Twenty six states reported that they have specific requirements for facilities serving people with dementia or Alzheimer's disease. Requirements address one or more of the following: disclosure requirements, staffing patterns and staff training, activities, environmental provisions, and admission/retention criteria. Staff training accounts for the special provisions in the majority of these states. Idaho's rules include a definition of Alzheimer's facilities. The rules define special care facilities as those that "are specifically designed, dedicated, and operated to provide the elderly individual with chronic confusion, or dementing illness, or both, with the maximum potential to reside in an unrestrictive environment through the provision of a supervised life-style which is safe, secure, structured but flexible, stress free and encourages physical activity through a well developed activity and recreational program. The program constantly strives to enable residents to maintain the highest practicable physical, mental or psychosocial well-being."
Arizona licenses directed care facilities which means programs and services, including personal care services, provided to persons who are incapable of recognizing danger, summoning assistance, expressing need or making basic care decisions. Regulations in most other states do not define special care facilities.
Disclosure requirements are included in state regulations in nine states. These provisions typically require that facilities advertising themselves as operating special care facilities or units, or that care for people with Alzheimer's disease, describe in writing how they are different. The regulations may require a description of the philosophy of care, admission/discharge criteria, the process for arranging a discharge, services covered and the cost of care, special activities available, and differences in the environment.
A voluntary disclosure process has been adopted in California under which facilities offering special services for people with Alzheimer's Disease disclose information concerning their program. A consumer's guide has been developed which alerts family members to several key questions that should be asked. The areas include the philosophy of the program and how it meets the needs of people with Alzheimer's, the pre-admission assessment process used by the facility, the transition to admission, the care and activities that will be provided, staffing patterns and the special training received by staff, the physical environment, and indicators of success used by the facility.
Eight states have admission/retention criteria that directly reference people with Alzheimer's disease. Tennessee does not allow people in the later stages of the disease to be served. People with Alzheimer's disease may be served only after a multi-disciplinary team determines that care can be provided safely. The determination must be reviewed quarterly.
Florida allows people with Alzheimer's disease to be retained in facilities with an extended congregate care license if they can make simple decisions and if they do not have a medical condition requiring nursing services. Georgia also requires that residents must be able to make simple decisions. California's criteria allows people with Alzheimer's disease to be admitted who are not able to respond to verbal instructions. Vermont's draft rules allow but do not require facilities to serve people who cannot make simple decisions.
Washington state has included separate requirements for boarding homes providing special dementia care units or services to people with dementia. Boarding home staff must be qualified to serve people with dementia, and homes must have sufficient staff to monitor and care for residents as well as an alarm or monitoring system to alert staff when a resident leaves the building or enclosed outside area. Boarding homes with dementia units must design floor and wall surfaces to augment orientation and provide access to secured outside space. Units must meet other requirements concerning doors that restrict egress, are alarmed, and release automatically during a fire or power failure. Officials are evaluating whether dementia care units are consistent with the state's assisted living model.
Idaho requires that residents of specialized care units be evaluated by their primary care physician for the appropriateness of placement into the unlocked specialized care unit/facility prior to admission. Residents cannot be admitted without a diagnosis of Alzheimer's disease or related disorder. Residents must be at a stage in their disease such that only periodic professional observation and evaluation is required. Residents in these units must be re-evaluated quarterly. Residents who require physical or chemical restraints cannot be admitted.
Facilities in South Dakota that admit or retain residents with cognitive impairments must have the resident's physician determine and document if services offered by the facility continue to enhance the functions in ADLs and identify if other disabilities and illnesses are impacting on the resident's cognitive and mental functioning.
Staffing and Training
Twenty states have regulations that address training requirements for staff in facilities serving people with Alzheimer's disease. In Maine, all new employees in facilities with Alzheimer's/ Dementia Care Units must receive a minimum of eight hours classroom orientation and eight hours of clinical orientation. The trainer must have experience and knowledge in the care of individuals with Alzheimer's disease or other dementia. The facility's regular orientation covers resident rights, confidentiality, emergency procedures, infection control, the facility's philosophy of Alzheimer's disease/dementia care, and wandering/egress control. The eight hours of classroom orientation includes 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.
Florida has recently implemented new training rules for staff in facilities serving people with Alzheimer's disease. The rules require four hours of initial training in areas of the disease in relation to the normal aging process; diagnosing Alzheimer's disease; characteristics of the disease process; psychological issues including resident abuse; stress management and burn-out for staff, families and residents; and ethical issues. An additional four hours is required on medical information, behavior management, and therapeutic approaches. Direct care staff must participate in four hours of continuing education each year.
Core training and Alzheimer's disease training may be obtained from persons approved by the Department of Elder Affairs or the Department staff. The rules contain a sliding fee for training that varies with the percentage of residents supported by public funds.
New rules in Arizona will require a special license to service people who are unable to direct their own care. These facilities are required to have services that are appropriate to people with Alzheimer's disease, including cognitive stimulation, encouragement to eat meals and snacks, and supervision to ensure personal safety. Staff must receive 12 hours of additional training or demonstrate skills in and knowledge of Alzheimer's disease, communicating with residents, providing services including problem solving, maximizing functioning and life skills training for those unable to direct care, managing difficult behaviors, and developing and providing social, recreational and rehabilitative activities.
