States using a full continuum approach have broad criteria that allow facilities to serve residents with a wide range of needs, permitting residents to age in place. However, providers are not required to serve everyone who meet these criteria and can establish their own admission and discharge standards within state parameters. They are required to inform prospective residents about these standards and the type of conditions that would trigger discharge. For example, Massachusetts allows providers to meet personal care needs and at a minimum must provide assistance with bathing, dressing, and ambulation. However, they are not required to offer assistance with other ADLs such as toileting and eating. Most other states allow, but do not require, residences to serve people with ADL needs.
States using the full continuum approach include Hawaii, Kansas, Maine, Minnesota, Nebraska, New Jersey, and Oregon, and those with the most flexible rules include Arizona, Hawaii, Kansas, Maine, Maryland, Minnesota, New Jersey, Oklahoma, and Oregon. Examples of this approach follow.
Oregon generally does not limit whom facilities may serve. The rules contain "move out" criteria that allow residents to choose to remain in their living environment despite functional decline as long as the facility can meet the resident's needs. However, facilities are not required to serve all residents whose needs increase. Providers may ask residents to move if: (1) their needs exceed the level of ADL services available; (2) the resident exhibits behaviors or actions that repeatedly interfere with the rights or well being of others; (3) the resident, due to cognitive decline, is not able to respond to verbal instructions, recognize danger, make basic care decisions, express need, or summon assistance; (4) the resident has a complex, unstable, or unpredictable medical condition; or (5) the resident has failed to make payment for charges.
Hawaii's rules do not specify who may be admitted and retained. Rather, each facility may use its professional judgment and the capacity and expertise of the staff to determine who it will serve. Facilities are required to develop their own admission and discharge policies and procedures. Discharge with 14 days notice is allowed based on behavior, needs that exceed the facility's ability to meet them, or a resident's established pattern of non-compliance.
Washington may accept and retain residents if: (1) they can meet the individual's needs, and provide required specialized training to resident-care staff; (2) the individual's health condition is stable and predictable, as determined jointly by the boarding home and the resident or the resident's representative if appropriate; and (3) the individual is ambulatory, unless the boarding home is approved by the Washington state director of fire protection to care for semi-ambulatory or non-ambulatory residents. Individuals must also meet all of the boarding home's established acceptance criteria.
Maine's rules are flexible to allow residents to age in place. The rules allow facilities to determine whom they will admit and the type of services they will provide. They may discharge residents who pose a direct threat to the health and safety of others, damage property, or whose continued occupancy would require modification of the essential nature of the program. Rules regarding the provision of nursing care vary by setting. Residential care facilities may provide nursing services with their own staff only to residents who do not meet the state's nursing home level of care criteria. Residents who meet the level of care criteria can be served, but nursing services must be provided by a licensed home health agency. Congregate housing programs may receive a license to provide nursing and medication administration services by registered nurses (RNs) employed by the program.
New Jersey's rules state that assisted living is not appropriate for people who are incapable of responding to their environment, expressing volition, interacting, or demonstrating independent activity. The rules allow facilities to provide a very high level of care, but they are not required to do so. The rules specifically state that facilities may choose to serve residents who:
- Require 24-hour, seven-day a week nursing supervision,
- Are bedridden longer than 14 days,
- Are consistently and totally dependent in four or more ADLs,
- Have cognitive decline that interferes with simple decisions,
- Require treatment of Stage III or IV pressure sores or multiple Stage II sores,
- Are a danger to self or others, or
- Have a medically unstable condition and/or special health problems.
The state also has a provision that can be characterized as a discharge trigger: facilities may not serve residents who require a respirator or mechanical ventilator or people with severe behavior management problems, such as combative, aggressive, or disruptive behaviors.
Vermont has two levels of licensure. One level--for assisted living--allows for a full continuum of care to be provided to residents who meet the nursing home level of care to be served if the facility can meet their needs except for the following conditions:
- A serious acute illness requiring medical, surgical, or nursing care provided by a general or special hospital;
- Care of Stage III or IV ulcers;
- Suctioning; or
- Two person assistance with transfer or ambulation.
Vermont's other level of licensure--for residential care facilities--allows the provision of personal care and nursing services. Facilities may retain current residents who develop a serious, acute illness as long as the care needs are met by appropriate licensed personnel. However, if the resident wanders, the facility must document appropriate interventions to manage this behavior. Residents may be discharged if they pose a serious threat to self or other residents and are not capable of entering into a negotiated risk agreement; are ordered by a court to move; or fail to pay rent, service, or care charges.
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