Assisted living facilities Title 22, MRSA §7902
Governor King signed legislation April 11, 1996 which revised the state's assisted living program. Emergency rules were effective in October 1997 and the rules will be finalized in the Spring of 1998. The bill created several levels of assisted living with varying licensing based on the level of service provided. Assisted living services may be provided by residential care facilities and congregate housing providers. However, the licensure requirements do not apply to congregate housing settings offering only meals and housekeeping services. Licensing is optional for congregate housing providers offering personal care. Licensure is required for congregate housing providers offering personal care and administration of medication, and/or offering nursing services. Full licenses may be issued for two years if the facility is in substantial compliance with the rules and has no history of health or safety violations.
The number of residential care facilities has increased significantly since Maine tightened the nursing home level of care criteria in 1994. Thirty one nursing homes have converted wings and 5 entire facilities have converted to residential care. Four nursing homes have closed. While there is no CoN requirement, the state agency issues an RFP for residential care facilities interested in contracting with the Medicaid program. In 1996, the legislature also passed a bill that creates an expedited certificate of need review for nursing facilities which convert and de-license beds and later seek to re-license the beds as part of the nursing facility within four years.
Assisted living services means the provision by a single entity of housing and assistance with ADLs and IADLs. Assisted living services must be provided by the provider of housing either directly by that provider or indirectly through written or verbal contracts with persons, entities or agencies. Services may include, but are not limited to, personal supervision; protection from environmental hazzards; ADLs; administration of medication; diversional, motivational or recreational activities; dietary services; and nursing services.
Congregate housing services program means a comprehensive program of supportive services, including meals, housekeeping and chore assistance, case management and other services that are delivered on the site of congregate housing and assist occupants to manage ADLs. Congregate housing services may also include personal care assistance, with or without supervision, or assistance in the administration of medication and nursing services subject to the licensing requirements.
Level I residential care facility (formerly known as adult foster homes or certain six bed boarding homes) means a residential care facility with a licensed capacity of six or fewer residents.
Level II residential care facility means "a house or other place that is licensed to care for seven or more residents that is maintained wholly or partly for the purpose of providing residents with assisted living services. These are facilities with three or more employees who are not owners and not related by blood or marriage to the owner.
CHSPs are multi-unit residential buildings and state and local building codes for such buildings are applied. The regulations require that all licensed CHSPs be inspected using Chapter 18, New Apartment Buildings, NFPA, Life Safety Code. These rules require a food service area, bathroom and bedroom. The statute indirectly addresses requirements for living units in congregate housing. The definition of personal care assistance implies that only facilities consisting of private apartments can be licensed as CHSPs. definition states:
"Personal care assistance means services provided in group residential settings consisting of private apartments including assistance with activities of daily living and the instrumental activities of daily living and supervision of residents self-administering medication."
In addition, the definition of nursing services also requires that they be provided in "group residential settings consisting of private apartments." However, these definitions do not apply to residential care facilities.
Level I residential care facilities must offer 100 square feet for single room and 80 square feet for double rooms. Bathrooms and showers/tubs must be based on the needs of residents. No more than two residents may share a room. Level II residential care facilities must offer 100 square feet for single room and 80 square feet per resident for double rooms. No more than two residents may share a room. Facilities offering apartment style units must have a fire extinguisher. Facilities in which the bedroom and kitchenette are not physically separate have 30 square feet deducted from usable floor space to determine if the bedroom meets code. Bathrooms are required for every six residents and shower/tubs for every 15 residents.
The rules encourage aging in place and have very flexible policies to do so. In its application, facilities must describe who may be admitted and the types of services to be provided. Facilities may discharge tenants who pose a direct threat to the health and safety of others, damage property or whose continued occupancy would require modification of the essential nature of the program. The rules also require facilities to permit reasonable modifications at the expense of the tenant or other willing payer to allow persons with disabilities to reside in licensed facilities. Facilities shall make reasonable accommodations for people with disabilities unless they impose an undue financial burden or result in a fundamental change in the program.
RCF II facilities may care for people who qualify for nursing home care, but professional or skilled services for these residents must be provided by a home health agency or a private duty nurse. Nursing needs of residents who do not meet the nursing home criteria may be met by registered and licensed nurses employed by the facility.
Assisted living services include a wide range of care (see definition above). Congregate housing sites licensed as assisted living providers must offer at least coordination, housekeeping, personal care assistance, at least one meal a day, chore services and other goods and services identified in the service plan.
CHSPs may offer personal assistance services, assistance with administration of medication and nursing services that are provided by licensed nurses and certified medication aides.
Facilities with Alzheimer's disease/dementia units must provide individual and/or group activities covering gross motor activities, self care activities, social, crafts activities, sensory enhancement activities, outdoor activities and spiritual activities.
