State Assisted Living Policy: 1998. Maryland

06/01/1998

Citation

Assisted living programs Title 10.07.14

General Approach

A legislative hearing on proposed rules combining multiple licensing categories was held on March 23, 1998. They were expected to be final by July 1998. The rules are based on a 1996 statute, SB 545, which created a licensing category for assisted living. The bill was based on the report of a 19 member task force created by the Governor. The task force report acknowledged that a number of programs are viewed as assisted living and found a lack of coordination among programs and differences in definitions. The report recommended creation of a uniform definition, consolidation of regulatory authority under the Department of Health and Mental Hygiene, a review of state and local fire and building codes and streamlined licensing procedures. The report recommended that the task force continue and address issues related to people with disabilities, accreditation, reimbursement and the fiscal impact, and the relationship among community based assistance services, traditional nursing homes and assisted living.

Definition

Assisted living program means "a residential or facility-based program that provides housing and supportive services, supervision, personalized assistance, health related services, or a combination thereof to meet the needs of residents who are unable to perform, or who need assistance in performing the activities of daily living or instrumental activities of daily living in a way that promotes optimum dignity and independence for the residents."

Unit Requirements

Programs licensed after the effective date of the regulations must provide a minimum of 80 square feet of functional space for single occupancy and 120 square feet for double occupancy rooms. No more than two residents may share a room. Facilities previously licensed as domiciliary care homes must provide a minimum of 70 and 120 square feet for single and double occupancy, respectively. Buildings with one to eight occupants must have one toilet for every four occupants and larger buildings must also have at least one toilet on each floor. Showers/baths must be available for every eight occupants.

Tenant Policy

Facilities are licensed by the level of impairment if residents. In general, programs may not serve anyone who, at the time of admission, requires more than intermittent nursing care; treatment of stage 3 or 4 skin ulcers; ventilator services; skilled monitoring, testing and aggressive adjustment of medications and treatments where there is the presence of, or risk for, a fluctuating acute condition; monitoring of a chronic medical condition that is not controllable through readily available medications and treatments; treatment for an active reportable communicable disease; or treatment for a disease or condition which requires more than contact isolation. Residents may not be admitted if they are a danger to self or others and the danger cannot be eliminated through appropriate treatment modalities or are at risk for health or safety complications which cannot be adequately managed.

Programs may request a waiver to care for residents with needs that exceed the licensure level and demonstrate that it can meet the resident's needs and others will not be jeopardized. Waivers for Level I and Level II programs may not be granted for more than 50% of the licensed bed capacity. Level III programs may not receive waivers for more than 20% of capacity or 20 beds, whichever is less.

Services

Three meals in a common dining area, special diets, personal care, laundry, housekeeping, social and spiritual activities, medication management. The program must facilitate access to health care and social services (social work, rehabilitation, home health, skilled nursing, physician services, oral health, counseling, psychiatric care and others).

Reimbursement

Medicaid is not currently planning to develop reimbursement for assisted living beyond the existing Senior Assisted Housing Program, which was considered assisted living prior to passage of the new law. State-subsidized participants with incomes no greater than 60% of the statewide median income and assets no greater than $11,000 apply their income (less a $60 needs allowance) toward costs. State-funded subsidies may cover the difference between the participant's contribution and the monthly fee, up to a maximum of $550 a month. Those eligible for the State's Medicaid waiver may have incomes no greater than 200% of the federal SSI payment and assets no greater than $2000.The maximum monthly fee which may be charged for assisted living services for a Medicaid waiver participant is $1200/month (an increase to $1400 a month is planned at a future date). Medicaid covers the full amount between the participant's contribution and the $1200 fee. Of the 2500 residents in group homes, about 47 are covered by the waiver and an additional 350 residents are covered by a state-only subsidy.

The state Medicaid agency is considering an 1115 demonstration waiver proposal to integrate acute and long term care for dual eligibles (Medicaid and Medicare). However, the Medicaid agency believes that an expansion of assisted living will increase Medicaid spending. Elders are more likely to choose alternatives that are available, more attractive and less expensive than nursing homes which will delay spend down. Market forces may lead to lower nursing home occupancy rates and closure of some facilities which also reduces Medicaid's exposure to future spending.

