Assisted living/Residential Health Care Facilities: KAR §28-39-144-148, KAR 28-39-240-256
General Approach and Recent Developments
Licensing rules were last amended in October 1999 and the recent focus has been on monitoring, training and improving outcomes. The law created an overall framework of adult care homes which includes nursing facilities, nursing facility for mental health, intermediate care facility for the mentally retarded, assisted living facility, residential health care facility, home plus, boarding care home, and adult day care facility. The regulations differentiate among the categories of adult care homes.
Responsibility for regulating assisted living facilities has been transferred from the Department of Health and Environment to the Department on Aging. A Money Follows the Person pilot program began in 2003 to support the service costs for people who move from a nursing home to a community setting.
|Assisted living facilities||191||7,971||129||5,658||80||4,521|
|Residential health care facilities||98||2,918||43||2,355|
Assisted living facility means any place or facility caring for six or more individuals not related within the third degree of relationship to the administrator, operator, or owner by blood or marriage and who, by choice or due to functional impairments, may need personal care and may need supervised nursing care to compensate for activities of daily living limitations and in which the place or facility includes apartments for residents and provides or coordinates a range of services including personal care or supervised nursing care available 24-hours a day, seven days a week for the support of resident independence. The provision of skilled nursing procedures to a resident in an assisted living facility is not prohibited by this act. Generally, the skilled services provided in an assisted living facility shall be provided on an intermittent or limited term basis, or, if limited in scope, on a regular basis.
The rules provide that the administrator or operator of facilities ensure that written policies and procedures are developed and implemented which incorporate the principles of individuality, autonomy, dignity, choice, privacy, and a home-like environment.
Each facility must offer apartments which include areas for sleeping, living, storage, kitchen (with sink, refrigerator, stove or microwave, and space for storage of utensils and supplies), and bathroom. They must also offer at least 200 square feet of living space, excluding bathroom, closets, lockers, wardrobes, other built-in fixed items, alcoves, and vestibules. Facilities licensed prior to January 1, 1995, as an intermediate personal care facility, are not required to offer kitchens and private baths.
Residential health care facilities are required to have individual living units with at least 100 square feet of living space and a private toilet room with a bathing facility.
Each facility develops admission, transfer, and discharge policies which protect the rights of residents. Facilities may not admit or retain people with the following conditions unless the negotiated service agreement includes hospice or family support services which are available 24 hours a day or similar resources:
- Incontinence where the resident cannot or will not participate in management of the problem;
- Immobility requiring total assistance in exiting the building;
- Any ongoing condition requiring two-person transfer;
- Any ongoing skilled nursing intervention needed 24 hours a day for an extended period of time; or
- Any behavioral symptom that exceeds manageability.
Nursing Home Admission Policy
A Standard Client Assessment Referral Evaluation (CARE) is used to assess impairments in ADLs and IADLs and risk. ADLs and IADLs are weighted. ADLs: dressing and mobility (3); bathing and eating (4); toileting and transfer (5). IADLs: meal preparation and medical management (5); money management (4); and shopping, transportation, telephone use, laundry, and housekeeping (3). The weightings are multiplied by a factor based on the need for no assistance (0); physical assistance or supervision (1), and unable to perform (3). Risk factors include: bladder incontinence (5), risk of abuse, neglect, or exploitation by others (5), falls (3), lack of support (4), and impaired cognition (4).
To be eligible, applicants must have a minimum of two ADLs with minimum combined weight of six; impairments in a minimum of three IADLs with a minimum combined weight of nine; and a total minimum score of 26, or a minimum score of 26 with at least 12 points in IADL impairments and the remaining 14 in any combination of IADL, ADL, and risk factor points.
Services may include meals; health care services based on an assessment by a licensed nurse; housekeeping; medical, dental, and social transportation; and other services necessary to support the health and safety of the resident. Health care services include personal care, supervised nursing care, and wellness and health monitoring. The service agreement contains the skilled nursing services to be provided and the licensed person or agency providing services.
The Medicaid waiver includes assisted living facilities as a provider of respite and health care attendant services. The services covered by the waiver include respite care, sleep cycle support, health care attendant (Level I and Level II), adult day care, and wellness monitoring. Sleep cycle support means “non-nursing physical assistance and supervision during the consumer’s normal sleeping hours in the consumer’s place of residence, excluding nursing facilities” and includes “physical assistance or supervision with toileting, transferring and mobility, prompting and reminding of medication.”
Health care attendant “provides physical assistance with activities of daily living and instrumental activities of daily living for individuals who are unable to perform one or more activities independently.” IADLs, excluding medication management or medication administration, may be performed without nurse supervision. These services are limited to 12 hours a day.
