State Assisted Living Policy: 1998. Vermont

06/01/1998

Citation

Residential care homes (Level III, IV) Regulations effective 10/7/93.

Assisted living (draft)

General Approach

Assisted living rules have been submitted to a legislative committee for a hearing and final adoption. The rules will be effective in 1998. Medicaid waiver coverage will be added to cover services in assisted living.

The Department of Aging and Disabilities established a task force in 1996 to develop an assisted living model. Both Medicaid and state funded homemaker and/or attendant care programs are being considered for financing services for low income residents. The purpose and philosophy of assisted living is described in the beginning of the rules. The draft rules are designed to support dignity, independence, individuality, privacy, choice and decision making of individual residents.

In 1995, the Vermont legislature approved funding for a pilot project to provide residential services to Medicaid recipients in licensed Level III residential care homes. The Department of Aging and Disabilities received approval from HCFA on March 1, 1996 for a Medicaid Home and Community Based Services Waiver to offer "enhanced residential care" to residents in Level III Residential Care Homes. The project established four outcome measures: participants are satisfied with Enhanced Residential Care Services; participants continue to reside in his/her residence of choice; participants receive all services which are necessary to live as independently as possible; and services provided are comprehensive and individualized.

There were 129 licensed residential care homes caring for 2,279 residents in 1998.

Definition

Assisted living residence means a program which combines housing, health and supportive services for the support of resident independence and aging place. Within a homelike setting, assisted living units offer, at a minimum, a private bedroom, private bath, living space, kitchen capacity and a lockable door. Assisted living promotes resident self-direction and active participation in decision-making while emphasizing individuality, privacy and dignity. A facility with a license under another section of 7102 is not an assisted living residence.

Residential care home is a place, however named, excluding a licensed foster home, which provides for profit or otherwise, room, board and personal care to three or more residents unrelated to the licensee. Level III means a residential care home licensed to provide room, board, personal care, general supervision, medication management and nursing overview. Level IV homes do not provide nursing overview. The Medicaid waiver for this program includes standards covering negotiated risk which is defined as "allowing residents choices in accepting certain risks. These choices are negotiated between the resident, case manager, provider, and family members with the intent of fostering independence, safety and self-determination."

Unit Requirements

Assisted living residences Residential living space must be a minimum of 225 square feet per unit, excluding bathroom and closets. Each unit must provide accessible or adaptable sleeping, living and eating areas. Units must include a private bathroom, bedroom, living space and kitchenette, adequate storage and a lockable door. Units may be shared only by choice. Kitchenettes must include food preparation and storage area, refrigerator, cabinets, counter space, sink and source of water, a cook top or microwave that can be removed or disconnected and outlets.

An 18 month grandfathering period is allowed for pre-existing structures being converted or remodeled. These residences must have a minimum of 160 square feet not including the bathroom or storage space. Kitchen capacity is not required but a community kitchen must be available.

Residential care homes The regulations indicate that every effort must be made to provide a home-like environment. Each private bedroom must have at least 100 square feet of usable floor space and multi-bed rooms must have 80 square feet per bed. After October 1993, all new homes may offer only single or double occupancy rooms. One bath, toilet and sink is required for every eight residents.

Tenant Policy

Assisted living residences Residents may be moved if they pose an immediate threat to others or have needs that cannot be met by the residence. Residents may be retained who have the following conditions:

  • Require 24-hour, seven day a week on-site nursing care;

  • Bedridden more than 14 days;

  • Consistently and totally impaired in four or more ADLs;

  • Cognitive decline severe enough to prevent making simple decisions;

  • Stage 3 or 4 pressure sores or multiple stage 2 sores; or

  • Medically unstable conditions and/or has special health problems and a regimen of therapy that cannot be implemented appropriately in the setting.

The facility must notify the licensing agency and describe how it will meet the person's needs. The licensing agency determines whether the plan is appropriate.

Residential care homes Facilities must provide a written agreement which describes the daily, weekly, or monthly rate to be charged, a description of the services covered in the rate and the policy concerning discharge or transfer when a resident's financial status changes from private pay to SSI.

Residential care homes may retain people who need nursing services if the following conditions are met:

  • The services are received less than three times a week; are provided seven days a week for no more than 60 days and the resident's condition is improving;

  • The home has an RN on staff or a contract with a home health agency;

  • The home is able to meet the resident's needs without detracting from services to other residents;

  • There is a written agreement concerning which nursing services the home provides or arranges which is explained to the resident before admission or at the time of admission, how services are paid for and the circumstances under which a resident will be required to move; and

  • Residents are fully informed of their options and agree to such care in the residential home.

RCHs cannot admit or retain anyone needing full time nursing care, the level of care provided in a nursing facility, or who has care needs which exceed the facility's capacity to safely and appropriately provide. Residents who have a serious, acute illness requiring medical, surgical or nursing care cannot be admitted or retained.

Services

Assisted living residences provide three meals a day appropriate to the needs and preferences of residents, 24-hour staff supervision to meet emergency, scheduled and unscheduled needs, personal and other laundry services, individual and group socialization, personal care, assistance with IADLs, intervention for residents who have dementia, weekly housekeeping, medication management, administration and assistance, medical and social transportation and maintenance of a personal fund account showing deposits and withdrawals. Residences may also provide nursing assessment, health monitoring, routine nursing tasks and intermittent skilled nursing services, including that which may be delegated to unlicensed staff.

