re-assessment procedures;
Procedures to notify physicians when behavior changes;
A written plan to minimize the use of psycho-tropic medications; and
A disaster and mass casualty plan.
Services are divided into basic services and care and supervision. Basic services include safe and healthful living accommodations; personal assistance and care; observation and supervision; planned activities; food service; and arrangements for obtaining incidental medical and dental care. Care and supervision covers assistance with ADLs and assumption of varying degrees of responsibility for the safety and well being of residents. The tasks include assistance with dressing, grooming, bathing and other personal hygiene; taking medications; and central storing and distribution of medications.
Facilities may assist with self-administration of medications and, if staff is authorized by law, administer injections.
Sufficient staff must be employed to deliver services required by residents. On the job training or experience is required in the principles of nutrition, food storage and preparation, housekeeping and sanitation standards, skill and knowledge to provide necessary care and supervision, assistance with medications, knowledge to recognize early signs of illness and knowledge of community resources.
Requirements for awake staff vary by the size of the facility. For 16 or less, staff must be available in the facility; 16-100, at least one awake staff; 101-200, 1 on call and 1 awake with an additional awake staff for each additional 100 residents.
Administrators Individuals shall complete an approved certification program prior to be being employed as an administrator. The program must include 40 hours of classroom training which covers laws, rights, regulations and policies (12); business operations (3); management and supervision (3); psycho-social needs of the elderly (5); physical needs of the elderly (5); community and support services (2); use, misuse and interaction of drugs (5); and admission, retention and assessment procedures (5). All administrators shall be required to complete at least 20 clock hours of continuing education per year in areas related to aging and/or administration.
Staff Personnel must be given on the job training or have related experience in: the principles of good nutrition, good food preparation and storage and menu planning; housekeeping and sanitation procedures; skill and knowledge required to provide necessary resident care and supervision including the ability to communicate with residents; knowledge required to safely assist with prescribed medications which are self-administered; knowledge necessary in order to recognize early signs of illness and the need for professional help; and knowledge of community services and resources.
Facilities licensed for 16 or more must have a planned on the job training program in the above areas including orientation, skill training and continuing education.
The licensing agency conducts a criminal background check of officers of the organization, adults responsible for administration and direct supervision, persons providing direct care and employees having frequent contact with residents and others and may approve or deny a license or employment based on its findings. A fingerprint clearance shall be received by the licensing agency on all persons subject to criminal record review prior to issuing a license.
Facilities must be inspected annually. Three levels of penalties are allowed for violations with an (A) immediate, (B) potential and (C) technical impact. $50 per day civil penalties are allowed for A and B violations increasing to $100 per day if the same violation is repeated 3 times in a 12 month period. Consultation is provided for Type C violations.
Licensing fees required at initial licensure and annually thereafter, are adjusted by facility size: 16 - $300; 7-15 - $450; 16-49 - $600 and 50+ - $750.