Residential care apartment complexes (formerly Assisted Living) Chapter HFS 89. WS Act 13, 1997.
Community based residential care facilities Chapter HFS 83
Two categories of facilities are available -- residential care apartment complexes (RCACs) and community based residential care facilities (CBRFs). Regulations providing for registration and certification of assisted living facilities were effective in March 1997. Legislation changing the category from assisted living facilities to RCACs was passed in September 1997. Certified facilities submit an application and may be visited by the department staff to determine compliance. Tenants must be notified that the department does not regularly visit or inspect registered facilities. Facilities who seek to receive Medicaid reimbursement must be certified. On-site review of all certified applications is conducted. Facilities must submit documents showing compliance with all applicable federal, state and local licensing, building, zoning and related requirements.
There are 28 registered residential care apartment complexes with a total of 823 units and 15 certified units with a capacity of 516.
Several levels of CBRFs are licensed based on size (small: 5-8; medium: 9-20; and large: 21 or more) and the six classes of care based on whether residents are ambulatory (walk without difficulty), semi-ambulatory (able to walk with difficulty or only with assistance of an aid such as crutches, a cane or walker) and non-ambulatory (not able to walk at all but able to be mobile with the help of a wheelchair).
Residential care apartment complex "a place where five or more adults reside that consists of independent apartments, each of which has an individual lockable entrance and exit, a separate kitchen, including a stove, and individual bathroom, sleeping and living areas, and that provides, to a person who resides in the place, not more than 28 hours per week of services that are supportive, personal and nursing services. Residential care apartment complex does not include a nursing home or a community-based residential facility, but may be physically part of a structure that is a nursing home or community based residential facility."
Facilities that are part of a nursing facility must be physically separate and distinct although they may share a common lobby and entrance. They may also share common dining and activity areas as long as they are not scheduled for concurrent use.
Community based residential facility is a place where five or more unrelated adults reside in which care, treatment or services above the level of room and board are provided to residents as a primary function of the facility.
Residential care apartment complex The rules require units with a minimum of 250 square feet for sleeping and living areas, excluding closets and cabinetry. The kitchen must be a visually and functionally distinct area of the unit. The sleeping and living area also has to be visually and functionally distinct but not a separate room. Variances may be granted for facilities converting to assisted living to allow up to a 10% reduction in square footage requirements.
Community based residential facilities Private rooms must offer 100 square feet and double rooms 80 square feet per person. No more than two residents may share a room. Small and medium facilities must offer one bathroom and shower facilities for every eight residents. Large facilities must have one toilet, bath and shower for every eight male residents and every eight female residents.
Residential care apartment complex The rules require the development of a mutually agreed upon service agreement and signing of a negotiated risk agreement. The risk agreement identifies situations or conditions known by the facility to arise from the tenant's preferences which are contrary to the facility's advice, how they will be accommodated, alternatives offered to reduce the risk, the agreed upon course of action and the tenant's understanding and acceptance of responsibility.
Facilities may retain tenants whose needs can be met by the facility or met by services available from another provider. Facilities may not admit anyone who has a court determination of incompetence, anyone who has an activated power of attorney for health care, anyone found by a physician or psychologist to be incapable of recognizing danger, summoning assistance, expressing need or making care decisions -- unless they share a unit with a competent person. Facilities may also retain a tenant who becomes incompetent as long as there is adequate oversight and the service and risk agreements are signed by the guardian or agent with power of attorney.
Facilities may terminate agreements with tenants whose needs cannot be met by the facility if service needs exceed 28 hours a week (unless additional services are secured by the tenant from other providers), tenants require 24-hours a day nurse availability, the tenant is a danger to self or others or fees have not been paid.
Community based residential facilities may not admit or retain anyone who is confined to bed by illness or infirmity (unless it is temporary); who is destructive; has physical, mental, psychiatric or social needs that are not compatible with the CBRFs client group; needs more than three hours of nursing care per week except for a temporary condition lasting no more than 90 days; requires 24-hour supervision by an RN or LPN; has chronic personal care needs that cannot be met by the facility or a community agency; or who requires restraints. A waiver may be granted for residents needing more than three hours of skilled care a week if condition is stable and the services needed are available in the facility.
Residential care apartment complex Facilities must provide or contract for services which are sufficient and qualified to meet the care needs identified in the tenant service agreement. The minimum service package includes supportive services (meals, housekeeping, laundry, arranging access to medical services and transportation to medical services); personal services (daily assistance with ADLs); and nursing services (health monitoring, medication administration, and medication monitoring). Services above these minimums may be provided during acute episodes, release from a hospital or at other times when the tenant may experience temporary need.
A comprehensive assessment must be done and used as the basis of a service plan and risk agreement. The assessment covers: physical health, physical and functional limitations and capacities, medication and ability to self-administer, nutritional status and needs, mental and emotional health, behavior patterns, social and leisure needs and preferences, strengths, abilities and capacity for self-care, situations or conditions which could put the tenant at risk, and the type, amount and timing of services desired by the tenant.