The FY 97 state budget included funds to support a demonstration project for 75 CHSP units. State officials developed a reimbursement methodology for the demonstration.
The Medicaid program provides reimbursement for personal care services in RCFs under the state plan in "Private Non-Medical Institutions" (Residential Care Facilities). Reimbursement is also available under the HCBS waiver for people living in congregate housing facilities.
A case mix system is expected to be implemented for residential care facility residents based on functional and other data collected on residents. The state developed an MDS for Residential Care Assessment (MDS-RCA). Data is collected at admission, annually, semi-annual reviews, and upon discharge. The annual MDS-RCA form contains the following sections: identification information; oral/nutritional status; demographic information; oral/dental status; customary routine; skin condition; mood and behavior patterns; activity pursuit patterns; psycho-social well-being; medications; physical functioning; special treatments and procedures; continence; discharge potential; diagnoses; assessment information; and health conditions.
Quality indicators will be used to identify problem areas, exemplary care, and support care decisions. Some of the quality indicators overlap with those developed for nursing facilities, but others provide more emphasis on relationships and psycho-social well-being. The quality indicators include the following: prevalence of self/family participation in assessment; positive psycho-social well-being; bladder incontinence; bowel incontinence; bladder incontinence without scheduled toileting plan; occurrence of injury and falls; prevalence of behavioral symptoms toward others; behavioral symptoms toward others without behavior management; residents using nine or more prescription medications; residents using more than the state average number of medications; prevalence of cognitive impairment; cognitive impairment; level of activity; anti-psychotic drugs; awake at night; communication difficulties; signs of distress or sad/anxious mood; absence of positive psycho-social well-being; and prevalence of unsettled relationships.
A separate level of licensure is required for administration of medications in residential care facilities and congregate housing sites.
CHSP The sponsor must assure that services will be provided to residents in accordance with individual service plans. Since these facilities may house residents who do not require assisted living services, staffing standards are not needed.
Level I RCFs Operators are responsible for assuring that residents have an opportunity to receive individualized services that help them function and restore them to an optimal state of health or opportunities for constructive activity. There are no other staffing standards. Level II RCFs. Staffing must be adequate to implement service plans. RCFs serving over 10 residents must have two awake staff on duty at night. The rules require a ratio of 1:12 residents from 7 AM to 3 PM; 1:18 from 3-11 PM and 1:30 from 11 PM to 7 AM.
Administrators must successfully complete a department approved training program. Ongoing training of at least 10 classroom hours annually is required in areas related to care of the population served.
Congregate Housing CHSPs providing personal care assistance and administration of medications must be licensed. Licensure is optional for CHSPs providing personal care. Qualifications are described for the CHSP sponsor and the services director. The CHSP sponsor is responsible for hiring and training qualified, capable staff. Staff must be 18 years of age or older.
Level I Residential Care Facilities All staff, other than certified nursing assistant (CNAs), whose job responsibilities include direct service to residents for at least twenty hours per week, shall successfully complete a Residential Care Specialist I certification course within one hundred twenty days of hiring. Caregivers shall attend and show evidence of successful completion of any training sessions which the Department determines to be necessary.
Level II Residential Care Facilities Administrator certification and training. For facilities serving six or more residents, the administrator must successfully complete a department approved training program. Ongoing training of at least 10 classroom hours annually is required thereafter in areas related to care of the population served by the facility.
All staff, other than certified nursing assistant (CNAs), whose job responsibilities include direct service to residents for at least twenty hours per week shall successfully complete a Residential Care Specialist I certification course within one hundred twenty days of hiring. Additional training specific to a facility's programs may be identified and required by the Department for any staff.
Pre-service training for Alzheimer's/Dementia Care Units For pre-service training, all facilities with Alzheimer's/Dementia Care Units must provide a minimum of eight hours classroom orientation and eight hours of clinical orientation to all new employees assigned to the unit. The trainer(s) shall be qualified with experience and knowledge in the care of individuals with Alzheimer's disease and other dementias. In addition to the usual facilities orientation, which should cover such topics as resident rights, confidentiality, emergency procedures, infection control, facility philosophy related to Alzheimer's disease/dementia care, and wandering/egress control, the eight hours of classroom orientation should include the following topics: a general overview of Alzheimer's disease and related dementias; communication basics; creating a therapeutic environment; activity focused care; dealing with difficult behaviors; and family issues.
During the licensure process, a criminal background check is done for the applicant and the administrator.
The state ombudsman program is authorized to visit and receive and investigate complaints concerning assisted living.
Residential care facilities will pay a fee of $10 per licensed bed. The fee for congregate housing services program is $50 to provide personal care assistance, $100 to provide personal care and administration of medications and $200 to provide nursing services.