State Residential Care and Assisted Living Policy: 2004. Connecticut

03/31/2005

Citation

Assisted living services agency; Connecticut General Statutes §19a-490
Connecticut Department of Public Health, Public Health Code §19-13-D105
Residential care homes (homes for the aged, rest homes) §19-13-D-6

General Approach and Recent Developments

Assisted living regulations issued by the Health Department were last revised in June 2001. The regulations take a unique approach by allowing “managed residential communities” (MRCs) to offer assisted living services through assisted living services agencies (ALSAs). MRCs may obtain a license to also serve as an ALSA. Rules governing medication administration in residential care homes were revised in March 2002. Medicaid waiver and state funds are being used to cover services provided by Assisted Living Service Agencies.

The State is currently focusing on level of care concerns in managed residential communities providing assisted living services. Since the regulations went into effect, residents have aged in place, and the State wants to ensure that residents are receiving the right amount of services. The State encourages aging in place, but as the regulatory body, needs to ensure that services are available to meet resident needs.

Supply
  Category   2004 2002 2000 1998
  Facilities     Units     Facilities     Units     Facilities     Units     Facilities     Units  
Assisted living services agencies 65 NA 63 NA 48 NA 22 NA
Managed residential communities   104 NA NR NR NR NR NR NR
Residential care homes 101 2,753 109 2,949 113 NR 113 NR

The ALSA regulations focus on the licensing of agencies to provide services rather than the licensing of building and services as an entity. MRCs have to notify the health department of their intention to provide assisted living services and present specified information and assurances to the department. The ALSA, either the MRC or another agency, must be licensed by the Department of Public Health to provide services. The MRC is not licensed by the Department of Public Health. MRCs must show evidence of compliance with local zoning ordinances and building codes.

A pilot program to build 300 units to serve low-income residents has been implemented jointly by the Department of Social Services, Department of Economic Development, Department of Public Health, Office of Policy and Management and the Connecticut Housing Finance Authority.

Definition

An assisted living services agency means an institution that provides, among other things, nursing services and assistance with activities of daily living to a population whose conditions are chronic and stable.

Assisted living services means nursing services and assistance with ADLs provided to clients living within a managed group-living environment having supportive services that encourage clients primarily age 55 or older to maintain a maximum level of independence. Routine household services may be provided as assisted living services or by the managed residential community. These services provide an option for elderly persons who require some help or aid with ADLs and/or nursing services.

A managed residential community means a facility consisting of private residential units that provides a managed group living environment, including housing and services primarily for persons age 55 or older.

Residential care home means an institution having facilities and all necessary personnel to furnish food, shelter and laundry for two or more persons unrelated to the proprietor and in addition, providing services of a personal nature which do not require the training or skills of a licensed nurse. Additional services of a personal nature may include assistance with bathing, help with dressing, preparation of special diets and supervision over medications which are self-administered.

Unit Requirements

Managed residential communities. To qualify as a managed residential community and a setting in which assisted living services may be provided, units are defined as a living environment belonging to a tenant(s) that includes a full bathroom within the unit including water closet, lavatory, tub or shower bathing unit, and access to facilities and equipment for the preparation and storage of food. Managed residential communities may not require tenants to share units. Sharing of a unit shall be permitted solely upon the request and mutual consent of tenants.

Residential care homes. Single rooms must have a minimum of 150 square feet, excluding closets, toilet rooms, lockers or wardrobes and vestibule. Multiple bed rooms must have a minimum of 125 square feet per bed. A resident unit shall be 25 beds. No resident room shall be designed to permit more than two (2) beds. Baths must have one separate shower or bathtub for every eight residents. There must be one separate shower and one separate bathtub per resident unit. One toilet may serve two resident rooms, but no more than four residents.

Admission/Retention Policy

Assisted Living Service Agencies. Each ALSA agency will develop its own admission and discharge criteria but the regulations do not allow the ALSAs to impose unreasonable restrictions and screen out people whose needs may be met by the ALSA. Assisted living services may be provided to residents with chronic and stable health, mental health, and cognitive conditions as determined by a physician or health care practitioner.

Discharge policies must include categories for the discharge of clients, which include but are not limited to change in resident’s condition; routine discharge; emergency discharge; financial discharge; and premature discharge.