RCHs provide personal care, medication management, laundry, meals, toiletries, transportation and nursing overview. Nursing overview means a process in which a nurse assures that the health and psychosocial needs of the resident are met. The process includes: observation, assessment, goal setting, education of staff and the development, implementation and evaluation of a written individualized treatment plan to maintain the resident's well being.

Intravenous therapy, ventilators or respirators, daily catheter irrigation, feeding tubes, care of stage III or IV decubitus, suctioning and sterile dressings may not be provided to any resident unless a variance is approved by the state licensing agency.

Medication

Assisted living residences provide assistance with self-administration of medications and administer medications under the supervision of and delegation by registered nurses. Each residence must have a policy on the procedures for delegation of administration, how medications will be obtained including choice of pharmacies and documentation procedures.

RCH staff are able to assist resident to self-administer medications and administer medication under the supervision of and delegation by registered nurses.

Reimbursement

An HCBS waiver will be submitted to cover assisted living residences. The Department of Aging and Disability has designed a unique three tiered system that was developed using MDS 2.0 and assessment data. Residents receive a score in five areas: ADLs, bladder and bowel control, cognitive and behavior status, medication administration and special programs (behavior management, skin treatment or rehabilitation/restorative care). Residents are assigned to a level (1 or 2) based on the extent of ADL impairments. Scores of 6-18 are assigned to level 1 and scores between 19-29 are assigned to level 2. The four remaining areas are rated and additional points are assigned. The payment tier is determined by combining the ADL level and the additional points. Payment rates have not been devised. The Department has piloted the classification system and will be developing rates for each tier.

PAYMENT AREAS AND SCORING SYSTEM

Area

Maximum Points

Factors

ADLs

29

Eating, toileting, mobility, bathing, dressing

Continence

13

Bladder and bowel

Cognitive/behavior status

65

Sleep pattern, wandering, danger to self/others

Medication administration

5

Administration

Special programs

49

Mood, behavior, cognitive loss. Skin: Turning/repositioning, nutrition or hydration, dressings, ulcer care, surgical wound care. Rehab: range of motion, skin brace assistance, transfer, walking, dressing/grooming, eating/swallowing, prosthesis care, communication.

 

VERMONT RATING SYSTEM
(proposed)

Tier 1

Tier 2

Tier 3

Level

Point

Level

Point

Level

Point

1

0-30

1

31-59

1

60+

 

 

2

0-35

0

36+

Residential care homes provide two levels of SSI reimbursement based on the provision of nursing oversight. A Medicaid waiver covers nursing overview (assessment, oversight, monitoring and routine tasks), personal care services, case management, medication assistance, recreational and social activities, support for individuals with cognitive impairments and 24-hour on-site supervision. The waiver allows up to 200 participants although funding is available for 70 participants a month and 98 unduplicated participants during the first year. Services must be provided in non-institutional, home-like settings. Participants must meet the nursing home eligibility criteria. While not required, preference is given to providers that offer single occupancy units.

Staffing

Assisted living residences must employ sufficient staff to meet the needs of each resident. At least one personal care assistant must be on duty at all times. A registered nurse shall be employed to oversee implementation of service plans, conduct nursing assessments, and provide health services. The RN shall be on-site to the degree necessary to achieve the outcomes as specified in the individual service plans.

RCHs must have a sufficient number of qualified staff to meet resident needs.

Training

Administrators

Residential care homes Managers must complete a state approved certification course.

Assisted living residences The director must be at least 21 and have demonstrated experience in gerontology and supervisory and management skills. Directors shall have evidence of 20 hours of training per year regarding assisted living and its principles and the care of elderly and disabled individuals.

Staff

Residential care homes Staff must receive 20 hours of training each year that includes at least procedures in case of fire, resident rights and mandatory reporting of abuse, neglect and exploitation. Training in direct care skills may be provided by a nurse.

Assisted living residences All staff must be trained in the principles of assisted living including assisted living principles, resident rights, laws relating to abuse and neglect and exploitation, dementia care, infection control policies and emergency response procedures. The residence shall employ or contract with personal care assistants trained in the provision of personal care services. Staff shall receive documented training from the residence or provide evidence of similar required training. At the time of employment, all staff shall be provided with and/or provide evidence of an initial orientation to the principles of assisted living and shall receive training on an annual basis regarding the provision of services in accordance with the resident-driven values of assisted living. RNs must receive 16 hours of training in assisted living principles and the care of elderly and disabled individuals annually. Staff providing personal care must receive training within four months of employment covering:

  • Personal care activities (earing, bathing, dressing, transferring, mobility, ambulation, toileting and personal hygiene),

  • Communication skills relating to residents with Alzheimer's disease and other dementias;

  • Infection control;

  • Transfers;

  • Documentation;

  • Alzheimer's disease and other dementias; and

  • Behavioral management.

Staff providing personal care shall also receive 16 hours of training annually in the above areas.

Background

A criminal records and adult abuse registry check is required for directors and all staff. Staff with substantiated charges of abuse, neglect or exploitation, or those convicted of an offense relation to bodily injury, theft or misuse of funds or property or other crimes inimical to the public welfare may not be employed or retained.

Monitoring

Residential care homes Monitoring is conducted by the licensing agency and the ombudsman program.

Assisted living residences Monitoring includes services plans, written outcome measures for residents based on service plans. No frequency of visits is described. Exist conferences must be held with the director.

Fees

RCHs Fees are $5 plus $1 per bed.

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