Assisted living 651 CMR 12.00
Chapter 354 (Acts of 1994) was signed into law in January 1995 and creates a process for the certification of assisted living facilities by the Executive Office of Elder Affairs. The law provides that the regulations "shall be sufficiently flexible to allow assisted living residences to adopt policies and methods of operation which enable residents to age-in-place." To be certified, residences must submit information such as the number of units and number of residents per unit, location of units, common spaces and egress by floor; base fees to be charged; services to be offered and arrangement for delivering care; number of staff to be employed and other information required by the Executive Office of Elder Affairs. The buildings are considered residential use for applying appropriate building codes.
In 1996, sixty assisted living residences received deemed certification and 20 residences were fully certified with a total of 3700 units. By March 1998, 93 residences with 5,116 units had been certified.
The Massachusetts Housing Finance Agency (MHFA) and the Massachusetts Industrial Finance Agency (MIFA) provide loans for assisted living. The MHFA "Elder CHOICE" program is designed to support development of appropriate housing and ADL assistance for frail elders. The agency's RFP indicates that assisted living offers a supportive residential environment which maximizes the ability of elders to live independently and reduces the need for costly institutionalization. MHFA has approved 14 projects with 900 units. Most projects require that 20% of the units be set aside for low income residents and two projects have a 50% set aside.
The Medicaid Group Adult Foster Care program, which reimburses assisted living for Medicaid recipients, has certified 70 programs of which 30 are located within certified assisted living residences and serve 312 beneficiaries.
Assisted living residence is any entity, however organized, whether conducted for profit or not for profit, which meets all of the following criteria:
Provides room and board; provides, directly by employees of the entity or through arrangements with another organization which the entity may or may not control or own, assistance with activities of daily living for three or more adult residents who are not related by consanguinity of affinity to their care provider and; collects payments or third party reimbursements from or on behalf of residents to pay for the provision of assistance with the activities of daily living.
Units must be single or double occupancy with lockable doors. New construction must provide for private baths. Existing buildings may qualify if they provide private half baths and one bathing facility for every three persons. All facilities must provide, at a minimum, either a kitchenette or access to cooking capacity for all living units. Cooking capacity is defined as each resident having access to a refrigerator, sink, and heating element. Facilities must comply with all federal and state laws and regulations regarding sanitation, fire safety, and access by persons with disabilities. The Secretary of Elder Affairs is authorized to waive the requirements for bathrooms and bathing facilities when determined to meet public necessity and to prevent undue economic hardship as long as the residence provides a home-like environment and promotes privacy, dignity, choice, individuality and independence.
The statute does not allow people needing 24-hour skilled nursing supervision to be admitted or retained in an assisted living residence. Facilities may admit and retain residents in need of skilled nursing care only if the care will be provided by a certified provider of ancillary health services or by a licensed hospice and the provider does not train the facility staff to provide skilled nursing care.
To qualify for reimbursement under the Medicaid Group Adult Foster Care program, tenants must require daily assistance with at least one ADL and assistance with managing medications as documented by a physician and a nursing assessment; be at risk of requiring nursing home placement; be chronically disabled; and require 24-hour supervision.
Chapter 354 requires that residences all provide or arrange for opportunities for socialization and access to community resources; supervision or assistance with ADLs identified in a plan of care (at a minimum residences must offer support for bathing, dressing and ambulation); instrumental activities of daily living; self-administered medication management; timely assistance to urgent or emergency needs by 24-hour per day on-site staff, personal emergency response systems, or any additional response systems required by the Executive Office of Elder Affairs; up to three regularly scheduled meals per day (minimum of one meal per day). The administrator may arrange for the provision of ancillary health services in the facility but may not use facility staff for these services unless the staff is an employee of a certified provider of ancillary health services and/or an employee of a licensed hospice. Nursing services provided by a certified provider of ancillary health services such as injection of insulin or other drugs used routinely for maintenance therapy of a disease may be provided to residents.
All residents must have an individual services plan that is developed prior to admission and reviewed/reassessed at least every six months or when health status or family circumstances change.
