Assisted living: House Enrolled Act 1630 (1997)
Residential care facilities: 410 IAC 16.2-5 et seq.
General Approach and Recent Developments
Residential care facilities are licensed under the licensure category for health facilities. This licensure category also includes rules for comprehensive care facilities, commonly known as nursing homes. Disclosure documentation legislation for housing with services establishments was passed during the 1998 legislative session. This legislation is very broad, and includes many different types of licensed and unlicensed providers, including licensed residential care facilities. The purpose of the legislation was to require all licensed and unlicensed providers to complete a disclosure form on an annual basis and submit the form along with a copy of the resident contract to the Division of Disability, Aging and Rehabilitation Services. An establishment may not use the term “assisted living” if it has not filed a disclosure form. The form includes the following information: the name and address of the owner and managing agent, description of services provided and the base rate, additional services available and their fees, the resident’s designated representative, if any, referral procedures if the contract is terminated, the process for modifying and terminating the contract, description of the complaint resolution process, and criteria for determining who may continue to reside in the establishment. As of March 2004, approximately 300 housing with service establishments that may be called assisted living facilities have filed disclosure information.
Revised regulations for residential care facilities went into effect in March 2003. A separate Medicaid assisted living waiver was implemented in October 2001. The State recently received a 5-year waiver renewal. The number of slots requested was reduced from 2,250 to a maximum capacity of 400 in Year 5 due to provider capacity and budget projections.
|Residential care facilities||147||11,767||140||11,555||127||10,098|
|Housing with services establishments||300||NR||NR||NR||NR||NR|
Residential care facilities. A health facility that provides residential nursing care and administers medications prescribed by a physician must be licensed as a residential care facility. A facility that provides services such as room, meals, laundry, activities, housekeeping, and limited assistance in activities of daily living, without providing administration of medications or residential nursing care is not required to be licensed.
A housing with service establishment is defined as an establishment providing sleeping accommodations to at least five residents and offering or providing for a fee at least one regularly scheduled health-related service or at least two regularly scheduled supportive services, whether offered or provided directly by the establishment or by another person arranged for by the establishment. Health-related services mean home health services, attendant and personal care services, professional nursing services, and central storage and distribution of medications. Supportive services mean help with personal laundry, handling or assisting with personal funds, arranging for medical services, health related services, or social services.
Residential care facilities. Rules require 100 square feet for single rooms and 80 square feet per bed for multiple occupancy rooms. For facilities licensed after 1984, no more than four people may share a room. One toilet and sink is required for every eight residents in facilities licensed after 1984.
Residential care facilities may not admit or retain individuals who require 24-hour comprehensive nursing care. Facilities that retain appropriate professional staff may provide comprehensive nursing care to residents needing care for a self-limiting condition. Residents must be discharged if the resident is a danger to self or others, requires 24 hour a day comprehensive nursing care or comprehensive nursing oversight; requires less than 24 hour per day comprehensive nursing care, comprehensive nursing oversight, or rehabilitative therapies and has not entered into a contract with an appropriately licensed provider of the resident’s choice to provide those therapies, is not medically stable or meets two of the following three criteria unless the resident is medically-stable and the facility can meet the resident’s needs: (1) requires total assistance with eating; (2) requires total assistance with toileting; and (3) requires total assistance with transferring.
Housing with services establishments. The establishment must, in the disclosure form, indicate when a resident must be transferred because the establishment and the resident are unable to develop a means for assuring that the resident is able to respond to an emergency in a manner that is consistent with local fire and safety requirements and when the establishment is unable to assure that the resident’s physical, mental, and psychosocial needs can be met. Except as stated in the contract, residency in the housing with services establishment may not be terminated due to a change in a resident’s health or care needs. Except where the resident’s health or safety or the health or safety of others are endangered, an operator shall provide at least thirty (30) days notice to the resident or the resident’s designated representative before terminating the resident’s residency.
Nursing Home Admission Policy
Individuals are eligible if they have an unstable medical condition or three or more of 14 substantial medical conditions or ADL impairments. The list includes: supervision and direct assistance on a daily basis to ensure that prescribed medication is taken correctly; 24-hour supervision and/or direct assistance due to confusion; disorientation not related to a mental illness; inability to eat, transfer from bed or chair, change clothes, bathe, manage bladder and/or bowel functions or ambulate or use a wheelchair without direct assistance. The criteria allow a person with three ADLs or 2 ADLs and the need for medication assistance to receive waiver services.
