State policy on the level of need that may be served in assisted living varies widely. States have set very general criteria while others are very specific. The criteria can be grouped in five areas:
- Health related conditions,
- Alzheimer's disease and dementia, and
Eighteen states have general criteria that require that the resident's needs can be met by the facility. Initially this domain was included to identify states using only this general criteria. Draft regulations in Hawaii and Vermont rely primarily on these criteria. Wisconsin also uses this threshold but limits the amount of services any resident can receive to 28 hours a week. Other states allow facilities to admit and retain residents whose needs can be met but include other limits as well. In effect, the requirement is used in combination with others that screen out residents with certain conditions and set expectations that any facility admitting residents with allowable service needs must be capable of meeting those needs.
A table comparing admission/retention criteria in the appendix summarizes the provisions of state regulations. Some states use general criteria (such as a resident must have stable health conditions or cannot need 24-hour nursing care). These criteria may be interpreted to mean that anyone needing a feeding tube, sterile wound care, or ventilator care could not be served.
Twenty-six states use criteria that specify that residents must not need 24-hour nursing care. Four states (Arizona, Kansas, New Jersey, and Vermont) specify that 24-hour care can be provided if the facility meets certain criteria (e.g., they are licensed to do so, or a care plan has been approved by the licensing agency). Nine states do not allow residents who need hospital or nursing home care to be served, and rules in eight states specify that facilities may provide part time or intermittent nursing care. States may specifically cite conditions or services that may not be met. For example, ten states include prohibitions against serving anyone with stage III or IV ulcers. Eight do not allow anyone who is ventilator dependent to be served or anyone needing naso-gastric tubes. Fourteen states specify that persons with a communicable disease may not be admitted or retained.
Criteria dealing with functional and Alzheimer's disease are less frequent. Six states require that residents are ambulatory, and five require that residents can evacuate without assistance. Four states specify that residents may not be totally bedfast and other states allow this level of care under specified conditions. Four states specify that facilities can admit people with mild dementia; however, most states allow people with dementia to be served without specifying it in their regulations. Facilities in twenty states cannot admit or retain people who are a danger to themselves or others, and people who need restraints are specifically excluded by regulations in nine states.
While state rules apply uniformly, actual practice may vary within the same state. State rules define the conditions that residents may or may not have in order to be admitted or retained in an assisted living residence. But these standards are not required for each residence. Individual residences are generally allowed to establish their own standards within state parameters, and residences are required to inform prospective tenants what the policy is and what conditions would trigger "move out." For example, Massachusetts' rules allow residences to meet personal care needs. At a minimum residences must offer support for bathing, dressing, and ambulation but are not required to offer assistance with other ADLs. Most other states allow, but do not require, residences to serve people with ADL needs.
Hawaii and Vermont are posed to join Oregon among the states with the broadest policies. Oregon's regulations generally do not limit whom facilities may serve. The rules contain "move out" criteria that allow residents to choose to remain in their living environment despite functional decline as long as the facility can meet the resident's needs. Facilities may ask residents to leave if the resident's behavior poses an imminent danger to self or others, if the facility cannot meet the resident's needs or if services are not available, if the resident has a documented pattern of non-compliance with agreements necessary for assisted living, or for not-payment.
Draft rules in Hawaii would require that each facility develop admission policies and procedures which support the principles of dignity and choice. The policies include a listing of services available, the base rates, services included in the base rates, services not provided but which may be coordinated, and a service plan and contract. Facilities must also develop discharge policies and procedures which allow 14 days notice for discharge based on behavior, on needs that exceed the facility's ability to meet them, or on the resident's established pattern of non-compliance. The rules do not specify who may be admitted and retained. Rather each facility may use its professional judgement and the capacity and expertise of the staff in determining who may be served.
New rules in Vermont allow residents to be moved if they pose an immediate threat to others or have needs that cannot be met by the residence. A resident may, but is not required to, be moved if he or she requires 24-hour, seven day a week, on-site nursing care, or if he or she is bedridden more than 14 days, is consistently and totally impaired in four or more ADLs, has cognitive decline severe enough to prevent making simple decisions, has stage III or IV pressure sores or multiple stage 2 sores, has medically unstable conditions, and/or has special health problems and a regimen of therapy that cannot be implemented appropriately in the setting. Facilities that want to serve people with these conditions must notify the licensing agency and describe how it will meet the person's needs. The licensing agency determines whether the plan is appropriate.
