Adult care facilities 18 NYCRR §487
Enriched housing programs 18 NYCRR §488.1 et seq.
Assisted living program. NY Social Service Law §461-1 et. seq.; NY Comp. Codes R & Regulations title 18, §485.1 et seq.
A complete review of the multiple regulations and categories is underway. Regulation activities are being consolidated under a new Office of Continuing Care that was created in January 1998 and includes responsibility for residential care, adult homes and enriched housing programs. The Long Term Care Omnibus Act of 1997 directs the Commissioner on Health to conduct a study on utilization in and the future development of assisted living, including demographic information on current residents and the population that could be served; service utilization patterns; options for further development and program financing; and an oversight structure. The report was expected to be completed in the summer of 1998.
A Task Force on Long Term Care Financing issued a report in 1996 that makes broad recommendations on long term care. A section of the report recognized that assisted living has been developed "as an alternative for low income people who would otherwise require nursing facility placement." The report recommends that the program be reformed "to require licensure of assisted living as a specific type of enhanced home care service under the auspices of one State agency." Currently, the program falls under two laws, one licensing adult care facilities and the other licensing home care agencies. The report recommended allowing the residential component to be provided in any type of residential setting, including adult care facilities that meet building requirements such as the State Uniform Fire Prevention and Building Code. A series of outcome based program requirements would be set for fire safety, nutrition, medication management and case management.
The New York Task Force saw assisted living taking a prominent place in the state's overall long term care strategy and affecting the need for nursing home beds. The report recommended a reexamination of all components of the nursing facility bed need methodologies for long term care that reflects projected demographic trends, expected changes in utilization patterns based on increases in managed care penetration, addition of new services options (eg., assisted living) and potential changes in utilization based financing recommendations.
In 1991, the state legislature created a 4,200 bed assisted living program (ALP). Since the program substitutes for nursing home beds, the nursing home bed need formula was reduced by an equivalent amount. Three rounds of bidding have resulted in the award of approximately 4,000 units. A fourth round was expected that will award 200 units in Long Island. Of the approved units, about 3,000 are operating and 2,100 are filled.
The state approaches assisted living as a service option in existing housing. Assisted living programs must be licensed as an adult home or enriched housing program (which addresses housing) and licensed as either a home care services agency, a certified home health agency or a long term home health care agency (which addresses home care service delivery).
Until January 1998, oversight was provided by two state agencies. The Department of Health reviews licenses for licensed home care agencies and the Department of Social Services licenses adult homes and enriched housing. Responsibilities were being consolidated in 1998.
Adult homes and enriched housing programs are both licensed under the state's adult care facility regulations. Both models serve five or more people and provide long term residential care, room, board, housekeeping, personal care and supervision. Adult homes represent the state's board and care model while enriched housing programs operate in community integrated settings resembling independent housing units. While the majority of Assisted Living Program beds are in adult homes, the demand from "enriched housing" providers is increasing among purpose built facilities rather than conventional elderly housing sites.
Adult care home is established and operated for the purpose of providing long term residential care, room, board, housekeeping, personal care and supervision to five or more adults unrelated to the operator. Adult homes may be either proprietary, public or non-profit.
Enriched housing program means an adult care facility established and operated for the purpose of providing long term residential care to five or more adults, primarily persons 65 years of age or older (no more than 25% under 65 and all are 55 or older), in community integrated settings resembling independent housing units. Such programs must provide or arrange for the provision of room and board, housekeeping, personal care and supervision.
Assisted Living Program (ALP) (Medicaid program) is available in some adult home and enriched housing programs, combines residential and home care services. It is designed as an alternative to nursing home placement for individuals who have historically been admitted to nursing homes for social rather than medical reasons. The operator of the ALP is responsible for providing or arranging for resident services that must include room, board, housekeeping, supervision, personal care, case management and home health services.
Adult homes provide single or double occupancy bedrooms and have one toilet and lavatory for every six residents and one tub/shower for every 10 residents.
Enriched housing programs must provide single occupancy units, unless shared by agreement, and each unit must include a full bathroom, living and dining space, sleeping area and equipment for storing and preparing food. Shared units must provide for toilets, lavatory, shower or tub shared by not more than three residents.
