Adult care residence 22 VAC 40-71-10 et seq.
The state legislature has created a two-tier licensing structure for adult care residences, residential living and assisted living. Regulations were effective February 1, 1996. A Medicaid HCBS waiver was effective August 1, 1996. The regulations contain a statement of philosophy and guiding principles. The regulations are intended to maximize independence and promote the principles of individuality, personal dignity, freedom of choice, and fairness for all individuals residing in adult care residences. The principles state that:
Residents are entitled to appropriate, safe and quality care;
Each resident shall be viewed as an individual and empowered to make decisions regarding his care;
Each residence should identify the types and extent of services offered and those services should reflect the needs of the population served;
The resident should be entitled to remain in care as long as the facility is able to adequately care for the resident within the limitations established by law so that social ties and relationships may be preserved to the fullest extent possible; and
Standards are consistent with the provision of cost effective services.
Adult care residence (ACR) means any place, establishment, or institution, public or private, operated or maintained for the maintenance or care of four or more adults who are aged, infirm or disabled and who are cared for in a primarily residential setting, except a facility or portion of a facility licensed by the State Board of Health or the Department of Mental Health, Mental Retardation and Substance Abuse Services (and other exceptions).
Residential living means a level of service provided by an adult care residence for adults who may have physical or mental impairments and require only minimal assistance with activities of daily living. Minimal assistance means dependency in only one ADL or one or more IADLs or medication administration.
Assisted living means a level of service provided by an adult care residence for adults who may have physical or mental impairments and require at least moderate assistance with activities of daily living. Moderate assistance means dependency in two or more ADLs. This level also includes individuals who are dependent in behavior pattern (abusive, aggressive, disruptive). Within assisted living, there are two payment levels for recipients of an Auxiliary Grant: regular assisted living and intensive assisted living as defined by the Department of Medical Assistance Services. Intensive assisted living services are for individuals who meet the criteria for home and community based waiver services (at risk of nursing home placement).
ACRs may offer single rooms (minimum 100 square feet for newer buildings) or multiple occupancy rooms (80 square feet per occupant). A maximum of four people may occupy a room. Facilities must provide one toilet and wash basin for every seven people and one bath tub for every 10 people.
ACRs cannot admit or retain residents with the following conditions or needs:
Dermal ulcers (III or IV) unless a stage III ulcer is healing;
*Intravenous therapy or injections directly into the vein;
Airborne infectious disease in a communicable state;
Psychotropic medications without an appropriate diagnosis and treatment plan;
*Gastric tubes except when an individual is capable of independently feeding himself and caring for the tube or by exception;
Individuals who present a danger to themselves or others;
Individuals requiring continuous nursing care (around the clock observation, assessment, monitoring, supervision, or provision of medical treatment by a licensed nurse);
Individuals whose physician certifies that placement is no longer appropriate;
Unless the individual's physician determines otherwise, individuals who require maximum physical assistance as documented by an assessment and meet Medicaid nursing facility level of care criteria; or
Individuals whose health care needs cannot be met in the specific ACR as determined by the residence.
* Exceptions are allowed when requested by resident and care is provided by a physician, a licensed nurse or a licensed home care organization except for Auxiliary Grant residents.
Public pay residents must have an assessment completed by a case manager or other qualified assessor. Assessments for private pay residents may be completed by a case manager or other qualified assessor, an independent physician, or an employee of the facility who has documented training in the completion of the uniform assessment instrument. Assessments completed by facility staff must be signed by the administrator or designated representative.
The regulations offer ACRs the flexibility to develop a program that meets the following criteria:
Meet physical, mental, emotional and psycho-social needs,
Provide protection, guidance and supervision;
Promote a sense of security and self worth; and
Meet the objectives of the service plan.
Each facility develops a written program description for prospective residents that describes the population to be served and the program components and services available. Facilities are permitted but are not required to offer all services as long as they have services that are appropriate for the needs of residents. ACRs must also provide 24-hour capacity to meet scheduled and unscheduled service needs. Skilled nursing services provided by a licensed home care organization for less than 30 days may be delivered. Eleven hours of activities per week for residential living and fourteen hours for assisted living must be scheduled. The Medicaid payment for intensive assisted living services covers personal care, homemaker, attendant care, companion services, medication oversight and therapeutic social and recreational programming.