Regulations in Arizona, Delaware, Kansas, Maine, Nebraska and New Jersey are also flexible, allowing a high degree of impairment. Arizona sets requirements for different supplemental licensing levels. Facilities providing supervisory care services may serve residents needing health or health-related services that are provided by a home health agency or licensed hospice agency.
Additional requirements allow facilities in Arizona providing personal care services to serve residents who require continuous nursing services, are bedbound or have Stage III or IV pressure sores. Residents requiring continuous nursing services may be served if nursing services are provided by a private duty nurse, a hospice agency, or if the facility is a foster care home operated by a licensed nurse. These facilities may serve someone who is bedbound or has stage III or IV pressure sores if a physician authorizes residency and nursing services are provided by a private duty nurse or hospice agency, a licensed nurse, or home health agency, and the facility is meeting the resident's needs. These facilities may not admit residents unable to direct their care.
Facilities in Arizona must have a supplemental license to provide directed care services to serve people with Alzheimer's disease who are not able to direct their care. This license requires policies that ensure the safety of residents who may wander, that control access and egress, and that provide appropriate training for staff.
Two groups of consumers cannot be served in Delaware--unless the attending physician certifies that despite the presence of the following factors, the consumer's needs may be safely met by a service agreement developed by the agency, the attending physician, a registered nurse, the consumer or his/her representative if the consumer is incapable of making decisions and other appropriate health care professionals:
- Consumers whose medical conditions are unstable to the point that they require frequent observation, assessment and intervention by a licensed professional nurse, including unscheduled nursing services, and
- Consumers who are bedridden for 14 consecutive days.
Facilities may not serve residents who need transfer assistance from more than one person and a mechanical device, unless special staffing arrangements have been made, or residents who present a danger to self or others or engage in illegal drug use.
Kansas also has very broad criteria. Each facility develops admission, transfer, and discharge policies which protect the rights of residents. Facilities may not admit or retain people with the following conditions unless the negotiated service agreement includes hospice or family support services which are available 24-hours a day or similar resources:
- Incontinence where the resident cannot or will not participate in management of the problem;
- Immobility requiring total assistance in exiting the building;
- Any ongoing condition requiring two person transfer;
- Any ongoing skilled nursing intervention needing 24-hour a day care for an extended period of time; or
- Any behavioral symptom that exceeds manageability.
Rules in Maine encourage aging in place and have very flexible policies to do so. In its licensing application, facilities must describe who may be admitted and the types of services to be provided. Facilities may discharge tenants who pose a direct threat to the health and safety of others, damage property, or whose continued occupancy would require modification of the essential nature of the program. The rules also require facilities to permit reasonable modifications at the expense of the tenant or other willing payer to allow persons with disabilities to reside in licensed facilities. Facilities must make reasonable accommodations for people with disabilities unless they impose an undue financial burden or result in a fundamental change in the program.
Maine's rules apply differently depending on the setting: congregate housing, adult family care, or residential care facility. Residential care facilities may only provide nursing services with their own staff to residents who do not meet the nursing home level of care. Residents who meet nursing home admission requirements can be served, but nursing services must be provided by a licensed home health agency. Congregate housing programs may receive a license to provide nursing and medication administration services by registered nurses employed by the program.
In Nebraska, anyone needing complex nursing interventions or whose conditions are not stable and predictable can be admitted if:
- The resident, or the resident's designee if the resident is not competent, the resident's physician or the registered nurse agree that admission or retention is appropriate;
- Care is arranged through private duty personnel, a licensed home health agency, or a licensed hospice agency; and
- The resident's care does not compromise the facility operations or create a danger to others in the facility.
Complex nursing interventions are defined as those requiring nursing judgement to safely alter standard procedures in accordance with the needs of residents, which require nursing judgement to determine how to proceed from one step to the next, or which require a multidimensional application of the nursing process. Facilities will be able to develop their own admission and retention policies within state guidelines.
New Jersey's rules allow, but do not require, assisted living residences to care for people who:
- Require 24 hours, seven day a week nursing supervision,
- Are bedridden longer than 14 days,
- Are consistently and totally dependent in four or more ADLs,
- Have cognitive decline that interferes with simple decisions,
- Require treatment of stage three or four pressure sores or multiple stage two sores,
- Are a danger to self or others, or
- Have a medically unstable condition and/or special health problems.
Assisted living in New Jersey is not appropriate for people who are not capable of responding to their environment, expressing volition, interacting, or demonstrating independent activity. Each resident receives an assessment and a care plan by a registered nurse. The admission agreement has to specify if the residence will retain residents with one or more of these characteristics and the additional costs which may be charged.
