State Residential Care and Assisted Living Policy: 2004. Michigan

03/31/2005

Citation

Homes for the aged: Michigan Comp. Law §333.20106(3); 333.21301 et seq.; Michigan administrative code R.325.1801 et seq.
Adult foster care: 400.701 et seq.
Adult foster care: Family homes (6 or less residents) R400.1401 et seq.
Adult foster care: Small group homes R400.14101
Adult foster care: Large group homes R400.15101 et seq.

General Approach and Recent Developments

The State licenses several types and levels of residential care and work continues on updating rules for homes for the aged. A public hearing was held in November 2003. Modifications were based on testimony received during public hearings. Recommended changes were submitted to a legislative committee for review and approval before they are promulgated. House Bill H4322, enacted in 2001, requires coverage of assisted living by long-term-care insurance policies. There has been a prohibition of new adult foster homes-congregate homes since the 1980s. There are only 13 adult foster care facilities remaining across the State that are licensed for 20+ residents. The trend in Michigan is away from large institutional-like settings.

Medicaid personal care coverage is available to beneficiaries in adult foster care and homes for the aged. Waiver services are available to beneficiaries living in housing that may be operated as an unlicensed facility, that is, a facility or building that does not provide personal care services and therefore not required to be licensed. Since these unlicensed settings are considered a person’s home, services can be received from providers of one’s choice.

Supply
  Category   2004 2002 2000
Facilities Units Facilities Units Facilities Units
Adult foster care--family homes 1,247 5,825 4,353 33,317 1,361 6,271
Adult foster care--small group homes 2,527 17,610 1,904 10,760
Adult foster care--large group homes 485 9,001 454 8,380
Adult foster care--congregate homes   13 491 NR NR NR NR
Homes for the aged 190 14,588 188 14,500 NR NR

Definition

Homes for the aged means a supervised personal care facility, other than a hotel, adult foster care facility, hospital, nursing home, or county medical care facility, that provides room, board, and supervised personal care to 21 or more unrelated, nontransient individuals 60 years of age or older. Home for the aged includes a supervised personal care facility for 20 or fewer individuals 60 years of age or older if the facility is operated in conjunction with and as a distinct part of a licensed nursing home.

Adult foster homes. There are four levels of adult foster homes:

  • Adult foster care family homes serve 6 or fewer residents and the licensee must reside in the home;
  • Adult foster care small group homes serve between 1 and 12 residents;
  • Adult foster care large group homes serve between 13 and 20 residents; and
  • Adult foster care congregate care homes serve 21 or more residents.

An adult foster care facility is a governmental or non-governmental establishment that provides foster care to adults. Adult foster care facilities include small and large group homes, adult foster care family homes and congregate homes that serve residents who are aged, mentally ill, developmentally disabled, or physically handicapped and require supervision on an ongoing basis but who do not require continuous nursing care. Adult foster homes in good compliance may apply for a certification for specialized programs for the mentally ill, developmentally disabled, or both populations. This certification is required in order to contract with community mental health agencies.

Unit Requirements

Homes for the aged. Homes constructed, converted or expanded after 1981 must provide 100 square feet of usable space for single rooms and 80 square feet per resident in shared rooms. Rooms may not be shared by more than four people. Homes licensed prior to 1981 must offer at least 80 square feet of usable floor space for single rooms while shared rooms must provide 70 square feet per resident. The regulations do not limit the number of residents that may share a room if licensed prior to 1981. Toilet facilities are required for every eight residents per floor and bathing facilities for every 15 residents.

Adult foster homes. A single bedroom must have at least 80 square feet of usable floor space; a multi-bed room must have at least 65 square feet of usable floor space per bed. A maximum of two beds are allowed per bedroom unless the facility has been continuously licensed since the effective date of the rules and unless the resident (or the resident’s representative) has agreed to reside in the multi-occupancy room, the home is in compliance with all state fire safety and environmental standards, and the bedroom provides no less than 70 square feet (65 square feet for homes licensed on or before December 31, 1976) of usable floor space per bed.

Admission/Retention Policy

Homes for the aged. Residents requiring nursing care cannot be admitted. After admission, residents requiring 24-hour nursing care or intensive nursing care may not be retained. However, an amendment to the statute in 2002 allows for the retention of residents whose condition changes after moving into the home, with the approval of the resident, resident’s family, resident’s physician, and the facility’s governing board, as long as the facility assures the care the resident needs can be provided. Physicians must certify that new residents are free from communicable diseases. Residents with a mental condition disturbing to others may not be admitted or retained.