Staff in specialized care units for Alzheimer's/dementia residents in Idaho must complete an orientation/continuing training program that includes information on Alzheimer's and dementia, symptoms and behaviors of memory impaired people, communication with memory impaired people, resident's adjustment, inappropriate and problem behavior of residents and appropriate staff response, activities of daily living for special care unit residents, and stress reduction for special care unit staff and residents. Staff must have at least six additional hours of orientation training, and four hours of the required twelve hours per year of continuing education must be in the provision of services to persons with Alzheimer's disease.
Draft rules in Texas contain special requirements for administrators and a combination of orientation, on-the-job supervision and in-service education (see state summary).
Vermont's ongoing training requirements include communication skills for residents with Alzheimer's disease and other dementias. South Dakota's rules require that all staff members attend an annual in-service training in the care of the cognitively impaired and those with unique needs.
Survey responses from 12 states indicated that state rules address activities for people Alzheimer's disease. Regulations in Maine, Nevada, and California require activities that address gross motor skills, self care, social activities, crafts, sensory enhancement, outdoor, and spiritual activities. Draft rules in Texas propose activities that encourage socialization, cognitive awareness (crafts, arts, story telling, reading, music, discussion, reminiscences and others), selfexpression and physical activity in a planned and structured program.
In Idaho, services in specialized care units for residents with Alzheimer's disease include habilitation services, activity program and behavior management according to the individualized plan of care.
Draft rules in Nebraska's would have required facilities serving special populations must provide an environment that conforms to their special needs to enhance quality of life, reduce agitation and difficult behaviors, and promote safety. The accommodations include offering secured outdoor space; high visual contrasts between floors, walls, and doorways in resident areas; lighting which minimizes glare; plates and eating utensils which provide visual contrast between the plate, food and the table; and chairs that allow for gliding. These provisions were not included in the final regulations.
Delaware's rules require that facilities have policies designed to prevent residents from wandering away from the grounds.
Facilities serving people with Alzheimer's disease in South Dakota must have exit alarms. California operated a three-year demonstration program to test the feasibility of serving people with Alzheimer's disease in Residential Care Facilities for the Elderly (RCFEs). Seventy-five percent of California's residential care facilities have six or fewer beds. Prior to the demonstration, RCFEs could serve people with mild or moderate dementia who require protective supervision as long as they can make their needs known and can follow instructions. The pilot was approved to test whether people with more advanced dementia who were required to transfer to nursing facilities could be served in RCFEs. The independent study variables were special staff training, resident activities, and the use of either locked or secured (alarmed) perimeters. No facilities were willing to participate as a control group without using the interventions. Staff in both groups received 25 hours of training in residential care, normal aging, Alzheimer's disease, managing problem behaviors, recreational activities, communication, medication use and administration, medications used for disruptive behavior, ADLs, and staff stress and burn-out.
Six facilities were selected to participate in the demonstration, three with locked or secured perimeters and three with alarms or other signal devices to alert staff when people were leaving the facility or the grounds.
In April 1994, the California Department of Social Services issued a report with recommendations based on findings from the demonstration program. The report found that both models reduced acting-out behavior, diversion of staff time from direct care, and incidents of wandering. The report recommended a separate licensing category for RCFEs specializing in care of people with moderate to severe dementia. However, the report concluded that RCFEs should not be allowed to serve people with serious medical conditions which would require staffing patterns that would significantly raise costs. Examples of conditions which the study found should not be allowed in RCFEs included urinary catheters, colostomies, ileostomies, tracheostomies, tube feeding, contractures, bedsores, and intravenous injections. Because of the demands of residents, the report recommended at least two staff be on duty at all times. Other recommendations included training in dementia care, pre-admission assessment and reassessments to determine suitability for admission and retention, family meetings, continued standards for the use of "chemical restraints," and increased frequency of monitoring by regulatory staff (quarterly rather than annually).
The report found that the staff-to-resident ratio was more important than the size of the facility and that requirements for specialty staff included in the legislation were not necessary. Beyond requiring one awake staff and two persons at all times, the report suggested that staffing patterns should reflect resident needs for assistance with planned activities and supervision. However, the report did emphasize the need to require adequate outdoor space for resident use. Regulations should specify standards for the amount of space and other physical characteristics based on the size of the facility.
The report concluded that the use of locked or alarmed perimeters had no impact on medication use and reduction in physical or verbal behaviors (kicking, biting, throwing, screaming, threatening harm) or agitation (pacing, repeated movements, hand wringing, rapid speech). The study was limited by sample problems. Baseline measures showed significant differences among residents in each facility (higher or lower wandering, medication use). The report suggested that increasing the time staff spent with residents and increasing resident social interaction may contribute to a reduction in problem behaviors. While outcomes were similar for both alarmed and secured models, the study found high satisfaction among family members and some reduction in disruptive behaviors.
During 1995, legislation (Chapter 550 of the Acts of 1995) was passed that allows RCFEs that serve people with Alzheimer's disease to develop secure perimeters. The law allows facilities to install delayed egress devices on exterior doors and perimeter fence gates. Resident supervision devices, wrist bracelets which activate a visual or auditory alarm when a resident leaves the facility, may also be used. Facilities must provide interior and exterior space for residents to wander freely, must receive approval from the local fire marshal, and must conduct quarterly fire drills. Facilities with delayed egress devices must be sprinklered and contain smoke detectors, and the devices must deactivate when the sprinkler system or smoke detectors activate. The devices must also be able to be deactivated from a central location and when a force of 15 pounds is applied for more than two seconds to the panic bar. In addition facilities shall permit residents to leave who continue to indicate such a desire, and staff must ensure continued safety. Reports must be submitted when residents wander away from the facility without staff. Delayed egress devices may not substitute for staff.