Residential or Assisted Living Facilities; Idaho Administrative Rules IDAPA 16, Title 03, Chapter 22
General Approach and Recent Developments
The title and scope of the regulations describes the philosophy that includes a humane, safe and home-like arrangement, a negotiated service agreement and the development of facilities that are tailored to meet the needs of individual populations that operate in integrated settings in communities where sufficient supportive services exist to give residents opportunities to participate in community activities and opportunities. Extensive changes made to the State’s regulations were effective in 2000. The State added coverage under the Medicaid state plan and the HCBS waiver during 2000.
Minor changes to the regulations were made in May 2003, including a changing of the name of the regulations from Residential and Assisted Living Facilities to Residential or Assisted Living Facilities, the addition of language concerning “authorized providers,” and a new definition for “substantial compliance.” The State is currently in the process of restructuring the assisted living program, reviewing the statute, rules, and the survey process. Draft rules are expected to be available in July 2004.
|Residential care or assisted living||266||6,193||253||5,815||226||5,185|
Residential or assisted living facility means one or more buildings constituting a facility or residence, however named, operated on either a profit or nonprofit basis, for the purpose of providing 24-hour care for three or more adults who need personal care or assistance and supervision essential for sustaining activities of daily living or for the protection of the individual.
Specialized care units/facilities for Alzheimer’s and dementia residents “are specifically designed, dedicated, and operated to provide the elderly individual with chronic confusion, or dementing illness, or both, with the maximum potential to reside in an unrestrictive environment through the provision of a supervised life-style which is safe, secure, structured but flexible, stress-free and encourages physical activity through a well developed activity and recreational program. The program constantly strives to enable residents to maintain the highest practicable physical, mental, or psychosocial well-being.”
Facilities licensed after July 1, 1992, must not have more than two residents in each bedroom and provide 100 square feet of floor space per single-bed room and 80 square feet per resident in multi-bed rooms. There must be at least one toilet for every six persons, residents, or employees, and at least one tub or shower for every eight persons, residents, or employees. New construction must meet the requirements of the Americans with Disabilities Act Accessibility Guidelines. Existing facilities must remove as many barriers as possible without creating an undue burden on the facility.
Facilities are licensed by the level of care provided: minimal assistance, moderate assistance, and maximum assistance (see table).
|Resident requires room, board, and supervision, and may require only minimal assistance with ADLs or non-medical personal assistance or minimal assistance with mobility (independently mobile), is capable of self-preservation, or does not require medication management or supervision or minimal behavior management.||Resident requires room, board, and supervision, and may require moderate assistance with ADLs or non-medical personal assistance or moderate assistance with mobility or self-preservation or medication management or behavior management.||Resident requires room, board, supervision, and 24-hour awake staff and may require extensive assistance with ADLs or personal assistance or mobility (may be non-mobile without assistance) or assistance in an emergency (may be incapable of evacuation without assistance) or medications or assistance with training or behavior management.|
Residents may not be admitted or retained if they require ongoing skilled nursing, intermediate care, or care that is not within the legally licensed authority of the facility unless there are specialized facility provisional agreements that allow for skilled nursing or intermediate care. Residents who require ongoing highly technical skilled nursing services may not be served. Residents who require 24-hour skilled nursing; have pressure ulcers or open wounds that are not healing; draining wounds; have needs beyond the fire safety rating of the facility or whose physical, emotional, or social needs are not compatible with the other residents may not be served. Residents may not be admitted without a written physician’s order, authorized provider, or Department, or if the resident places the facility over its licensed bed capacity.
Facilities may request a waiver to serve people if they show good cause for granting the waiver, describe the extenuating circumstances and any compensating factors such as additional floor space or staffing that have a bearing on the waiver.
Facilities are required to ask if the resident has an advance directive, and they may assist residents in developing advance directives.
