States seeking to facilitate aging-in-place and to offer consumers more long-term-care options allow more extensive services. These states view assisted living as a person's home. In a single family home or apartment in an elderly housing complex, older people can receive a high level of care from home health agencies and in-home service programs. Several states extend that level of care to assisted living facilities.
The extent and intensity of services generally follows state admission/retention criteria. Services can be provided or arranged that allow residents to remain in a setting. Mutually exclusive resident policies, which prohibit anyone needing a nursing home level of services from being served in board-and-care, have been replaced by "aging-in-place" provisions. However, drawing the line has been controversial in many states. Opponents of assisted living legislation in Tennessee initially opposed allowing personal care to be provided. In many states, some nursing home operators see assisted living as competition for their "patients" and oppose rules which allow skilled nursing services to be delivered outside the home or nursing home setting.
Most states require an assessment and the development of a plan of care that determines what services will be provided, by whom and when. Residents often have a prominent role in determining what they will receive from the residence and what tasks they will do for themselves. A key factor in assisted living policies is the extent of skilled nursing services.
Arizona has three service levels that allow supervisory care services, personal care services, and directed care services. Residents in facilities with a supervisory care license may receive health services from home health agencies. Facilities with a personal care services license can provide intermittent nursing services and administer medications. Other health services may be provided by outside agencies. Directed care service facilities provide supervision to ensure personal safety, cognitive stimulation, and other services for residents who are unable to direct their care.
Alaska's regulations also require that tenant contracts spell out the services and accommodations that will be provided and that reflect the diversity and availability of providers in the state. Intermittent nursing services are allowed for residents who do not require 24-hour nursing care, and supervision and tasks approved by the Board of Nursing may be delegated to unlicensed staff.
Connecticut allows client teaching, wellness counseling, health promotion and disease prevention, medication administration, and skilled services to clients with chronic but stable conditions. Draft legislation in Illinois would allow intermittent health services (medication administration, dressing changes, catheter care, therapies). Kentucky's statute does not specifically mention nursing services in a listing of services but includes the phrase "is not limited to" which may allow other services to be added when regulations are prepared.
Facilities in Florida may provide limited nursing services (e.g., medication administration and supervision of self-administration, applying heat, passive range of motion exercises, ice caps, urine tests, routine dressings that do not require packing or irrigation, and others), and intermittent nursing services (e.g., change of colostomy bag and related care, catheter care, administration of oxygen, routine care of an amputation or fracture, prophylactic, and palliative skin care).
Facilities in Florida may not provide oral or nasopharyngeal suctioning, assistance with tube feeding, monitoring of blood gasses, intermittent positive pressure breathing therapy, intensive rehabilitation services for a stroke or fracture or treatment of surgical incisions which are not clean and free from infection, and any treatment requiring 24-hour nursing supervision. Washington has developed a list of skilled services that may and may not be delivered by licensed nurses and unlicensed staff. Nursing services are differentiated by licensing category. RNs or LPNs may provide insertion of catheters, nursing assessments, and glucometer readings. Unlicensed staff may provide the following under supervision of an RN or LPN: stage-one skin care, routine ostomy care, enema, catheter care, and wound care. Changes in the nurse practice are pending in the legislature which would allow greater delegation.
Hawaii's draft regulations require facilities to provide nursing assessment and health monitoring; medication administration; services to assist with ADLs; support, intervention and supervision for residents with behavior problems; opportunities for socialization; meals; laundry; and housekeeping. Facilities must also provide or arrange for transportation and ancillary services for medically related care (physician, pharmacist, therapy, podiatry, home health, and others).
In keeping with its admission/retention criteria, New Jersey's rules allow levels of skilled care that are specifically barred in many states (e.g., stage III or IV pressure sores, ostomy care, 24hour nursing supervision). Oregon's policy allows a wide range of delegation under which nurses must train unlicensed staff for each resident receiving delegated services. Further, there are no explicit discharge criteria based on service needs.
Legislation in Massachusetts, as in other states, does not allow 24-hour nursing services. However, 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 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 Massachusetts statute only allows skilled nursing services to be provided by a certified home health agency. As a result, registered nurses, if hired by an assisted living facility, presumably, would not be allowed to deliver skilled care. The initial draft of state regulations did not allow skilled services to be received for more than 90 days in a one-year period. The attorney general's office reviewed the draft and advised that such limits may conflict with fair housing rules. The 90-day limit was removed.
The Massachusetts statute specifies a minimum level of personal care services that must be provided (bathing, dressing, ambulation) and requires that tenant agreements include the services which will be provided and those which will not be provided. Facilities certified under the law may offer a broader range of personal care services. Alabama's rules mandate personal care for bathing, oral hygiene, hair, and nail care but do not require assistance with eating, dressing, or toileting.
Rules governing residential care facilities in Ohio will limit skilled services to 120 days with exceptions for diets, dressing changes, and medication administration.
Missouri's rules governing residential care facilities allow advanced personal care services to be provided which include residents with a "catheter or ostomy, require bowel or bladder routines, range of motion exercises, applying prescriptions or ointments and other tasks requiring a highly trained aide."
Iowa's legislation allows health related care which are services provided by a registered nurse, a licensed practical nurse, or home care aide and services provided by other licensed professionals as defined by rule. Health related and personal care services can be provided on an intermittent and part-time basis, which is defined as up to 35 hours a week of personal care and health related services on a less than daily basis, or up to 8 hours personal care and health related services provided 7 days a week for temporary periods not exceeding 21 days.
Because of its funding source, New York allows for skilled nursing, home health aide, and therapies. Regular Medicaid state plan services have been included in a capitated rate to include the full range of Medicaid long-term care services that can be delivered in the home.
In Utah facilities must arrange for necessary medical and dental care although medication administration of prescription drugs is allowed. Maine's revised policy allows skilled services to be provided by a residential care facility or a congregate housing program. Previous policy required skilled services to be provided by a licensed home health agency.
State policy generally specifies the range of allowable services but facilities are not required to provide the full range of services allowed under the law. Facilities are usually authorized to determine which services will be provided. Combined with facility-based admission/retention policies, facilities may offer a very light, moderate, or heavy level of care. Owners of assisted living facilities who also own nursing homes may develop assisted living as a "feeder" system for their nursing homes and set policies which require residents to "move out" when they develop multiple ADL impairments or require nursing services. Although state regulations frequently explicitly support aging-in-place and resident involvement in care planning decisions, facility specific policies may be developed which limit the potential impact of assisted living to serve residents with higher levels of need.