Personal care homes. Texas Rev. Health and Safety Stat. Ann. § 247.001 et. Seq.; Texas Administrative Code Title 25, §146.321 et seq.
New personal care home rules were effective in June 1998. Further amendments to the training and staffing sections are being developed. Legislation was passed in 1996 that sets new standards for personal care homes providing specialized care for people with Alzheimer's Disease and regulations implementing this law have been proposed. These rules set standards for administrators, staff, activities and a secure environment.
Assisted living/residential care services are provided through the state's Medicaid Home and Community Based Services waiver program in licensed personal care homes. Settings must be licensed as personal care homes and may contract with Medicaid under three models: assisted living apartments, residential care apartments and residential care non-apartments.
The Texas Medicaid program contracts with 169 facilities to provide assisted living/residential care services. About 565 beneficiaries are being served.
Personal care facility is "an establishment, including a board and care home, that furnishes food and shelter, in one or more facilities, to four or more persons who are unrelated to the owner of the establishment; and provides personal care services; and in addition, provides minor treatment under the direction and supervision of a physician ... or services which meet some need beyond basic provision of food, shelter and laundry."
Four types of Personal Care Homes are licensed.
Type A home residents are capable of evacuating the facility unassisted, do not require routine attendance during night time hours and are capable of following directions under emergency conditions.
Type B facility residents may require staff assistance to evacuate, may not be able to follow directions, require attendance during the night and while not permanently bedfast, may require assistance in transferring to and from a wheelchair.
Type C facilities offer up to four beds and are considered adult foster care but after the effective date of the regulations, will be required to obtain a personal care license.
Type D facilities are operated by the Department of Mental Health and Mental Retardation.
Medicaid Assisted living/residential care services provide a 24-hour living arrangement for persons who, because of a physical or mental limitation, are unable to continue independent functioning in their homes. Services are provided in personal care facilities licensed by the Texas Department of Human Services (DHS). In effect the rules recognize three types of units provided in licensed personal care facilities. Nursing facility waiver participants are responsible for their room and board costs and, if applicable, a copayment for assisted living/residential care services.
Personal care facility rules require 80 square feet for single bedrooms and 60 square feet per bed for multiple occupancy rooms in Type A facilities and 100 square feet and 80 square feet respectively in Type B facilities. A maximum of four people may share a room. Units with separate living/dining and bedroom space may include 10% of the required bedroom space as living area. Not more than 50% of the beds may be in rooms of three or more. Bathrooms, including bathing units, are required for every six residents.
The Medicaid program guidelines distinguish among assisted living apartments, residential care apartments and residential care non-apartments. Assisted living apartments must provide each participant a separate living unit to guarantee their privacy, dignity and independence. Units must include individual living and sleeping areas, a kitchen, bathroom and adequate storage. Units must provide 220 square feet, excluding bath, but units in remodeled buildings may provide 160 square feet. Double occupancy units may be provided if requested.
Residential care apartments must be double occupancy with a connected bedroom, kitchen, and bathroom area providing a minimum of 350 square per client. Indoor common space used by residents may be counted in the square footage requirement. Kitchens must be equipped with a sink, refrigerator, cooking appliance (stove, microwave, built-in surface unit) that can be removed or disconnected and space for food preparation.
Residential care non-apartments means a licensed personal care facility which does not meet either of the above definitions. These units may be double occupancy units in free standing buildings that have 16 or fewer beds.
Personal care facility rules allow facilities to serve residents who have mental or emotional disturbance but are not a danger, need assistance with movement, bathing, dressing, and grooming, routine skin care (such as application of lotions, treatment of minor cuts and burns), need reminders to encourage toileting, require temporary services by professional personnel, need assistance with medications, supervision of self-medication or administration of medications, have hearing or speech impairments, are incontinent but without pressure sores, require established therapeutic diets, require self-help devises, or need assistance with meals.
Facilities may not admit or retain residents whose needs cannot be met by the facility or residents requiring services from the facility's RN on a daily or regular basis (exceptions are made for residents with terminal conditions or for short term needs).