Residential care facilities. Services offered to a resident must be appropriate to the scope, frequency, need and preference of the resident. Services must be reviewed and revised as appropriate and discussed with the resident as his or her needs change. If administration of medications and/or the provision of residential nursing services are needed, a licensed nurse must be involved in the determination and documentation of needed services. The administration of medications and the provision of residential nursing services must be ordered by a physician and supervised by a licensed nurse on the premises or on call.
The facility must provide activities programs appropriate to the ability and interests of the residents. Scheduled transportation must be provided or coordinated to community-based activities.
Each facility must determine whether it will administer medications or provide residential nursing services. This must be clearly stated in the admission agreement.
Residential nursing care may include, but is not limited to: identifying human responses to actual or potential health conditions, deriving a nursing diagnosis, executing a minor regimen based upon a nursing diagnosis or as prescribed by a physician, physician’s assistant, chiropractor, dentist, optometrist, podiatrist, or nurse practitioner, or administering, supervising, delegating, and evaluating nursing activities.
A minor regimen may include, but is not limited to: assistance with self-maintained ex-dwelling or indwelling catheter care for a chronic condition; prophylactic and palliative skin care; routine dressing that does not require packaging or irrigation; general maintenance care of ostomy; restorative nursing assistance; toileting care; routine blood glucose testing; enema and digital stool removal therapies; general maintenance care in connection with braces, splints, and plaster casts; observation of self-maintained prosthetic devices; administration of subcutaneous and intramuscular injections; metered dose inhalers, nebulizer/aerosol treatments self-administered by a resident, and routine administration of medical gases after a therapy regimen has been established.
Housing with services establishments. Except as stated in the contract and identified in the disclosure document, an operator may not restrict the ability of a resident to use a home health agency, home health provider, or case management service of the resident’s choice or require a resident to use home health services.
Residential care facilities. Facilities must make available three meals a day, seven days a week that provide a balanced distribution of the daily nutritional requirements. Facilities must meet daily dietary requirements and requests, with consideration of food allergies, reasonable religious, ethnic, and personal preferences, and temporary need for meals to be delivered to the resident’s room. All modified diets must be prescribed by a physician.
Housing with services establishments. Not specified
Residential care facilities. Some of the provisions typically included in resident agreements are contained in the section on resident rights. They include the right to receive (at the time of admission) a written notice of the basic daily or monthly rate; all facility services (including those offered on a need basis); information on related charges; and admission, readmission, and discharge policies. A 30-day notice of changes in rates or services is required.
An evaluation of the individual needs of each resident must be initiated before admission and must be updated at least semiannually or upon a significant change in condition. Subsequent evaluations must be used to compare against the baseline evaluation to assure that the care a resident requires is within the range of personal care and supervision provided by the facility. At a minimum the evaluation must include information on the resident’s physical and mental status, independence in activities of daily living, weight, and ability to self-administer medications.
Housing with services establishments. The disclosure document must be provided to a prospective resident or his or her legal guardian and made readily available at any time.
Provisions for Serving People with Dementia
Residential care facilities. Staff caring for residents in dementia-specific units must have a minimum of 6 hours of dementia-specific training within 6 months and 3 hours annually thereafter.
Housing with services establishments. Not specified.
Residential care facilities. Medications may be administered under physician’s order by licensed nursing personnel or qualified medication aides. Other treatments may be given by nurse aides upon delegation by licensed nursing personnel except for injectable medications which may be given only by licensed staff. The resident must be observed for effects of medications and documentation of undesirable effects is required, followed by notification of the resident’s physician.
Residents who self-medicate may keep and use prescription and non-prescription medications in their unit as long as they are kept secure.