Level I activities include assistance with ADLs and IADLs (bathing, grooming, toileting, transferring, feeding, mobility, accompanying to obtain necessary medical services, shopping, house cleaning, meal preparation, laundry, and life management).
Level II activities are health maintenance activities and include monitoring vital signs, supervision and/or training of nursing procedures, ostomy care, catheter care, enteral nutrition, medication administration/assistance, wound care, range of motion, and reporting changes in function or condition. These services must be authorized by a physician or a nurse.
A dietetic services supervisor or licensed dietician must provide scheduled on-site supervision in facilities with 11 or more residents. Therapeutic diets are provided if included in the negotiated service agreement, based on instructions from a physician or licensed dietician. Menus must be planned based on the dietary guidelines for Americans, 4th edition, published by USDA and DHHS.
Facilities must develop a negotiated service agreement with each resident in collaboration with the resident, the resident’s legal representative, family (if agreed to by the resident), or case manager. The agreement describes the services to be provided, the provider of service, and the parties responsible for payment when services are provided by an outside agency. The agreement supports the dignity, privacy, choice, individuality, and autonomy of the resident. The agreement is reviewed at least annually or when requested by any of the participating parties. The agreements also address services that are refused by the resident; the potential negative consequences; and the resident’s acceptance of the risks involved.
Provisions for Serving People with Dementia
People with special needs may be served if the facility has admission and discharge criteria that identify the diagnosis, behavior, or specific clinical needs of the residents to be served. A written physician’s order is required for admission. Prior to admission, the resident or their legal representative must be informed of the services and programs available. Staff must complete training on the needs of the residents to be served. Exits must be controlled in the least restrictive possible manner.
A drug regimen review conducted by a pharmacist is required for residents who receive assistance with medication administration or whose medications are administered by facility staff. Medication aides may administer oral and topical medications and assist with medication administration. Medication reminding may be performed by a licensed nurse, medication aide, or nurse aide. Medication reminding includes asking if the medication has been taken, handing the medication to the resident, and opening the container. Medication reminding does not include taking the medication out of the container.
A “Money Follows the Person” pilot program began in 2003. Using available HCBS waiver slots for 75 nursing residents, the State uses funds from the nursing home appropriation to pay for services in the community, many of whom are moving to assisted living facilities.
Medicaid waiver services have been available since 1997 to elderly recipients who meet the nursing home level of care criteria and have income below 300 percent of the federal SSI payment. The room-and-board amount is negotiated between the facility and the resident but the amount of income that may be retained by the resident is limited to $716 a month, which is the maintenance allowance. SSI beneficiaries retain a $30 personal needs allowance.
The State uses a “care plan” method for paying for services. The care plan is developed by a case manager in the Area Agency on Aging. Services are billed fee for service. The maximum rate for health care attendant services is $3.18 per unit (15 minutes) for Level I tasks and $3.52 per unit for Level II tasks. Plans requiring a mix of both levels are reimbursed at the Level II rate. Family members may supplement resident income for room and board costs.
Sufficient numbers of qualified personnel must be available to ensure that residents receive services in accordance with negotiated service agreements.
Administrator. The licensee shall appoint an administrator or operator who holds a Kansas license as an adult care home administrator or has successfully completed an operator training program as designated by the secretary. The hours of training for operators was increased from 24 to 32 to spend more time on regulatory requirements and nursing issues.
Staff. Facilities shall provide orientation to new employees and regular in-service training for all employees to ensure that services provided assist residents to attain and maintain their individuality, autonomy, dignity, independence, and ability to make choices in a home-like environment.
In-service education must include: principles of assisted living; fire prevention and safety; disaster procedures; accident prevention; resident rights; infection control; and prevention of abuse, neglect, or exploitation of residents.
In-service education on treatment of behavioral symptoms shall be provided to all employees of facilities that admit residents with dementia.
Surveyors inspect every facility annually. Consistent enforcement of the regulations has been credited with improved compliance and fewer complaints. Deficiencies are written more concisely with a focus on the consumer and outcomes. Under a new survey process, facility staff accompany the surveyor during the review. Problem areas are identified and discussed with the staff. Educational efforts have been increased. The licensing agency conducts regular one-day training courses for nurses, owners and operators on the role of nursing in assisted living, how to conduct an assessment and develop a service plan, managing medications and the nurse practice act. During the training, scenarios are presented and participants prepare a care plan based on the information presented.
$50, plus $15 for each resident.
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