Community Residence Facilities; DC Law 5-48; DC Code §32-1301 et seq.; Chapter 34, §3400 et seq.
Assisted Living Residences; DC Law 13-127 §60847 of DC Register, p. 2647
General Approach and Recent Developments
An RFP was issued in March 2004 to hire a contractor to develop a program to license and monitor Assisted Living Residences (ALRs). The goals of the program are to assure the quality of care provided in ALRs according to the Act, develop a monitoring system that is client centered, and develop an evaluation system that will measure the quality of care being given to residents. The Assisted Living Residence Regulatory Act was passed in June 2000. The assisted living law includes a philosophy of care that emphasizes personal dignity, autonomy, independence, privacy, and freedom of choice. The services and physical environment should enhance a person’s ability to age in place in a home-like setting by increasing or decreasing services as needed.
The HCBS Medicaid waiver was amended in June 2003 to include a new category of service for assisted living. The service will be implemented after licensure regulations for assisted living are developed.
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An assisted living residence means an entity, whether public or private, for profit or not for profit, that combines housing, health services, and personal assistance--in accordance with individually developed service plans--for the support of individuals who are unrelated to the owner or operator of the entity.
A community residence facility is one that provides safe, hygienic sheltered living arrangements for one or more individuals aged 18 years or older (except in the case of group homes for mentally retarded persons, no minimum age limitation shall apply), not related by blood or marriage to the residence director, who are ambulatory and able to perform the activities of daily living with minimal assistance. The definition includes facilities, including halfway houses and group homes for mentally retarded persons, which provide a sheltered living arrangement for persons who desire or require supervision or assistance within a protective environment because of physical, mental, familial, or social circumstances, or mental retardation. The definition does not include facilities providing sheltered living arrangements to persons who are in the custody of the Department of Corrections of the District of Columbia.
Assisted living residences. Newly constructed or renovated rooms must have 80 square feet per resident. No more than two persons may share a bedroom. Full bathrooms must be available for every six residents. ALRs serving more than 16 residents may offer living units that include kitchenette, living rooms, and bathrooms. Units that do not include bathrooms must limit sharing of bathrooms to four residents.
Community residence facilities. No more than four persons may share a bedroom. Minimum square footage and bathing and toilet facilities requirements are specified in the DC Housing Code (14 DCMR).
Assisted living residences. ALRs may not accept those who are dangerous to themselves or others, exhibit behavior that negatively impacts the lives of others, are at risk for health or safety complications which cannot be addressed by the home, and requires more than 35 hours a week of skilled nursing and home health aide services, provided on less than a daily basis, and residents who require more than intermittent skilled nursing care, treatment of Stage III or IV skin ulcers, ventilator services, or treatment for an active, infectious, and reportable disease.
Residents have the right to remain in the facility despite a recommendation to transfer, if they obtain additional services that are acceptable to the ALR.
Community residence facilities. Prospective residents, the residence director and the resident’s physician must agree that the prospective resident does not need professional care and can be assisted safely and adequately within a community residence facility. Residents must be able to perform ADLs with minimal assistance, generally be oriented as to person and place, and capable of exercising proper judgment in taking action for self-preservation under emergency conditions. By special permission of the mayor, persons who are not generally oriented or who are substantially ambulatory but need minimal ADL assistance may be admitted if sufficient staff resources are available.
Assisted living residences. ALRs must offer or coordinate for payment 24-hour supervision, assistance with scheduled and unscheduled ADLs and IADLs as needed, as well as provision or coordination of recreational and social activities and health services in a way that promotes optimum dignity and independence for residents. Services include 24-hour supervision and oversight, three nutritious meals and snacks modified to meet individual dietary needs, at a minimum some assistance with ADLs and IADLs to meet scheduled and unscheduled needs, and laundry/housekeeping services. ALRs facilitate access to appropriate health and social services and provide or coordinate transportation to community based services.
An assessment must be completed within 30 days of admission. An individual service plan is required that is signed by the resident and identifies services provided, when they are provided, and by whom. The plan is based on a medical, rehabilitation, and psychosocial assessment; functional assessment; and reasonable accommodation of resident and surrogate preferences. A shared responsibility agreement is also required. Whenever disagreements arise as to lifestyle, personal behavior, safety, and service plans the ALR staff, resident or surrogate, and other relevant service providers shall attempt to develop a shared responsibility agreement.
