Assisted Living: Chapter 420-5-4,
Specialty Care Assisted Living Facilities: Chapter 420-5-20
General Approach and Recent Developments
Sections of the regulations governing building requirements for assisted living facilities and specialty-care facilities were revised in July 2003. Revisions to incident investigations were effective in 2004. The regulations license three categories of facilities:
- Congregate assisted living facilities serve seventeen or more adults;
- Group assisted living facilities serve four to 16 adults; and
- Family assisted living facilities serve two to three adults.
Specialty-care facilities must receive a separate certification from the Board of Health.
The Department of Health is evaluating whether the regulations adequately address safety related issues, e.g., if residents have recurring problems with falls, should the rules limit admission/retention or should the staffing and training requirements be changed. The Department, Board of Nursing and Legislature are considering proposals to allow unlicensed staff to administer medications either through nurse delegation or creation of medication technician category.
|Assisted living facilities||241||7,260||302||9,140||304||8,000|
Assisted living facility “means an individual, individuals, corporation, partnership, limited partnership, or any other entity that provides or offers to provide residence and personal care to individuals who are in need of assistance with activities of daily living. A facility shall not be deemed to meet the definition of assisted living facility unless a residence and personal care services are provided to two or more individuals not related to the owner or administrator. To be deemed related to the owner or administrator for the purposes of this definition, an individual residing at the facility and receiving personal care must be the parent, sibling, grandparent, great-grandparent, child, grandchild, niece, nephew, aunt, uncle, first cousin, or spouse of the owner or administrator, or must stand in such relationship to the owner’s or administrator’s spouse.
Building requirements vary for congregate assisted living facilities, group assisted living facilities and family assisted living facilities.
“Specialty Care Assisted Living Facility” means a facility that meets the definition of Assisted Living Facility but which is specially licensed and staffed to permit it to care for residents with a degree of cognitive impairment that would ordinarily make them ineligible for admission or continued stay in an assisted living facility.
The regulations do not require separate living and sleeping quarters. Private bedrooms without sitting areas must provide 80 square feet, and double rooms 130 square feet. If sitting areas are included, private rooms must be 160 square feet and double rooms 200 square feet. Bathtubs or showers must be available for every eight beds; lavatories and toilets for every six beds. Lockable doors are permitted. No more than two people may share a room.
Facilities may not admit nor retain a resident who requires medical care, skilled nursing care, is severely cognitively impaired, or requires any care beyond assistance with activities of daily living unless the resident is capable of performing and does perform all tasks related to his or her own care; or is incapable of performing some or all tasks related to his or her own care due to limitations of mobility or dexterity but has sufficient cognitive ability to direct his or her own care and is able to direct others and does direct others to provide the physical assistance needed to complete such tasks, and the facility staff is capable of providing such assistance and does provide such assistance.
The statute allows residents to be served who need medical care, medication administration, or skilled nursing care due to an injury as long as the need does not exceed 90 days and arrangements are made for care from “properly licensed individuals.”
Facilities may not serve individuals with acute infectious pulmonary disease, such as influenza or active tuberculosis, or other communicable diseases, and individuals with infected draining wounds until the wound is sufficiently healed.
Nursing Home Admission Policy
A physician must certify the need for continuing stay. Nursing care is required on a daily basis that as a practical matter can only be provided in a nursing facility on an in-patient basis. Residents must need two of the following services on a regular basis:
Administration of a potent and dangerous injectable medication and intravenous medications and solutions on a daily basis or administration of routine oral medications, eye drops, or ointment.
Restorative nursing procedures (such as gait training and bowel and bladder training) in the case of residents who are determined to have restorative potential and can benefit from the training on a daily basis.
Nasopharyngeal aspiration required for the maintenance of a clear airway.
Maintenance of tracheostomy, gastrostomy, colostomy, ileostomy, and other tubes indwelling in body cavities as an adjunct to active treatment for rehabilitation of disease for which the stoma was created.
Administration of tube feedings by naso-gastric tube.
Care of extensive decubitus ulcers or other widespread skin disorders.
Observation of unstable medical conditions required on a regular and continuing basis that can only be provided by or under the direction of a registered nurse.
Use of oxygen on a regular or continuing basis.
Application of dressing involving prescription medications and aseptic techniques and/or changing of dressing in noninfected, post-operative, or chronic conditions.
Comatose patient receiving routine medical treatment.
Assisted living facilities must provide personal care for bathing, oral hygiene, hair and nail care, shaving, laundry services, personal safety and assistance making and keeping appointments. Facilities may provide for general observation and health supervision and may arrange for or assist residents in obtaining medical attention or nursing services when needed. Home health may be provided by a certified agency as long as residents do not require hospital or nursing home care. A written plan of care is required at the time of admission based on the medical examination, diagnoses, and recommendations of the resident’s treating physician. It shall document the personal care and services required from the facility. Plans of care are kept current and reviewed and updated at least annually by the attending physician.
Menus must be planned and posted one week in advance. Alternate food selections must be available for residents on medically prescribed diets, including hypertension, diabetes, hyperlipdemia, and modified consistency diets. A dietician is available for residents who need special diets. Congregate assisted living facilities must be under the direction and supervision of a full- or part-time professionally qualified dietician or a consulting dietician.