New Jersey officials report that, although the experience is limited, no complaints have been made about the level and quality of care and monitoring surveys have not detected any violations. Licensing applications show a bell-shaped curve with most facilities selecting 3-4 conditions which they will serve. A few on either end will not serve people with any of the eight criteria while a similar number will serve people meeting all eight criteria.
Oregon and other states have developed assisted living as the equivalent of nursing home care, at least for people at lower acuity levels. The New Jersey regulations require that at least 20% of the occupants meet the nursing facility admission criteria within three of years licensing.
Tenant admission/retention criteria often result from compromises reached with trade associations. In Massachusetts and Tennessee, state home-care associations supported requirements that all skilled services must be provided by a certified or licensed home health agency. However, most of the controversy over admission/retention criteria has been sparked by drawing the line between nursing home and assisted living. State respondents reported consistent, though varied, opposition from nursing home operators to allowing people who need skilled services to be served in assisted living facilities. In at least one state, an association objected to the ability of these facilities to provide personal care. As a result of the policy formulation and legislative process, a number of compromises have emerged. States typically include a general statement that residents must have stable health conditions and do not need 24-hour, skilled nursing supervision. A number of states have specified which conditions may or may not be treated in an assisted living residence.
Nursing home providers participating on a Maryland task force created to recommend policy on assisted living sought upper limits on admission/retention criteria, but the task force adopted a policy which allows residents to remain as long as the care is appropriate to the person's needs. Draft regulations in Maryland do not allow programs to serve anyone who, at the time of admission, requires one or more of a number of listed conditions (see state summary). However, programs may request a waiver to care for residents with needs that exceed the licensing level if they can demonstrate that they can meet the residents' needs and that others will not be jeopardized. Programs are licensed based on their level of service. 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.
Utah's facilities may not serve anyone who requires inpatient hospital care or 24-hour continual nursing care that will last more than fifteen calendar days or people who cannot evacuate without physical assistance of one person. Written acceptance, retention, and transfer policies are required of each facility. Facilities may not accept anyone who is suicidal, assaultive, or a danger to self or others, has active tuberculosis or other communicable disease that cannot be adequately treated at the facility or on an outpatient basis or that may be transmitted to other residents through general daily living. Physicians' statements are required to document the resident's ability to function in the facility and to confirm that the resident's health condition is stable and free from communicable disease. They are also required to list the following: allergies; diets; current prescribed medications with dose, route, time of administration and assistance required; physical or mental limitations; and activity restrictions.
Florida's regulations for "admissions" are very detailed. New residents must:
- Be able to perform ADLs with supervision or assistance (but not total assistance);
- Be free from signs and symptoms of communicable diseases;
- Not require 24-hour nursing supervision;
- Be capable of taking their own medication or may require administration of medication and the facility has licensed staff to provide the service;
- Not have bed sores or stage II, III, or IV pressure ulcers;
- Be able to participate in social activities;
- Be capable of self-preservation;
- Not be bedridden;
- Be non-violent; and
- Not require 24-hour mental health care.
Additional criteria affect continued residency. In regular assisted living facilities, people who are bedridden more than seven days or develop a need for 24-hour supervision may not be retained. In Extended Congregate Care facilities, a higher level of care, residents may not be retained if they are bedridden for more than fourteen days. Residents may stay if they develop stage II pressure sores but must be relocated for stage III and IV pressure sores. Residents who are medically unstable, become a danger to self or others, or experience cognitive decline to prevent simple decision making may not be retained. People who become totally dependent in four or more ADLs (exceptions for quadraplegics, paraplegics, and those with muscular dystrophy, multiple sclerosis, and other neuro-muscular diseases if the resident is able to communicate his or her needs and does not require assistance with complex medical problems) may not be retained. State officials are planning to undertake a review of the criteria to evaluate their impact.
Tennessee's new regulations allow residences to retain for 21 days but not admit anyone requiring: intravenous or daily intramuscular injections of feedings; gastronomy feedings; insertion, sterile irrigation and replacement of catheters; sterile wound care; or treatment of extensive stage 3 or 4 decubitus ulcers or exfoliative dermatitis; or who, after 21 days, require four or more skilled nursing visits per week for any other condition.
In Washington, residents may be required to move when their needs exceed the services provided through the contract with the state agency or when the resident requires a level of nursing care that exceeds what is allowed by the boarding home license.
Although Wyoming expanded their regulations to allow skilled services, they do not allow residents who wander or need wound care, stage II skin care, are incontinent, need total assistance with bathing and dressing, or need continuous assistance with transfer and mobility in order to be served.