The ALR must explain to the resident, or surrogate, why the decision or action may pose risks and suggest alternatives to the resident; and discuss with the resident, or surrogate, how the ALR might mitigate potential risks. If the resident decides to take action that may involve increased risk of personal harm and conflict with the ALR’s usual responsibilities, the ALR describes to the resident the action or range of actions subject to negotiation; and negotiate a shared responsibility agreement, with the resident as a full partner, acceptable to the resident and the ALR that meets all reasonable requirements implicated. The shared responsibility agreement shall be signed by the resident or surrogate and the ALR.
Community residence facilities. Meals, housekeeping, laundry, and dietary services are provided. Short-term nursing care, 72 hours, may be provided or arranged by the facility.
Assisted living residences. Written contracts cover the ALRs’ organizational affiliation, the nature of any special care offered, services included or excluded, residents’ rights and grievance process, unit assignment procedures, admission and discharge policies, responsibilities for coordinating health care, arrangements for notification in the event of the resident’s death, obligations for handling finances, renting of equipment, coordinating and contracting for services not provided by the ALR, purchase of medications and durable medical equipment, rate structure and payment provisions, 45-day notice for changes in rates, procedures to be followed in the event the resident can no longer pay for services, and terms governing refunds.
Provisions for Serving People with Dementia
Assisted living residences. Trained aides may administer medications. A medication aide training program approved by the board of nursing will be developed. ALRs must arrange for an on-site review by a registered nurse every 45 days that covers supervision of administration by trained medication aides, resident responses to medications, and resident ability to self-administer medications.
Community residence facilities. Facilities must provide each resident a means of storing medications. Assisting with self-administration is listed as an activity of daily living.
Assisted living residences. A Medicaid HCBS waiver amendment was approved by CMS in June 2003. The amendment added the 18 to 64 population with physical disabilities, and added two additional services: consumer-directed care and assisted living. Assisted living, while an approved service, will not be implemented until assisted living licensure regulations have been passed. The State has contracted with an independent consultant to develop a case-mix reimbursement system for nursing homes, and will also develop assisted living rates. This work cannot be completed until the assisted living licensure regulations are in effect.
Community residence facilities. The SSI payment standard is $564 a month and the PNA is $70.
Administrators must have a high school diploma or GED and at least 1 year’s experience as a direct care provider/administrator and have satisfactory knowledge of the philosophy of assisted living, the health and psychosocial needs of residents, assessment process, development and use of ISPs, medication administration, provision of ADL/IADL assistance, residents’ rights, fire and life safety codes, infection control, food safety and sanitation, first aid and CPR, emergency disaster plans, human resource management, and financial management.
The ALR must have a staffing plan to assure the safety and proper care of residents based on the needs of residents, the size and layout of the facility, and the capabilities and training of staff.
Forty hours of initial training is required on delivering care for bedbound residents, use of first aid kits, procedures for detecting and reporting abuse, managing difficult behaviors, advanced body mechanics, communicating with adults with communication deficits, recognizing the signs and symptoms of dementia, caring for people with cognitive impairments, techniques for assisting in overcoming trauma, awareness of changes in conditions, and basic competence in housekeeping.
Staff must complete 12 hours of in-service training annually on emergency procedures and disaster drills, and rights of residents. Staff must also complete 12 hours of annual training on managing residents with dementia conducted by a nationally recognized organization with experience in Alzheimer’s care.
Assisted living residences. Background checks as required by federal and district laws are required.
Community residence facilities. The licensing agency may conduct background checks on the licensee which include contacts with the police to determine criminal convictions.
Assisted living residences. The proposed system, as outlined in the RFP, will measure the ability of the ALR to fulfill customers’ expectations and to provide for the health and safety of the residents. Surveyors will gather information from a variety of sources including: a survey questionnaire; interviews with the residents, family, staff and other customers; and, from a review of the medical records. It will also include a customary inspection of life safety support, fire safety systems, emergency and disaster planning, physical plant, environmental services, food services, sanitation, medical administration and other systems.
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