Nursing Home Admission Policy
The assessment areas are divided into critical, high, and medium indicators. To qualify for nursing home admission, applicants must have one or more critical indicators; two or more high indicators; one high and two medium indicators; or four or more medium indicators. The indicators are presented below.
|Indicators||Level of Need|
(one or more)
(two or more; or one high and two medium)
(four or more)
Services include assistance with activities of daily living, arrangements for medical and dental services, provisions for trips to social functions, recreational activities, maintenance of self-help skills, special diets, arrangement for payments, and medication management. A licensed nurse must visit the facility at least once a month to conduct a nursing assessment of each resident’s response to medications and to assure that the medication orders are current. The nurse also assesses the health status of each resident and makes recommendations to the administrator regarding any needs.
A uniform assessment and a negotiated service agreement must be used with residents. The agreement covers the assessment, service needs, need for limited nursing, need for medication assistance, frequency of needed services, level of assistance, habilitation/training needs, behavioral management needs, physician signed and dated orders, admission records, community support systems, resident desires, transfer/discharge, and other items.
Larger facilities (>16 beds) must have written policies covering job descriptions and personnel responsibilities. Menu must reflect current recommended dietary allowances; as well as include foods commonly served within the community; seasonal food selections and residents’ food habits, preferences, and physical abilities. Menus must be reviewed, signed, and dated by a dietician, nutritionist, or home economist to ensure that current RDAs are met. Physicians’ orders must be received for therapeutic or modified diets.
Agreements must be signed prior to or on the date of admission. The agreements cover: services provided; whether or not the resident will be responsible for his or her own medication; whether the facility is responsible for personal funds; handling of a partial month’s refund; responsibility for valuables; 15- or 30-day written notice of transfer or discharge; conditions for emergency transfers; permission to transfer pertinent information; resident’s responsibilities; and other items. The agreement may be integrated with the negotiated service agreement provided all requirements for both are met.
An agreement may not be terminated except under the following conditions: a 15 day written notice; the resident’s physical or mental condition deteriorates to a level where the facility can no longer provide care; nonpayment; for the protection of the resident or other residents from harm; and other conditions.
Provisions for Serving People with Dementia
Services in specialized care units for Alzheimer’s disease include habilitation services, activity program, and behavior management according to the individualized negotiated service agreement. Residents of specialized care units for Alzheimer’s disease must be evaluated by their primary care physician for the appropriateness of placement in the unlocked specialized care unit/facility prior to admission. No resident shall be admitted to these units without a diagnosis of Alzheimer’s disease or related disorder. Residents must be at a stage in their disease such that only periodic professional observation and evaluation is required. Residents in these units must be re-evaluated quarterly. No resident shall be admitted who requires physical or chemical restraints. Staff must have an additional 6 hours of training in addition to orientation, and must have an additional 2 hours of continuing education annually beyond the required 8 hours dedicated to the provision of services to people with Alzheimer’s disease or other dementias.
Facilities have to describe the population served; the philosophy, objectives, and beliefs upon which decisions will be made; admission and discharge criteria; security systems; staffing pattern; plan for specialized training; and the program and social activities.
Licensed nurses may fill medi-sets for residents. Aides who have passed required training may administer medications. The requirements are specified by the Board of Nursing.
Problems with medication administration occur frequently. Common problems include failure to follow doctors’ orders, failure to get medications from the pharmacy, and an unclear line between medication assistance and medication administration.
Personal care in assisted living was added as a state plan service in 2000. Services under a Medicaid HCBS waiver using the waiver application definition and including medication administration and assistance with personal finances was implemented in 1999. Elders, people with disabilities, and people with mental retardation, traumatic brain injuries, or developmental disabilities are eligible. Coverage was phased in across the State. The HCBS aged and disabled waiver program now serves 1,714 residents living in residential or assisted living facilities. Individuals are eligible for the waiver using the 300 percent SSI eligibility criteria. There are two programs covering services for individuals living in residential or assisting living facilities:
State plan services are available to individuals who require no more than 16 hours of personal care services per week. Individuals must meet state income limits for financial eligibility. The service payment is currently $13.40/hour. The amount of payment a facility receives is based upon the number of hours a resident’s plan of care requires. The resident is responsible for paying for room and board. The State’s suggested limit is $497 per month; however the facility may charge the resident more. Family supplementation is allowed. Any money remaining after paying for room and board is retained as a personal needs allowance.
