Assisted living facilities. Florida Statute chapter 400 Part 3; Florida Administrative Code Chapter 58A-5 et seq.
Chapter 97-82, passed in 1997, revised training requirements and added new provisions for facilities serving people with Alzheimer's disease. An earlier law requires that such facilities disclose in its advertising or other documents how its services are especially applicable to people with Alzheimer's disease. Facilities serving more than 17 persons must have awake staff 24 hours a day, or if serving under 17 residents, either awake staff or mechanisms to monitor and ensure the safety of residents. These facilities must also offer special activities, maintain a physical environment that provides for the safety and welfare of residents and employ staff who have completed appropriate training. The law also removes a barrier to admitting residents who need a higher level of care.
Florida's original legislation (1975) was amended in 1987, 1989, 1992, 1995 and 1997. The 1997 legislation transferred rule authority for assisted living from the Department of Health and Rehabilitative Services to the Department of Elderly Affairs, renamed adult congregate living facilities to assisted living facilities. Extended congregate care (ECC) was created as a higher level of assisted living and new requirements were added for providing mental health services and staff training. The law and rules apply a different philosophy and training for ECC facilities than standard ALFs. Licensing authorization for ALFs remained with the Agency for Health Care Administration.
In November, 1995 there were approximately 5400 units of assisted living in 1900 facilities. About 120 of the 1900 facilities also hold a license to provide ECC services. In March 1998, 2,056 facilities with a total of 66,293 beds were licensed. This includes 235 ECC beds, 110 limited nursing services beds and 152 limited mental health beds.
"Assisted living facility means any building or buildings, section of a building or distinct part of a building, residence, private home, boarding home, home for the aged or other place, whether operated for profit or not, which undertakes to provide through its ownership or management, for a period exceeding 24 hours, housing, food service, and one or more personal services for four or more adults, not related to the owner or administrator by blood or marriage, who require such services; or to provide extended congregate care, limited nursing services, or limited mental health services, when specifically licensed to do so pursuant to s. 400.407, unless the facility is licensed as an adult family care home."
"Extended congregate care means acts beyond those authorized in subsection 16 that may be performed pursuant to chapter 464 by persons licensed thereunder while carrying out their professional duties; and other supportive services which may be specified by rule. The purpose of such services are to enable residents to age in place in a residential environment despite mental or physical limitations that might otherwise disqualify them from residency in a facility licensed under this part." This definition creates a higher level of care in assisted living which requires an additional license.
Facilities with a limited nursing services license can provide nursing assessments, assessment of the physical and mental status of residents, administration of medications, supervision of self-administration, applying heat, routine changes of colostomy bags, passive range of motion exercises, ice caps, urine tests and routine dressing that no require packing or irrigation, replacement of self-maintained indwelling catheters, enemas and digital stool removal therapies, and care of casts, braces or splints.
Facilities with an ECC license must develop policies which allow residents to age in place and which maximize the independence, dignity, choice and decision making; specify the personal and supportive services that will be provided; specify the nursing services to be provided and describe the procedures to ensure that unscheduled service needs are met.
Facilities licensed to provide extended congregate care must provide private rooms or apartments, or semi-private room or apartment shared with a roommate of choice, with a lockable entry door. Facilities that offer rooms rather than apartments must have bathrooms shared by no more than three residents.
Facilities that do not have the ECC license may offer shared rooms, maximum four per room, a bathroom for every six residents and bathing facilities for every eight residents.
Admission The regulations for "admissions" to all assisted living facilities are very detailed. New residents must:
Be able to perform ADLs with supervision or assistance (but not total assistance);
Be free of signs and symptoms of communicable diseases;
Not require 24-hour nursing supervision;
Be capable of taking their own medication or the facility has licensed staff to administer medications or the resident contracts with an outside agency for administration;
Not have bed sores or stage 2, 3, or 4 pressure ulcers;
Be able to participate in social activities;
Be capable of self-preservation with assistance;
Not be bedridden;
Cannot require 24-hour mental health care.