The legislation and regulations limit supportive, personal and nursing services to 28 hours a week. The threshold was devised to prevent facilities from discharging residents prematurely. The threshold was developed based on an analysis of the amount of care required by participants in the state's Community Options (Medicaid Waiver) program and the Community Integration Program and reflects a higher level of care than the average community client.
The hours of service include staff time attributable to providing or arranging supportive, personal and nursing services including nursing assessment, documentation and consultation, and standby assistance. Services that are not included are meals, laundry, social and recreational activities. Tenants have the right to contract for or arrange for additional services outside the service agreement.
Community based residential facilities Residents receive an assessment upon admission, a plan of care and an individualized service plan. Facilities provide general services, medication administration and assistance and client group specific services. General services include supervision, information and referral, leisure time activities, community activities, family contacts, transportation, and health monitoring. Client group specific services include personal care, independent living skills, communication skills, socialization, activity programming for persons with dementia, transitional services, and nursing care (up to three hours a week).
Residential care apartment complex State funding is provided to Medicaid recipients who meet the nursing home level of care criteria through the Medicaid Community Options Program Waiver (COP-W) and the Community Integration Program II (CIP II). CIP II funding is only available when nursing home beds are closed and funding is transferred to provide community care to replace the closed capacity.
The legislation limits state reimbursement to 85% of the average statewide Medicaid nursing home rate excluding room and board. Rates are negotiated between facilities and the county. The maximum spending for the resident's total service plan is $52.32 per day which includes assisted living services provided by the facility, and other waiver costs such as county care management, transportation and therapies not covered by the Medicaid state plan. Room and board is not included in this ceiling.
Fifteen facilities currently contract with counties with a total capacity of 504 apartments. About 25 of the units are occupied by waiver participants.
Residential care apartment complex Facilities can offer medication administration and medication management (storage, preparation or organization or reminder system, assessment of effectiveness of medications, monitoring of side effects, negative reactions and drug interaction and delegation and supervision of administration).
Residential care apartment complex The number, assignment and responsibilities of all staff shall be adequate to provide all services identified in the tenants' service agreements including assisting tenants with unscheduled care needs.
Residential care apartment complex administrators Each RCAC must have a service manager responsible for the day to day operation of the facility, including ensuring that the services provided are sufficient to meet tenant needs and are provided by qualified persons; that staff are appropriately trained and supervised; that facility policies and procedures are followed; and that the health, safety and autonomy of the tenants are protected. The service manager shall be capable of managing a multi-disciplinary staff to provide services specified in the service agreements.
Community based residential facilities administrators must be 21, have a high school diploma or GED and have administrative experience or one post high school course in business management and one year experience or a post high school course related to the needs of the client group.
Residential care apartment complex Services shall be provided by staff who are trained in the services that they provide and are capable of doing their assigned work. Personal and supportive services shall be provided by staff who have documented training or experience in needs and techniques for assistance with tenant care and activities of daily living such as bathing, grooming, skin care, transfer, ambulation, exercise, meal preparation, and eating assistance, dressing and use of adaptive aids and equipment. All facility staff shall have training in safety procedures, including fire safety, first aid, universal precautions and the facility's emergency plan and facility policies and procedures relating to tenant's rights. Staff providing assisted living services must have documented training in the following areas:
Physical, functional and psychological characteristics associated with aging or likely to be present in the tenant population and their implications for service needs;
The purpose and philosophy of assisted living, including respect for tenant privacy, autonomy and independence; or
Assigned duties and responsibilities, including the needs and abilities of individual tenants.
Community based residential facilities Administrators and staff must have 45 hours of initial training covering: resident rights; recognizing and responding to challenging behaviors; client group specific training; needs assessment of prospective residents and individualized service plans; universal precautions; and fire safety, first aid and procedures to alleviate choking. Administrators and appropriate staff must receive three hours training in dietary needs, menu planning, food preparation and sanitation. The administrator and appropriate staff who are not under the supervision of a registered nurse or pharmacist must receive eight hours training in management and administration of medications. Exemptions from training are allowed for employees with specified licenses or credentials.
Administrators and staff must receive 12 hours of continuing education beginning the second year of employment that is relevant to their job responsibilities.
Residential care apartment complex Facilities must conduct a criminal record check with the Wisconsin Department of Justice and with the registry for nurses aides, home health aides and hospice aides for managers, service providers and others.
Community based residential care facilities The department conducts a criminal records check of the applicant or licensee during the licensing process. Criminal checks are conducted for administrators and staff, using form DJ-LE-250 or 250A, from the Department of Justice. The state's registry for nurses assistants, home health aides and hospice aides are also checked.
Residential care apartment complex The Department conducts periodic inspections to determine compliance.
Fees are charged for plan review of new construction or additions for CBRFs based on the estimated value of the project.