The law directs the Office of Aging to develop assisted living programs in conjunction with public or private profit or non-for profit entities, maximizing the use of rent and other subsidies available from federal and state sources. These activities can include finding sponsors; assisting developers formulating design concepts and meeting program needs; providing subsidies for congregate meals, housekeeping and personal services; developing eligibility requirements in connection with the subsidies; adopting regulations governing eligibility; and reviewing compliance with relevant regulations.

Medications

The regulations allow for the delegation of medication administration with on-site review every 45 days by the delegating nurse. Staff who administer medications and are not health care professionals must complete a medication management course which is updated every two years.

Staffing

Programs must have staff capacity to deliver the care for which it is licensed. See table.

Training

Administrators Assisted living managers must have adequate knowledge of the health and psycho-social needs of the population served; resident assessment process; use of service plans; cuing, coaching and monitoring residents who self-administer medications with and without assistance; providing assistance with ambulation personal hygiene, dressing, toileting and feeding; residents' rights; fire and life safety; infection control; basic food safety, basic first aid; basic CPR; emergency disaster plans; and individual job requirements of all staff.

Staff must participate in an orientation and ongoing training program to ensure that residents receive services that are consistent with their needs and generally accepted standards of care for the specific conditions of those residents to whom staff will provide services. Staff must receive initial and on-going training in: fire and life safety, infection control, including standard precautions; basic food safety; basic first aid; emergency disaster plans; and individual job requirements as appropriate to their job.

Staff must have knowledge in: health and psycho-social needs of the population served as appropriate to their job responsibilities; resident assessment process; use of service plans; and resident rights

If job duties involve the provision of personal care services, staff must have knowledge in cuing, coaching and providing assistance with ADLs.

Background Check

Applicants must document any felony conviction of the applicant, assisted living manager or household member. Management must conduct either a criminal history records check or a criminal background check consistent with §19-1901 et seq. Annotated Code of Maryland.

Monitoring

Under the law, the Department of Health and Mental Hygiene may delegate monitoring and inspection of programs to the Office on Aging and the Department of Human Resources or local health departments through an interagency agreement.

Fees

$25 a year for programs monitored by the Department of Human Resources or the Office on Aging; $100 a year for programs inspected and monitored by the Department of Health and Mental Hygiene. For programs with 16 beds or more, $100 a year plus $6 per each bed over 15.

MARYLAND LEVEL OF CARE DIFFERENCES
Area Level I - Low Level II - Moderate Level III - High
Health and wellness Ability to recognize the cause and risks associated with a resident's health condition once these factors are identified by a health care professional.

Provide occasional assistance in accessing and coordinating health services and interventions.

Ability to recognize and accurately describe and define a resident's health condition and identify likely causes and risks associated with the resident's condition.

Provide or ensure access to necessary health services and interventions.

Ability to recognize and accurately describe and define a resident's health condition and identify likely causes and risks associated with the resident's condition.

Provide or ensure ongoing access to coordination of comprehensive health services and interventions.

Functional Provide occasional supervision, assistance, support, set up, or reminders with some but not all ADLs. Provide or ensure substantial support with some, but not all, ADLs or minimal supports with any number of ADLs. Provide or ensure comprehensive support as frequently as needed to compensate for any number of ADLs.
Medication and treatment Ability to assist with taking medications or coordinate access to necessary medications and treatments. Provide or ensure assistance with taking medications, and to administer necessary medications and treatments, including monitoring their effects. Provide or ensure assistance with taking medication, or to administer necessary medications and treatments, including monitoring or arranging for monitoring the effects of complex medication and treatment regimens.
Behavioral Monitor and provide uncomplicated intervention to manage occasional behaviors that are likely to disrupt or harm the resident or others. Monitor and provide or ensure intervention to manage frequent behaviors which are likely to disrupt or harm the resident or others. Monitor and provide or ensure ongoing therapeutic intervention or intensive supervision to manage chronic behaviors which are likely to disrupt or harm the resident or others.
Psychological Monitor and manage occasional psychological episodes or fluctuations that require uncomplicated intervention or support. Monitor and manage frequent psychological episodes or fluctuations that may require limited skilled interpretation or prompt intervention or support. Monitor and manage a variety of psychological episodes involving active symptoms, condition changes or significant risks that may require some skilled interpretation of immediate interventions.
Social and recreational Occasional assistance in accessing social and recreational services. Ability to provide or ensure ongoing assistance in accessing social and recreational services. Provide or ensure ongoing access to comprehensive social and recreational services.

 

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