Continued residency Additional criteria affect continued residency. In regular assisted living facilities, people who are bedridden more than seven days or develop a need for 24-hour nursing supervision may not be retained.
In ECC facilities, residents may not be retained if they are bedridden for more than 14 days. Residents may stay if they develop stage 2 pressure sores but must be relocated for stage 3 and 4 pressure sores. Residents who are medically unstable, become a danger to self or others or experience cognitive decline to prevent simple decision making may not be retained. People who became totally dependent in 4 or more ADLs (exceptions for quadraplegics, paraplegics and victims of muscular dystrophy, multiple sclerosis and other neuro-muscular diseases if the resident is able to communicate their needs and does not require assistance with complex medical problems) may not be retained.
Residents with a diagnosis of Alzheimer's disease or advanced dementia may be retained if they have no significant health problems requiring nursing services. Terminally ill residents may continue in any assisted living facility if a licensed hospice agency coordinates services, an interdisciplinary care plan is developed and all parties agree to the continued residency.
To receive services under the Medicaid waiver, tenants must be 60 years of age or older and meet one of the following criteria:
Require assistance with four or more ADLs or three ADLs plus supervision or administration of medications;
Require total help with one or more ADLs;
Have a diagnosis of Alzheimer's disease or another type of dementia and require assistance with two or more ADLs;
Have a diagnosed degenerative or chronic medical condition requiring nursing services that cannot be provided in a standard ACLF;
Are Medicaid eligible, awaiting discharge from a nursing home but cannot return to a private residence because of a need for supervision, personal care, periodic nursing services or a combination of the three.
Three levels of licensure are available: standard, limited nursing service and extended congregate care. The first level allows facilities to provide personal care and administration of medications. Facilities with an ECC license may provide a higher level of service including total care with up to three ADLs and any nursing service allowed under the scope of the nurse's license except those that are prohibited in the rule. ECC facilities must describe the personal, supportive and nursing services to be made available. Facilities may provide limited nursing services (eg., medication administration and supervision of self-administration, applying heat, passive range of motion exercises, ice packs, urine tests, routine dressings that do not require packing or irrigation and others), intermittent nursing services (eg., routine change of colostomy bag and related care, catheter care, administration of oxygen, routine care of an amputation or fracture, prophylactic and palliative skin care).
Other supportive services that may be provided include counseling, emotional support, networking, assistance securing social and leisure services, shopping, escort, companionship, family support, information and referral, transportation assistance developing and implementing self-directed activities. In addition, facilities provide ongoing medical and social evaluation, dietary management, and medication administration.
ECC facilities must make available nursing diagnosis or observation and evaluation of physical conditions, ongoing medical and social evaluation to determine when the person's conditions cannot be met within the facility, control of occurrence of infections, promotion of normal elimination patterns through diet and exercise, routine measurement and recording of vital functions, dietary management, administration of medications and treatment, preventive regimens for residents liable to develop pressure sores, provide or arrange for rehabilitation services, transportation or escort services for health related services.
ECC facilities may not provide oral or nasopharyngeal suctioning, assistance with tube feeding, monitoring of blood gasses, intermittent positive pressure breathing therapy, intensive rehabilitation services for a stroke or fracture or treatment of surgical incisions which are not clean and free from infection and any treatment requiring 24-hour nursing supervision.
The Medicaid waiver includes the following services for recipients in ECC settings: personal care, homemaker, attendant and companion, medication administration and oversight, therapeutic social and recreational programming, physical, occupational and speech therapy, intermittent nursing services, specialized medical supplies, specialized approaches for behavior management for people with dementia, emergency call systems and case management.
Services are reimbursed through SSI, SSDI, an optional state supplement to the federal SSI payment and a Medicaid home and community based services waiver. The waiver reimburses providers $750 a month for services for a total payment of $1415 less the $43 personal needs allowance. The SSI benefit is $665 a month. State officials are exploring a system to base payment on the level of care required by residents.
To be eligible for the waiver program, recipients receive SSI, have income under 300% of the federal SSI benefit or, for aged and disabled applicants, have income under 90% of the federal poverty level. Only facilities with an ECC or limited nursing services license may participate in the waiver program.