Nursing Home Admission Policy

The State requires that residents have uncontrolled and/or unstable and/or chronic conditions requiring continuous skilled nursing services and/or nursing supervision or have chronic conditions requiring substantial assistance with personal care on a daily basis.

Services

Assisted Living Service Agencies. Core services provided by managed residential communities include three meals a day; laundry; scheduled transportation; housekeeping; maintenance services including chore services for routine domestic tasks that the tenant is unable to perform; and social and recreational services. In addition, 24-hour a day security and emergency call systems in each unit are required. Communities must have a service coordinator who assists tenants and acts as a liaison with the ALSA. Service coordinators ensure that all core services are provided to or are made available to residents, assist residents in making arrangements to meet their personal needs, establish collaborative relations with provider agencies, support services and community resources, establish a resident council, and ensure that a resident information system is in place.

The managed residential community, through its service coordinator or any other representative, may not provide health services, including but not limited to the provision of rehabilitative therapy, administration or supervision of the self-administration of medications, nursing care or medical treatment, unless it has been licensed as an assisted living services agency. It may contract with one or more assisted living services agencies, home health care agencies, or other appropriately licensed health care providers to make available health services for tenants provided by such licensed persons or entities.

Trained aides may provide assistance with ADLs; assistance with exercise, ambulation, transfer, and self-administration of medications; and routine household tasks.

Nursing services may only be provided by licensed ASLAs or other appropriately licensed agencies or individuals. Nursing services include client teaching, wellness counseling, health promotion and disease prevention, medication administration and delegation of supervision of self-administered medications, and provision of care and services to clients whose conditions are chronic and stable.

Registered nurses may also perform quarterly assessments, coordination, orientation, training, and supervision of aides.

Residential care homes. Services provided include recreational activities, laundry, housekeeping, and maintenance services.

Dietary

Assisted Living Service Agencies. Managed residential communities must offer three meals a day. Other aspects of food service are not specified in the Assisted Living Service Agency regulations.

Residential care homes. Menus shall be prepared, posted and filed and shall meet state department of health requirements for basic nutritional needs.

Agreements

Assisted Living Service Agencies. A “bill of rights” must be developed and signed for each resident upon move-in. The agreement includes: services available, charges and billing mechanisms; 15-day notice of changes; criteria for admission to service; rights to participate in service planning; client responsibilities; information about the complaint process; circumstances for discharge; description of Medicare-covered services and billing and payment for such services and other rights.

Residential care homes. Agreements are not required for residential care homes.

Provisions for Serving People with Dementia

Not specified.

Medication Administration

Assisted Living Service Agencies. The regulations allow for administration of medications by licensed staff. Assisted living aides may supervise the self-administration of medications which includes reminding, verifying, and opening the package. All medications must be stored in the resident’s unit.

Residential care homes. Residents of licensed residential care homes may self administer medications, and may request assistance from staff with opening containers or packages and replacing lids. Unlicensed personnel who administer medications must be certified.

Prior to the administration of any medication by program staff members, the program staff members who are responsible for administering the medications shall first be trained by a registered pharmacist, physician, physician assistant, advanced practice registered nurse or registered nurse in the methods of administration of medications and shall have successfully completed a written examination and practicum administered by the Connecticut League For Nursing or other department-approved certifying organization.

Public Financing

The State provides assisted living services through ALSAs to elders in sixteen state funded congregate housing projects and three HUD facilities that have been approved as MRCs. State general revenue and Medicaid waiver funds were made available January 1, 2003, for a pilot program that serves 75 people in private assisted living facilities. State funds are available to residents who do not meet Medicaid financial or functional criteria.

Medicaid Participation
2004 2002 2000
  Facilities     Participation     Facilities     Participation     Facilities     Participation  
34 65 NA NA NA NA

A nursing home transition grant is being implemented to assist residents to relocate to community settings. The grant includes funding for transitional expenses. The grant is going to be coming to a close in 2004. However, the Governor’s budget for FY 2005 includes a recommendation for the State to fund 100 percent of the grant for an additional 3 years.