Assisted living programs comply with the relevant requirements under which the contracting facility is licensed.
Enriched housing programs Operators may not accept or retain anyone who: requires continual nursing or medical care; suffers from a serious and persistent mental disability sufficient to warrant placement in an acute care or residential treatment facility; is a danger to self or others; requires continual skilled observation; refuses or is unable to comply with treatment; is chronically bedfast or chairfast and requires assistance from another person to transfer; regularly needs assistance from another person to walk or climb and descend stairs unless on the ground floor; has chronic un-managed urinary or bowel incontinence; has a communicable disease; is dependent on medical equipment (with exceptions); has chronic personal care needs which cannot be met by the staff; is not self-directing and engages in drug or alcohol use which results in aggressive or destructive behavior.
Medicaid To receive Medicaid reimbursement for home care services provided in an ALP, applicants must be determined by a physician to be appropriate for this level of care. The applicant must then be assessed by the ALP to determine the care required and the program's ability to meet those needs. Participants must have stable medical conditions and are able to assure self-preservation in an emergency.
Adult homes and enriched housing programs can provide supervision, personal care, housekeeping, case management, activities, food service assistance with medication and activities under their adult care facilities license. To operate as an assisted living program, additional services and licenses are needed. The facility may seek a license to provide nursing care and therapies or they may contract with a home health agency or a long term home health care program. A care plan is jointly developed by the ALP and the CHHA/LTHHCP which is based on the physician's orders and the assessment process.
The Medicaid ALP capitation rate covers personal care, home health aide, personal emergency response services, nursing services, physical therapy, occupational therapy, speech therapy, medical supplies that do not require prior authorization and adult day health care, if needed.
For Medicaid recipients, the home care service reimbursement is set at 50% of the resident's Resource Utilization Group (RUG) which would have been paid in a nursing home. The state has created 16 RUG categories for 10 geographic areas of the state. The attached chart includes rates in use for 1998. Facilities must comply with the adult home retention criteria. However, the full array of rates are shown since facilities receive a higher rate when a resident deteriorates and is retained until a nursing home placement can be made.
The reimbursement category is determined through a joint assessment by the Assisted Living Program and the designated home health agency or long term home health care program. The assessment and the RUG category are reviewed by the Department of Social Services district office which must prior authorize the Medicaid home care payment.
The residential services (room, board and some personal care) are covered by SSI which also varies by region. In 1998, the SSI rates were $929 in New York City, Nassau, Suffolk and Westchester counties and $899 in the rest of the state. Using the four lowest RUG categories and the SSI rates, the total monthly rate in New York City ranges from $1706 to $2516.
Assistance with self-administration is allowed including prompting, identifying the medication for the resident, bringing the medication to the resident, opening containers, positioning the resident, disposing of used supplies and storing the medication.
Adult homes must have a case manager and staffing that is sufficient to provide the care needed by residents.
Administrators Program coordinators must be 21 or older, have a master's degree in social work and one year experience, or a bachelor's degree and three years of acceptable experience.
Staff providing personal care must complete a personal care aide or home health aide training course or other examination approved by the state Department of Health. Enriched housing programs must provide an orientation and in-service training in the characteristics and needs of the population served, resident rights, program rules and regulations, duties and responsibilities of all staff, general and specific responsibilities of the individual being trained and emergency procedures.
Applicants for a license must disclose and submit a history of legal actions including criminal actions.
|RUG RATES IN NEW YORK STATE|
|BA||$44.47||$63.76||$47.65||$44.86||$48.47||$59.28||$41.52||$55.63||$41.52||$45.24 - hour|
|SA||$66.25||$98.11||$70.48||$66.31||$72.65||$91.56||$61.34||$84.24 - hour||$60.96||$67.34|
|CB||$57.39||$84.40||$61.28||$57.52||$62.79||$78.68||$53.24 - hour||$72.68||$53.06||$58.36|
|PD||$57.05||$84.02||$60.95||$57.13||$62.42||$78.32||$52.93||$72.24 - hour||$52.78||$58.00|
|NOTE: ALPs receive one half the rate listed.