Twenty-four hour nursing services are not allowed. Skilled services may only be provided by a certified home health agency on a part time or intermittent basis. Medical conditions requiring services on a periodic, scheduled basis are also allowed. In addition, residents may "engage or contract with any licensed health care professional and providers to obtain necessary health care services ... to the same extent available to persons residing in private homes." The initial draft of the regulations limited the provision of skilled services to 90 days in a one year period. The attorney general's office issued an informal opinion that such a limit was contrary to the fair housing rules and the limitation was withdrawn in the final regulations.
The MHFA Elder CHOICE program requires, at a minimum, personal care (assistance with bathing, dressing, continence, ambulation, toileting, eating and transfers); housekeeping and maintenance, laundry, medical monitoring and transportation, up to three meals a day, twenty- four hour emergency response and service coordination and case management.
The Massachusetts Housing Finance Agency and the Massachusetts Industrial Finance Agency provide loans for the construction of assisted living projects.
Services for low income tenants are subsidized through Medicaid's Group Adult Foster Care (GAFC) which is a service available under the "state plan" rather than a Medicaid waiver. GAFC provides an average of $33.70 per day for services and administrative costs. To support low income residents who do not have sufficient income to pay for room and board, the state has created a special SSI living arrangement for assisted living residences. The SSI payment standard is $948 a month for a single individual. The regular community payment standard for an aged person living alone is approximately $620 a month.
Residence staff are allowed to remind residents to take medications, open containers, open prepackaged medications, read the label, observe, check dosage against the label and reassure residents that the proper dosage has been taken.
No staffing specific guidelines are included concerning the type and number of staff. However, the residence must maintain an ability to provide timely assistance to residents and to respond to urgent or emergency needs through on site staffing, personal emergency response or other means.
Administrators The manager of an ALR must be at least 21 years old and have demonstrated administrative experience. The manager must have a Bachelor's degree or equivalent experience in human services management, housing management and/or nursing home management. The service coordinator of a residence must have a minimum of two years of experience working with elders or disabled individuals and a Bachelor's degree or equivalent experience.
Staff Prior to active employment, all staff and contracted workers having direct contact with residents and all food service personnel must receive a six hour orientation covering the following topics:
Philosophy of independent living in an ALR,
Resident bill of rights,
Elder abuse, neglect and financial exploitation,
Review of the aging process,
Dementia/cognitive impairment, resident health and related problems,
Job requirements and
Sanitation and food safety.
A minimum of 6 hours per year of ongoing education and training is required for all employees. All employees and providers shall receive ongoing in-service education and on the job training aimed at reinforcing the initial training. ALR staff and contracted providers of personal care services must complete an additional 54 hours of training prior to providing personal care services to a resident (34 hours general training and 20 hours of training specific to the provision of personal care). The 20 hours of personal care training must be conducted by a qualified registered nurse with a valid Massachusetts license. The 54 hours of training must include, but not limited to, the following topics:
Self-administration of medications;
Human growth and development;
Grief, loss, death and dying;
Maintenance of a clean, safe and healthy environment; home safety; and
Assistance with appliances.
Applicants must assure that none of officers, directors, trustees, limited partners or shareholders have ever been found in violation of any local, state or federal statute, regulation, ordinance or other law by reasons of the individual's relationship to an assisted living residence.
The Executive Office of Elder Affairs conducts compliance reviews of assisted living residences every two years. The reviews include inspections of the common areas, living quarters (by consent of the resident), inspection of the service plans, and a review of the resident satisfaction survey.
Board and Care
Rest homes provide room and board and personal care services to persons not requiring skilled nursing services. Residents who need skilled nursing services may not be retained. Home health care services may be provided in the home as long as the services are not skilled and the resident does not require 24-hour supervision. Medication administration is available, however, most residents are able to self-administer their own medications. The "responsible person" for the facility must be at least 18 years old and have a high school diploma or GED. A license is not required for this position. If the home provides medication administration, the responsible person must take a course in this area. The home must have nursing and dietary consultants. Care staff are not required to have training, although they must have access to consultations with professional disciplines.