An RFP was issued in 1999 by the Connecticut Housing Finance Authority “to test the extent to which subsidized assisted living communities are a viable and cost effective response for frail seniors facing inappropriate nursing facility admission.” Four projects have been approved for development. Two of the projects are under construction with the first to open this summer and the other in late 2004/early 2005. Two hundred nineteen subsidized units have been selected thus far. At least 40 percent of the units must be occupied by residents with less than 50 percent of the median income. Services for eligible low-income residents (less than $1,692 per month income or 300 percent of the federal SSI benefit) are covered by the State’s home care and Medicaid waiver programs. Tenants may retain a personal needs allowance of $164. Residents pay a share of the rent and $330 a month for meals. Any remaining income is applied to the cost of the Medicaid, or state-funded, services. Family supplementation is allowed.

Reimbursement for core services (housekeeping, laundry, maintenance/chore, recreation, medical and nonmedical transportation, emergency response, and service coordination) is $8 per day. Meals are billed to the client. Per diem payments for four levels of personal assisted living services are reimbursed as follows:

  • Occasional personal services: 1 hour per week and up to 3.75 hours, including nursing supervision as needed
  • Limited personal services: 4 hours per week and up to 8.75 hours per week of personal services plus nursing visits as needed
  • Moderate personal services: 9 hours per week and up to 14.75 hours of personal services plus nursing visits as needed
  • Extensive personal services: 15 hours per week and up to 25 hours of personal services plus nursing visits as needed.

Under the Demonstration project described above, each project sets its own rates for each level of care but cannot exceed a maximum amount for each level. For the other assisted living initiatives the State is sponsoring, the rate for each level of care is set by the State.

Staffing

ALSAs must have at least one RN in addition to an on-site supervisor. A supervisor must be available 20 hours a week for every 10 or fewer licensed nurses or assisted living aides and a full-time supervisor for every 20 licensed nurses or aides. A sufficient number of aides must be available to meet residents’ needs. All aides must be certified Nurses Aides or Home Health Aides and must complete 10 hours of orientation and one hour of in-service training every 2 months.

Twenty-four hour awake staff are not required since the needs vary among managed residential communities. However, 24-hour staffing could be required if indicated by resident plans of care. An RN must be available on-call, 24 hours a day.

Residential care homes. There must be at least one attendant on duty at all times for every 25 residents.

Training

Each ALSA must have a 10-hour orientation program for all employees which shall include but not necessarily be limited to the following:

  • Organizational structure of the agency and philosophy of assisted living services;
  • Agency client services policies and procedures;
  • Agency personnel policies; and
  • Applicable regulations governing the delivery of assisted living services.

Aides must pass a competency exam. Each agency shall have an in-service education policy that provides an annual average of at least 1 hour bimonthly for each assisted living aide.

The in-service training shall include but not be limited to current information regarding specific service procedures and techniques and information related to the population being served.

Residential care homes. New staff must receive an initial orientation prior to being allowed to work independently including, but not limited to, safety and emergency procedures for staff and residents, the policies and procedures of the residential care home, and resident rights.

Continuing education for program staff shall be required for 1 percent of the total annual hours worked (to a maximum of 12 hours) per year. Such education shall include, but is not limited to, resident rights, behavioral management, personal care, nutrition and food safety, and health and safety in general.

Background Check

Not described.

Monitoring

ALSAs are required to establish a quality assurance committee that consists of a physician, a registered nurse, and a social worker. The committee meets every four months and reviews the ALSA policies on program evaluations, assessment and referral criteria, service records, evaluation of client satisfaction, standards of care, and professional issues relating to the delivery of services. Program evaluations are also to be conducted by the quality assurance committee. The evaluation examines the extent to which the managed residential community’s policies and resources are adequate to meet the needs of residents. The committee is also responsible for reviewing a sample of resident records to determine whether agency policies were followed, whether services are provided only to residents whose level of care needs can be met by the ALSA, and whether care is coordinated and appropriate referrals are made when needed. The committee submits an annual report to the ALSA summarizing findings and recommendations. The report and actions taken to implement recommendations are made available to the State Department of Public Health.

Agencies are inspected biennially. Penalties include revocation, suspension, or censure; letter of reprimand; probation; a restriction on acquisition of other entities; a consent order compelling compliance; and civil monetary penalties.

Fees

Fees are not required for ALSAs.

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