Agreements must be signed prior to or at the time of admission and include: basic charges (room, board, laundry, personal care, and services); period covered; services for which there are special charges; refund policy and termination provisions; bed hold policy and process; documentation that the resident and sponsor understand that the facility is not staffed and not authorized to perform skilled nursing services nor to care for residents with severe cognitive impairment and that the resident and sponsor agree that if the resident should need skilled nursing services or care for a severe cognitive impairment as a result of a condition that is expected to last for more than ninety days, that the resident will be discharged by the facility after prior written notice; and a reminder to the resident or sponsor that the local ombudsman may be able to provide assistance if the facility and the resident or family member are unable to resolve a dispute about payment of fees or monies owed.
Provisions for Serving People with Dementia
No facility may serve anyone with Alzheimer’s disease or dementia unless they have a specialty-care facility license. Facilities are allowed to serve residents who do not have dementia if they have readily available egress from the facility. Specialty-care facilities must have a medical director, at least one registered nurse who is responsible for staff training, resident assessment, and plans of care and medication. Minimum ratios of awake staff are specified: two staff for less than 16 residents; one staff for every eight residents for facilities with 16 or more residents from 7 a.m. to 9 p.m.; three staff from 9 p.m. to 7 a.m. for facilities with 17-24 residents; and three staff plus one for every 16 residents for facilities serving 25 or more residents. Activity programs are required. Residents must have a Physical Self Maintenance Scale score of 23 or less and may not have unmanageable behavior problems.
Continuing Education. All staff members of a specialty care assisted living facility shall have at least six hours of continuing education annually. All direct care staff, including the administrator, shall have initial training and refresher training as necessary. An RN shall identify staff refresher training needs and shall provide or arrange for needed training. Prior to providing any resident care, all staff shall complete the DETA (Dementia Education and Training Act) Brain Series Training developed by the Alabama Department of Mental Health and Mental Retardation or equivalent training approved by the State Health Officer. In addition to the training areas for staff in assisted living facilities, special care staff members must receive training on: resident fire and environmental safety; specialty care assisted living facilities Chapter 420-5-20; understanding the aging mind; basic brain function; common neuro-psychiatric disorders in the elderly; basic evaluation of the dementia patient; cognitive symptoms of dementia; psychiatric symptoms of dementia; behavioral problems associated with dementia; end of life issues in dementia; dementia other than Alzheimer’s; research and dementia; nutrition and hydration needs of the resident with dementia to include feeding techniques; safety needs of residents with dementia.
Assistance is limited to reminders, reading container labels to the resident, checking the dosage, and opening containers. Licensed nurses are allowed to administer medications for residents who are not aware of their medications.
Residents who are aware of their medications may self-administer medications. A licensed nurse may administer medication to a resident who is capable of self-administration. Facility staff may assist with the self-administration of medication. Assistance includes reminding, physically assisting by opening or helping to open a container holding oral medications, offering liquids, physically bringing a container of oral medications. Assistance does not include giving injections, administering eye drops, eardrops, nose drops (unless the resident is aware but has dexterity limitations), inhalers, suppositories, or enemas, telling or reminding a resident that it is time to take a PRN, or as needed medication, crushing or splitting medications, placing medications in a feeding tube, or mixing medications with food or liquids.
A Medicaid waiver to cover people with dementia in assisted living was approved in 2003 by CMS but has not been implemented due to budget limitations. The legislature is considering funding in 2004. The program would service SSI recipients and people who qualify under the 300 percent option. The personal needs allowance would be between $65 to $72 per month and room and board would be capped at about $500 a month. The program planned to pay providers $66 per day or $2,046 per month--total monthly reimbursement $2546. If implemented, the waiver would serve 500 people in Year 1, 650 in Year 2, and 700 in Year 3. Families would be allowed to supplement the room and board charges.
An assisted living facility shall employ sufficient staff and ensure sufficient staff are on duty to meet the care needs of all residents 24 hours a day, seven days a week. This means that an assisted living facility must not only have a sufficiently large number of staff members to meet the care needs of all residents, it must also manage and direct the activities of staff members in a manner that results in adequate care being provided. An assisted living facility shall likewise employ sufficient staff, ensure sufficient staff are on duty, and manage and direct staff activities in a manner that results in maintenance of a neat, clean, orderly, and safe environment at all times.
Administrators. Legislation passed in 2001 creates a Board of Examiners for Assisted Living Administrators. Within 18 months of passage, all administrators must be licensed which includes passing an examination and meeting education and training requirements. Existing rules require that administrators have 6 hours of continuing education annually.
Staff. Administrators and direct care staff receive initial and refresher training on state law and rules on assisted living facilities; identifying and reporting abuse, neglect and exploitation; special needs of the elderly, mentally ill, and mentally retarded; basic first aid; advance directives; protecting resident confidentiality; safety and nutritional needs of the elderly; resident fire and environmental safety; and identifying signs and symptoms of dementia.
Not specified. Facilities are required to check the nurse abuse registry before hiring staff.
Facilities are monitored through licensing review and periodic inspections by the Board of Health depending on funding for inspectors. Incidents are reported through a hotline. Written reports may be requested to determine the cause of an incident or if the facility acted appropriately. Facilities are currently inspected every 2 to 3 years. The oversight agency is seeking additional staff to permit annual inspections.
Licensure fees for assisted living facilities and specialty-care assisted living facilities rising to the level of intermediate care are $200, plus $15 per bed.
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