Medications may be administered by staff within the scope of their license.
Facilities must employ sufficient staff in accordance with required ratios and based on the physical and mental condition of residents, size and layout of the facility, capabilities of trained staff and compliance with all minimum standards. Staff must be employed that are able to assure the safety and proper care of residents and implement the evacuation and emergency management plan.
Administrators employed on or after October 1995 must be over 18, have a high school diploma or GED, or have been an administrator for one of the last three years. Effective July 1997, administrators must complete the core training requirements, including a competency exam and a background check. Administrators must also receive 12 hours of continuing education every two years. ECC administrators must complete six hours of initial training on the physical, psychological or social needs of frail elders or persons with Alzheimer's disease and adults with disabilities and six hours of continuing training each year.
Staff New staff must complete one hour training each on the following topics: infection control, including universal precautions; reporting major incidents and emergency procedures; resident rights and recognizing/reporting abuse, neglect or exploitation. HIV/AIDS training is required on hiring (two hours) and every two years (one hour). Staff who supervise self-administration of medications must receive two hours of training prior to assuming these responsibilities.
For direct care staff, the department shall establish a core educational requirement to be used in these programs. Staff must successfully complete a competency test. The 26 hour core educational requirement must cover at least the following topics:
State law and rules on assisted living facilities, including life safety requirements and procedures;
Identifying and reporting abuse, neglect and exploitation;
Special needs of elderly persons, persons with mental illness and persons with developmental disabilities and how to meet those needs;
Nutrition and food service, including acceptable sanitation practices for preparing, storing and serving food;
Proper techniques for assisting residents with self-administered medication, including record keeping;
Fire safety requirements, including fire evacuation; and
Four hours on Alzheimer's disease.
Effective April 20, 1998, the department will review and approve curricula for HIV/AIDS training, First Aid, and CPR.
Staff who have not taken the core training program shall receive a minimum of two hours of training within the first 30 days of employment in the following subjects:
Understanding common resident behavior, needs and rights;
Common behavior issues and how to respond;
Abuse, neglect and exploitation;
Reporting of major incidents; and
Emergency procedures including procedures for immediate evacuation such as fire, procedures for planned evacuations such as hurricanes, chain of command and staff roles.
The following training is required for staff performing specific functions:
Staff providing personal hygiene must receive training in personal hygiene care from a nurse. CNAs exempt.
Staff assistance with ADLs other than toileting shall receive a minimum of three hours of training in how to perform this care within 30 days of employment.
Persons designated to provide assistance with supervision of self-administered medications shall receive a minimum of two hours of training.
Nutrition and food service. Person responsible for total food services and day to day supervision of food services shall participate in continuing education with a minimum of two hours on an annual basis.
Six hours of initial training that addresses ECC care, concepts and requirements and delivery of personal care and supportive services is required for ECC staff.
New rules for staff in facilities serving people with Alzheimer's disease require 4 hours of initial training in areas of the disease in relation to the normal aging process, diagnosing Alzheimer's disease, characteristics of the disease process; psychological issues including resident abuse, stress management and burn out for staff, families and residents; and ethical issues. An additional four hours is required on medical information, behavior management and therapeutic approaches. Direct care staff must participate in four hours of continuing education each year.
Core training and Alzheimer's disease training may be obtained from persons approved by the Department of Elder Affairs or the Department staff. The draft rules contain a sliding fee for training that varies with the percentage of residents supported by public funds.
A criminal history record check, AHCA form 3110-0002 September 1996, shall be obtained from the Florida Department of Law Enforcement on each applicant, administrator, offices of the corporation and general partners. Applicants must submit a Florida Abuse Hotline Information Systems background check (Form AHCA 3110-0003). Administrators may request a background check pursuant to Chapter 435 on employees.
Registered nurses must visit ECC facilities twice a year to monitor residents and to determine if the facility is in compliance with relevant rules.
The base biennial fee is $253 per license plus $33 per resident. Facilities providing ECC services pay an additional fee of $410.