Assisted living: House Enrolled Act 1630 (1997)
Residential care facilities: 410 IAC 16.2 et seq.
The state has not adopted legislation or administrative rules governing assisted living at this time although state agencies are investigating options for regulating and reimbursing assisted living.
In 1996, the Family and Social Services Administration completed a study of assisted living and made recommendations in response to a Concurrent Resolution adopted by the legislature. In 1997, HB 1630 directed a legislative committee, the Health Finance Committee, to develop recommendations concerning licensing of assisted living. The recommendations were based on the principles of promoting resident choice, dignity, privacy, autonomy, independence and encouraging aging-in-place. The recommendations included a definition and minimum requirements for living units. HB 1630 also directed the Indiana State Department of Health to identify, contact and survey all facilities that market, advertise or identify themselves as assisted living. The survey was to determine the number and type of units, services provided, manner of service provision and the steps taken to provide for choice, dignity, privacy, autonomy, independence and aging-in-place. The survey was completed in November 1997.
HB 1630 also directed the Community Home Options to Institutional Care for the Elderly and Disabled (CHOICE) Board, which advises the Division of Disability, Aging and Rehabilitative Services, to establish long term care goals for the state that include an array of services, including assisted living, and to recommend legislation, policies and rules to implement a system and other items. The CHOICE Board adopted a vision statement, goals and objectives on September 23, 1997 which included assisted living licensure and coverage under Medicaid. The Board forwarded the recommendations on assisted living to the Health Finance Commission in August 1997.
A disclosure bill (SB 436) passed during the 1998 legislative session. The bill requires that all housing with services establishments complete a disclosure form and send the form along with a copy of the resident contract to the Division of Disability, Aging and Rehabilitation Services. An establishment may not use the term "assisted living" if it has not filed a disclosure form. The bill also lists specific information that must be included in the resident contract. This requirement goes into effect September 1, 1998. The form includes the following information: the name and address of the owner and managing agent, description of services provided and the base rate, resident contracts, additional services available and their fees, the resident contact, the process for modifying and terminating the contract, description of the complaint resolution process and criteria for determining who may continue to reside in the establishment.
A housing with service establishment is defined as an establishment providing sleeping accommodations to at least five residents and offering or providing for a fee at least one regularly scheduled health related service or at least regularly scheduled supportive services. Health related services means attendant and personal care services, professional nursing services and central storage of medications. Supportive services means personal laundry, handling or assisting with personal funds, arranging for medical services, health related services or social services.
The following summaries describe the assisted living recommendations and the current licensing requirements for residential care facilities. None of the assisted living recommendations have been adopted as yet by the legislature.
Assisted living must be driven by a philosophy of service that emphasizes choice, personal dignity, autonomy, independence, and privacy. It should enhance a person's ability to age-in- place in a homelike setting while services intensify or diminish as the individual's needs change.
Assisted living recommendation Assisted living provides, coordinates or arranges activities; personal and health related services; 24-hour supervision and assistance (scheduled and unscheduled) in a homelike setting; minimizes the need to move; accommodates changing needs and preferences; maximizes choice, dignity, autonomy, privacy and independence; meets federal, state and local requirements accommodates multiple funding options and encourages family and community involvement.
Residential care facilities Residential care facility means a facility that provides room, food, laundry and occasional assistance in daily living for residents who need less services than the degree of service provided by a comprehensive care facility (nursing home). There is an overall general supervision of health care, medications and diets as defined in the written policies of the facility.
Assisted living recommendation Living units should include an opportunity for single occupancy, except at the request of the resident. Each unit should include a sleeping area, a living area, an accessible bathroom and a kitchenette. The kitchenette should include an area for hot and cold food preparation, sink, storage, and appliances that can be removed or disabled. There should be minimum square footage requirements, resident controlled climate controls, lockable doors, emergency call system, telephone jacks, common areas, including physical fitness options and meal service.
Residential care facilities Rules require 100 square feet for single rooms and 80 square feet per bed for multiple occupancy. No more than four people may share a room. One toilet and sink is required for every eight residents.
Assisted living recommendation Facilities should not establish restrictive occupancy policies except for people needing 24-hour skilled nursing supervision for an extended period of time. All components of the contract should be specific and clearly defined.
Residential care facilities The rules do not allow anyone needing nursing care to be admitted or retained. Residents may need only occasional assistance with activities of daily living.
Assisted living recommendation Services should include housekeeping, congregate dining, assistance with ADLs and medication administration and reminders. Each resident should have a care plan which is updated regularly and negotiated risk agreements should be developed when indicated. Service provisions should not inhibit services provided through Medicare and Medicaid.
Residential care facilities Personal care, supervision of nutritional status, assistance with self-administration of medications or administration by qualified personnel are allowed services. The rules state that "each resident shall be assisted in or occasionally given personal care as needed."
Assisted living recommendation The report recommends coverage through a Medicaid waiver that allows residents to retain sufficient income to cover the room and board costs (eg., 300% optional eligibility category). This would not preclude use of other publicly funded programs.
Residential care facilities Medications may be administered under physician's order by licensed nursing personnel or qualified medication aids. Other treatments may be given by nurses aides upon delegation by licensed nursing personnel.
Assisted living recommendation Twenty four hour staffing should be required. Administrators should be licensed and initial and annual training should be required for all staff. Medical oversight should be provided by licensed nurses.
Residential care facilities Sufficient staff must be on duty to assure adequate care. At least one staff member must be on duty at all times in facilities with less than 100 residents and one additional staff member for every 50 residents in facilities with over 100 residents.
Residential care facilities Administrators must be licensed.
Staff Prior to working independently, each employee shall be given an orientation of the facility by the supervisor. Orientation of all employees shall include:
Instructions on the needs of the specialized populations served in the facility;
A review of the facility's policy manual and applicable procedures including organizational chart, personnel policies, appearance and grooming and resident rights;
Instructions in first aid, emergency procedures and fire and disaster preparedness, including evacuation procedures;
A detailed review of the appropriate job description, including a demonstration of equipment and procedures required of the specific position to which the employee will be assigned;
Review of ethical considerations and confidentiality in resident care and records;
For direct care staff, personal introduction to and instruction in, the particular needs of each resident to whom the employee will be providing care; and
Documentation of orientation in the employee's personnel record.
Direct care staff must complete nurse aid training. The training program may be established by the facility and training must commence within 60 days of employment. Training includes:
30 hours of classroom instruction including orientation to the facility, policies, duties, basic nursing skills, clinical practice, resident safety and rights, and the social and psychological problems of residents; and
75 hours of supervised training under supervision of a licensed nurse.
An ongoing in-service training that includes prevention and control of infection, fire prevention, safety and accident prevention and the needs of the specialized populations is also required. In-service training programs shall contain means to assess learning by participants. These may include testing such as self-graded, before and after tests, clinical practice sessions under supervision, instructor assessment, etc. Monthly in-service training shall be conducted for nursing staff. In addition, for personnel administering medications, no less than eight programs on medication administration shall be offered per year.
Assisted living recommendation A quality assurance/improvement process that covers resident satisfaction, education, choice of providers and quality service should be developed. Residents who are Medicaid beneficiaries would be assessed through the preadmission screening program (a requirement for waiver services) and receive ongoing case management through an Area Agency on Aging or other appropriate agency.