Licensed staff may provide supervision or oversight of the physical and mental well-being of residents.
An assessment must be completed within 14 days of admission. Personal care facility rules allow licensed staff to administer medications and provide occasional treatment which enables residents to maintain independence. Residents may contract to have home health services provided. The rules broaden the definition of personal care to include the administration or assistance with or supervision of medication to implement changes that allow nurse delegation under the nurse practice act.
Services that can be provided through the waiver include 24-hour supervision, personal care, administration of medications, congregate meals and social and recreational activities. Nursing services must be provided through contracts with certified home health agencies.
Special care facilities must have activities that encourage socialization, cognitive awareness (crafts, arts, story telling, reading, music, discussion, reminiscences and others), self-expression and physical activity in a planned and structured program.
The Medicaid waiver provides $35.06 a day for services in single occupancy assisted living apartments, $27.64 a day for double occupancy residential care apartments and $22.63 a day for residential care non-apartments. The SSI payment for room and board is $409 a month and the personal needs allowance is $85. The combined room and board and service rates are $1,460.80 a month for assisted living apartments, $1,238.20 for residential care apartments and $1,087.90 for residential care non-apartments. The rates are being reviewed and increases were expected to be approved in August 1998. The waiver includes a cap that limits community based alternatives services to no more than 95% of rate paid to nursing homes.
Licensed staff may administer medication. The waiver rules allow the direct administration of all medications or assistance with or supervision of medication.
The proposed changes in personal care home rules allow unlicensed staff to administer medications as well as to assist with or supervise medications through nurse delegation provisions.
Required staff ratios are 1 to 16 for day shifts; 1 to 20 for evening shifts and 1 to 40 for night shifts. Night staff must be immediately available in facilities with less than 40 residents and available and awake in facilities with 40 or more residents. Night staff must be available and awake in Type B facilities regardless of size.
Special care facilities (16 or less residents) must designate an activities staff; facilities of 17 or more must have an activity director at least 20 hours a week.
Administrators Managers must have a high school diploma or equivalency and 12 hours of annual continuing education in at least one of the following areas: resident and provider rights and responsibilities; abuse/neglect, and confidentiality; basic principles of supervision; skills for working with residents, families and other professional service providers; resident characteristics and needs; community resources; accounting and budgeting; basic emergency first aide; and relevant federal laws. Administrators in special care facilities must have a college degree (psychology, social work, counseling, gerontology, nursing or related field) with documented course work in dementia; or one year experience with persons with dementia and complete six hours of continuing education in dementia care.
Staff Facilities must document that attendants are competent to provide personal care and have the following knowledge: needs of residents and the tasks to be provided, health conditions and how they affect the provision of tasks and conditions about which the attendant should notify the manager. Annual in-service training must cover communication techniques and skills providing geriatric care (communicating with hearing impaired, visually impaired and cognitively impaired); assessment and nursing interventions related to common physical and psychological changes of aging for each body system; geriatric pharmacology; common emergencies of geriatric residents; common mental disorders with related nursing implications; ethical and legal issues regarding advance directives, abuse and neglect, guardianship and confidentiality.
Staff in special care facilities must receive:
Four hours of dementia specific orientation on basic information about the causes, progression and management of dementia;
16 hours of on the job supervision with 16 hours of orientation providing assistance with ADLs, emergency and evacuation procedures and managing dysfunctional behavior; and
12 hours of annual in-service training regarding Alzheimer's disease covering assessing resident capabilities and developing and implementing service plans; promoting dignity, independence, and privacy; planning and facilitating activities; communicating with families; resident rights and principles of self-determination; care of persons with physical, cognitive, behavioral and social disabilities; medical and social needs of residents; common psycho-tropic drugs and side effects and local community resources.
Unlicensed facilities are subject to restraining orders and civil penalties between $1,000 and $10,000 a day.
Fees for Type A and B facilities are $100 plus $3 for each bed with a maximum of $400. Type C licenses are $50.