An assessment using the approved Uniform Assessment Instrument must be performed on all residents prior to admission, every 12 months, and whenever a change in the resident's condition warrants a level of care change. An individualized service plan or plan of care is developed from the assessment in conjunction with the resident, family, case worker, case manager and health care providers. The service plan shall reflect the philosophy and values described above.
Two payment levels for the provision of personal care services in ACRs with an assisted living license have been developed to supplement the ACR's Auxiliary Grant rate which covers room, board, basic supportive services and supervision. The Auxiliary Grant program is a state and locally funded assistance program to supplement the income of a recipients of the federal Supplemental Security Income (SSI) program and certain other aged, blind and disabled individuals residing in an ACR. The maximum Auxiliary Grant payment is $737 or $848 depending upon the area of the state. DMAS provides an additional per diem payment above the current auxiliary grant rate for regular assisted living services, which are reimbursed by General Funds rather than Medicaid, at a rate of $3 a day to a maximum of $90 a month; and the rate for intensive assisted living services, which is a combination of general funds and federal waiver funds, is $6 a day and a maximum of $180 a month. Nursing care would not be covered in the rate.
Residents may self-administer medications, although assistance with self-administration is not described in the regulations. Medication administration is permitted when licensed staff are available or a medication training program approved by the Board of Nursing has been completed.
Staffing patterns must be appropriate to deliver the services required by the residents as described in the plans of care.
Administrators must be 21, a high school graduate with one year of post graduate study or experience and attend at least 20 hours of training related to management or operation of a residential facility for adults or client specific training needs within each 12 month period. When adults with mental impairments reside in the facility, at least five of the required 20 hours of training shall focus on the resident who is mentally impaired.
Administrators of assisted living facilities must complete at least two years of post secondary education or one year of courses in human services or group care administration from an accredited college or a department curriculum specific to the administration of an adult care residence.
Staff All employees shall be made aware of: the purpose of the facility; the service provided; the daily routines; and required compliance with regulations for adult care residences as it is related to their duties and responsibilities.
All personnel shall be trained in the relevant laws, regulations and the residence's policies and procedures sufficiently to implement the following:
Emergency and disaster plans for the facility;
Techniques of complying with emergency and disaster plans including evacuating residents where applicable;
Use of first aid kit and knowledge of its location;
Observance of rights and responsibilities of residents;
Procedures for detecting and reporting abuse, neglect or exploitation of residents to the appropriate local department of social services;
Techniques for assisting residents to overcome transfer trauma;
Confidential treatment of personal information; and
Specific duties and requirements of their positions.
Within the first 30 days of employment, all direct care staff shall have been trained to have a general knowledge in the care of aged, infirm or disabled adults with due consideration for their individual capabilities and their needs. On an annual basis, all direct care staff shall attend at least eight hours of training. The training shall be relevant to the population in care and shall be provided through in-service training programs or institutes, workshops, classes or conferences. When adults with mental impairments reside in the facility, at least two of the eight required hours of training shall focus on the resident who is mentally impaired. Documentation of this training shall be kept by the facility in a manner that allows for identification by individual employee.
Staff in assisted living residences must also be trained to deal with residents who have a history of aggressive behavior or of dangerously agitated states covering information, demonstration and practical experience in self-protection and prevention and de-escalation of aggressive behavior. Training to serve residents who are restrained is also required which covers proper techniques for applying and monitoring restraints, skin care, and active assisted range of motion exercises, assessment of blood circulation, turning and positioning, provision of sufficient bed clothing and covering to maintain body temperature and provision of additional attention to meet the physical, mental, emotional and social needs of restrained residents.
Assisted living staff must attend at least 12 hours of training annually which focuses on the needs of residents who are mentally or physically impaired as appropriate to the populations served.
The statute (§63.1-173.2) does not allow persons convicted of specific types of crimes to be employed. Staff must submit a sworn statement disclosing criminal convictions or pending charges. False statements are a Class 1 misdemeanor. An original criminal records check must be obtained by the facility from the Central Criminal Records Exchange.
Public pay residents receive annual reassessments by assigned case managers. Residents who require coordination of multiple services, are not able and do not have support available to assist in coordinating activities and need a level of coordination that is beyond what the ACR is able to provide, receive Medicaid funded, targeted case management from a case manager.
Private pay residents also receive annual reassessment to assure continued appropriate placement and services.
The Department of Social Services conducts regular licensing inspections of ACRs. DMAS conducts on-site visits to monitor the quality and appropriateness of assisted living services provided to public pay residents of ACRs.