Adult foster homes may not accept, retain, or care for residents who require continuous nursing care. This does not preclude the accommodation of a resident who becomes temporarily ill while in the home but does not require continuous nursing care, or a resident who becomes a patient of a licensed hospice program. All residents must be assessed by the facility to determine the amount and type of services required by the resident are available at the facility. Facilities may not accept or retain residents who require isolation or restraint.

Nursing Home Admission Policy

The criteria were revised in 2004. The state has adopted a system that uses seven “doors” to eligibility (see table).

Services

Homes for the aged provide necessary assistance with personal care, including care of the skin, mouth and teeth, hands and feet, and the shampooing and grooming of hair. The rules require that residents wash their hands before meals and receive a bath or shower at least once a week.

Services in adult foster homes include supervision, protection, personal care, medication administration, social activities, and assistance with activities of daily living. Homes must arrange for transportation services.

For adult foster care homes, personal care means personal assistance provided by a licensee or an agent or employee of a licensee to a resident who requires assistance with dressing, personal hygiene, grooming, maintenance of medication schedule as directed and supervised by the resident’s physician, or the development of those personal and social skills required to live in the least restricted environment.

Michigan Level of Care Criteria
Door Areas Scored Threshold
1. ADLs (A) Bed mobility, transfers, toilet use and
(B) eating
Score of 6:
(A) independent or supervision, 1; limited assistance, 3; extensive or total, 4; did not occur, 8.
(B) independent/supervision, 1; limited assistance, 2; extensive or total, 3; did not occur, 8
2. Cognitive performance Short-term memory, cognitive skills for daily decision making, communication Must have severely impaired decision making, memory problems and moderate or severely impaired decision making, or memory problem and sometimes or rarely understood
3. Physician involvement Under care for an unstable medical condition Based on frequency of physician visits and orders
4. Treatments and conditions Stage 3-4 pressure sores; intravenous or parenteral feedings; intravenous medications; end-stage care; daily trach care, respiratory care, or suctioning; pneumonia; daily oxygen therapy; daily insulin with two order changes in past 14 days; peritoneal or hemodialysis At least one of nine conditions
5. Skilled rehabilitation therapies   Speech, occupational, or physical therapy Requires at least 45 minutes of active therapy in last 7 days and continues to require therapy
6. Behavior Wandering, physical/verbal abuse, socially inappropriate/disruptive, resists care, delusions/hallucinations Either has delusions/hallucinations or exhibits other behaviors at least 4 of last 7 days
7. Service dependency Currently receiving services in a NF or waiver program Must be a participant for 1 year

Dietary

Adult foster care. Administrators and/or licensees must have competency in nutrition. Homes serving seven or more residents must have a specific staff person who is experienced in food preparation by education or experience. Three nutritious meals must be provided according to the recommended daily allowances contained in the Basic Nutrition Facts: A Nutrition Reference published by the Michigan Department of Health. Special diets must be provided when prescribed by a physician.

Homes for the aged. Three meals a day and snacks that meet the recommended dietary allowances are required. Fluid, supplementary nourishments and special diets ordered by a physician must be provided.

Agreements

Adult foster care. The agreement includes: assurance of the provision of care, supervision, and protection; description of the services provided and the fee; costs in addition to the basic fee; description of the transportation services provided and the fee; agreement by the resident/family to provide necessary intake information; agreement to provide a current health care appraisal; agreement to follow house rules; to respect and safeguard resident’s rights and to provide a written copy; discharge policy and procedures; refund policy; statement of how funds and valuables are handled; and a statement that the home is licensed to provide care.

Homes for the aged. Not specified.

Provisions for Serving People with Dementia

Regulations cover admission-retention and staff training. Facilities serving people with dementia must disclose the services that are available.

Medication Administration

Trained aides may administer medications.