HCBS waiver payments are capped at the average per capita nursing home cost and individual payments are based on a care plan. The facility can charge whatever it wants for room and board however the State’s suggested rate is $497 per month for rent, utilities, and food. The individual SSI payment rate for individuals residing in residential facilities is currently $564. Any monies remaining after payment of room is board is retained as the personal needs allowance.
State supplementation to the SSI program has been phased out. In 2002, the Legislature directed the transition of individuals who were receiving the supplemental grant to the Medicaid state plan. Supplementation for the room-and-board payment is allowed in all categories. A uniform assessment instrument is used to determine the unmet ADL needs for all applicants. The unmet needs are converted to a payment that is available to the beneficiary regardless of where he or she lives: in assisted living or their own home or apartment. The process was developed to eliminate differences in payment and service delivery depending on where a person lived.
Facilities must have sufficient staff to serve residents in keeping with negotiated service plans. At least one staff member must be immediately available to residents at all times. Facilities admitting Level III residents or a combination of Level I, II, or III residents must have a minimum of one awake staff during sleeping hours. Waivers may be sought by small facilities. A full-time administrator must devote no less than 20 hours per week to the day-to-day administrative duties.
Administrators must have a valid residential care administrator’s license. Personnel must be given an orientation to the facility and participate in a continuing training program developed by the facility.
Staff. Each facility shall develop and follow a structured written orientation program for a minimum of 8 hours. Continuing training: staff providing personal assistance must receive a minimum of 8 hours of training a year. Evidence of the completed training and topics are kept on file. Staff, including housekeeping personnel and contract personnel must be trained in Universal Precautions.
Staff in specialized care units for Alzheimer’s/dementia residents must have an additional 6 hours of orientation covering information on Alzheimer’s and dementia, symptoms and behaviors of memory impaired people, communication with memory impaired people, resident’s adjustment, inappropriate and problem behavior of residents and appropriate staff response, activities of daily living for special care unit residents, and stress reduction for special care unit staff and residents. Staff must have an additional 2 hours of continuing education, beyond the required 8 hours of continuing training, on the provision of services to persons with Alzheimer’s disease.
Applicants for licensure must submit a criminal history clearance as described in IDHW rules Title 05, Chapter 06 which is repeated every 3 years. The rules include finger printing, FBI, National Criminal History Background Check System, state registries and Medicaid sanctions lists. Individuals pay $34 for the cost of the check which must be updated every 5 years.
With the exception of the initial surveys for licensure, all inspections and investigations shall be made unannounced and without prior notice. Inspections are conducted at least annually. Inspections entail reviews of the quality of care and service delivery, resident records, and other items relating to the running of the facility. If deficiencies are found, then plans of correction are made and follow-up surveys are conducted to determine if corrections have been made. Complaints against the facility are investigated by the licensing agency. A complainant’s name or identifying characteristics may not be made public unless “the complainant consents in writing to the disclosure; the investigation results in a judicial proceeding and disclosure is ordered by the court; or the disclosure is essential to the investigation. The complainant shall be given the opportunity to withdraw the complaint before disclosure.”
Inspections of specialized care units for Alzheimer’s disease are conducted by the licensing agency with participation from the Regional Department staff who have program knowledge of and experience with the type of residents to be served and the proposed program offered by the facility. Facilities that are specialized or have specialized care units must submit a synopsis of the program of care to be offered by the unit/facility.
Enforcement options include ban on admissions, ban on residents with certain diagnosis, civil monetary penalties, appointment of temporary management, suspension or revocation of the license, transfer of residents, issuing a provisional license and other remedies. Facilities operating without a license may be subject to six months in jail and fines up to $5,000.
Historically, the State has reported that the consultative process used during the monitoring process has positively impacted overall quality of care and compliance. Typically, surveyors would be able to provide input and suggestions to problems that were identified, and providers welcomed this feedback. In recent years, due to a shortage of staff, the State is working hard just to keep up with the surveys they are required to do. As a result, they do not have the time to provide feedback and suggestions to providers during the survey process. They also do not have the staff to go back and determine whether corrections have been made.
$500 for a building evaluation.
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