Assisted living. Services are covered under an HCBS waiver. The waiver renewal was approved to serve 186 beneficiaries in the first year, 282 in Year 2, 330 in Year 3, 359 in Year 4, and 400 in Year 5. Currently, 14 facilities have been approved for the waiver program and 71 beneficiaries are being served. Provider and client participation has not expanded as quickly as the State initially projected due to start up delays, and difficulty recruiting providers. Licensed facilities must meet additional requirements for private bedrooms and baths, and a number of additional service requirements. Existing unlicensed assisted living facilities that have submitted a disclosure form and are considered housing with services establishments and meet the waiver program requirements have not expressed an interest in becoming waiver providers because they would need to become licensed, and would need to serve a much higher acuity population than desired.
Medicaid contracting requirements provide for private apartments, shared only by choice, square footage, meal preparation, temperature controls, and door locks that differ from the licensing rules. A three-tiered payment system has been developed based on points from the assessment process (see table below). The rates do not include room and board. The SSI payment maximum is currently $564 (less a $52 personal needs allowance). The State has not issued a policy on family supplementation. The waiver uses the definition and covered services included in the HCBS waiver preprinted format: case management, RN oversight, personal care, homemaker, chore, attendant care, companion, medication oversight, and therapeutic and recreational programming.
The Residential Care Assistance Program is a state-funded program that covers limited services for residents who are aged, blind, mentally ill or disabled, low income, and/or cannot live alone but do not qualify for nursing home care. Payments are based on a flat rate. County home (housing with services establishments) rates are $27 per day for room, board, laundry, housekeeping, and limited oversight. Private residential care facility rates are $39.35 per day. Nineteen county homes and 42 RCFs served 418 county home residents and 1,121 people in private residential care facilities respectively as of March 2004.
|Level 1: (<36 points)||$45.86|
|Level 2: (36-60 points)||$53.78|
|Level 3: (61-75 points)||$61.68|
Residential care facilities. Each facility must have one administrator who is responsible for the overall administration of the facility. Staff shall be sufficient in number, qualifications and training to meet the 24-hour scheduled and unscheduled needs of the residents and services provided. A minimum of one awake staff person, with CPR and first aid certificates, must be on duty at all times. If 50 or more residents require nursing services and/or administration of medication, at least one nursing staff person must be on staff at all times. For facilities with 100 or more residents requiring nursing services and/or administration of medication, at least one awake staff person must be on duty at all times, with an additional staff person required for every additional 50 residents.
A consultant pharmacist must be employed or under contract. The facility must designate an activities director who is a recreational therapist, an occupational therapist or a certified occupational therapist assistant, or someone who will complete, within 1 year, an activities director training course approved by the State.
Housing with services establishments. Not specified.
Residential care facilities. Administrators must be licensed.
Staff (residential care facilities). Prior to working independently, each employee shall be given an orientation of the facility by the supervisor. Orientation of all employees shall include:
- Instructions on the needs of the specialized populations served in the facility;
- A review of the facility’s policy manual and applicable procedures including organizational chart, personnel policies, appearance and grooming, and resident rights;
- Instructions in first aid, emergency procedures, and fire and disaster preparedness, including evacuation procedures;
- A detailed review of the appropriate job description, including a demonstration of equipment and procedures required of the specific position to which the employee will be assigned;
- Review of ethical considerations and confidentiality in resident care and records;
- For direct care staff, personal introduction to and instruction in the particular needs of each resident to whom the employee will be providing care; and
- Documentation of orientation in the employee’s personnel record.
Ongoing training must include resident’s rights, prevention and control of infection, fire prevention, safety, and accident prevention, the needs of specialized populations served, medication administration, and nursing care. For nursing personnel, training must include at least 8 hours of in-service per calendar year and 4 hours of training for nonnursing personnel.
Any unlicensed employee providing more than limited assistance with activities of daily living must be either a certified nurse aide or home health aide.
Residential care facilities. Annual surveys are conducted by the Department of Health.
Housing with services establishments. The State may impose financial penalties for violations of the disclosure requirement. A housing with services establishment may request a review of the penalty. If the State determines that an establishment has had substantial and repeated violations, the State may prohibit an establishment from using the term “assisted living” to describe the establishment’s services and operations to the public. If the State determines that the establishment has made intentional violations of the disclosure requirement or has made fraudulent and material misrepresentatives to a resident, the State may request the attorney general to investigate and take appropriate action against the operator or administrator.
Licensure fees are collected annually: $200 for the first 50 beds and each additional bed is $10.
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