Public Financing

Medicaid personal care coverage has been available since 1983 through the state plan. Over time, the number of licensed adult foster home facilities serving Medicaid beneficiaries has dropped from 80 percent to 20 percent, due both to the rise in the number of private pay only facilities and the payment rate compared to private rates which may not be supplemented. Personal care services are provided to approximately 14,138 residents living in adult homes for the aged and adult foster care. Adult foster homes receive $174.38 a month in Medicaid personal care funds. Adult foster care residents receive $721.50 from SSI and the state supplementfrom which $44 a month personal needs allowance is paid to the facility. Homes for the aged residents receive $743.30 from SSI and the state supplement, from which $44 a month personal needs allowance is paid to the facility.

Medicaid Participation
2004 2002 2000
Facilities Participation Facilities Participation Facilities Participation
NA 14,138 NA 13,000 NR NR

Eligible beneficiaries may receive Medicaid waiver services in unlicensed assisted living facilities and elderly housing buildings. Participation data is not tracked separately for persons in unlicensed facilities.

Staffing

Homes for the aged. The governing body shall appoint a competent administrator and shall delegate the responsibility for operating the home. An administrator and all other persons in supervisory positions shall be at least 21 years of age. An administrator designates a competent person at least 21 years old to carry out the responsibilities and duties of the administrator in his or her absence. A sufficient number of attendants are required for each shift to assist residents with personal care under direction from a supervisor.

Adult foster homes. The ratio of direct care staff in facilities housing between 13 and 20 residents must be no less than one staff to 15 residents during waking hours and one staff to 20 residents during normal sleeping hours. The ratio for facilities for 12 or fewer residents must be no less than one staff per 12 residents. In all facilities, there must be sufficient direct care staff on duty at all times for the supervision, personal care, and protection of residents and to provide the services specified in the resident’s care agreement and assessment plan. Direct care staff must be at least 18 years old.

Training

Homes for the aged. A licensee or administrator shall provide in-service training or make training available through other sources to direct care staff. Direct care staff shall be competent before performing assigned tasks.

In adult foster homes, administrators must have at least one year of experience working with persons who are mentally ill, developmentally disabled, physically handicapped, or aged. Both the licensee of the home and the administrator must complete either 16 hours of training approved by the Michigan Family Independence Agency or 6 credit hours at an accredited college or university in content areas that are relevant to the licensee’s admission policy and program statements as approved by the Family Independence Agency. The licensee or administrator must provide in-service training or make training available through other sources for direct care staff in the following areas: reporting requirements, first aid, CPR, personal care, supervision, protection, resident rights, safety and fire prevention, and prevention and containment of communicable disease.

Adult foster homes (large group homes). Before a license is issued, an applicant and an administrator shall be competent in all of the following areas: nutrition; first aid; CPR; foster care; safety and fire prevention; financial and administrative management; needs of the population to be served; resident rights; and prevention and containment of communicable diseases. Direct care staff shall be competent before performing assigned tasks which shall include being competent in all of the areas detailed above for adult foster homes. A licensee, administrator, or direct care staff must be trained in the proper handling and administration of medication before supervising the taking of medication by a resident.

Background Check

Homes for the aged. As of September 2002, shall not employ, independently contract with, or grant clinical privileges to an individual who regularly provides direct services to patients or residents in a facility who has been convicted of a felony, and a list of other crimes. Each facility must conduct a criminal background check before hiring any staff.

Adult foster care. Criminal background checks are completed on licensees, administrators, and non-employee adult members of the household. Currently, it is the licensee’s responsibility to determine the good moral character of his/her employees. A statute requiring criminal background checks on newly hired adult foster care employees was signed into law in April 2004 but will not be effective until August 2004. Large group homes must submit to the licensing agency the name of any employee or volunteer who is on a court-supervised probation or parole or who has been convicted of a felony.

Monitoring

Adult foster care homes are inspected by the Family Independence Agency, Department of Labor and Economic Growth for fire safety inspections, or a local health department at the request of the Family Independence Agency. Homes for the aged are inspected annually by the Family Independence Agency, and the Department of Labor and Economic Growth for fire safety. Licenses for homes for the aged are renewed annually and adult foster home licenses are renewed every 2 years.

Fees

Licensing Fees
Type   Original     Renewal  
AFC foster home (1-6) $65 $25
AFC small group (1-6) $105 $25
AFC small group (7-12) $135 $60
AFC large group (13-20) $170 $100
AFC congregate (21+) $220 $150
Home for the aged (21+)   $3.13* $6.27*
* Per bed per year.

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