State Residential Care and Assisted Living Policy: 2004. Montana

03/31/2005

Citation

Assisted living facilities, Administrative Rules of Montana (ARM) 32§102 Subchapter 2800.

Adult foster care homes, ARM 32§100 Subchapter 100

General Approach and Recent Developments

The purpose section of the regulations states that personal care or assisted living facilities are a setting for frail, elderly or disabled persons, which provide supportive health and service coordination to maintain the resident's independence, individuality, privacy and dignity.

Legislation replacing personal care facilities with assisted living facilities was codified in October 2003. Regulations implementing the rules were published in February 2004, and became final on May 7, 2004. The major components of the new regulations include a separate section for facilities serving people with cognitive impairments and requirements for administrators. HB 681 passed in 2003 and authorizes the Board of Nursing to issue rules to implement a medication aide program in assisted living. The State's Medicaid HCBS waiver reimburses services provided in assisted living facilities (ALFs) and adult foster care homes.

Supply
  Category   2004 2002 2000
Facilities Units Facilities Units Facilities Units
Assisted living facilities   177 3,730 149 3,276 127 2,600

Definition

Assisted living facility means a congregate residential setting that provides or coordinates personal care, 24-hour supervision and assistance, both scheduled and unscheduled, and activities and health related services.

Activities of daily living (ADLs) means tasks usually performed in the course of a normal day in a resident’s life that include eating, walking, mobility, dressing, grooming, bathing, toileting and transferring. Assistance with, or the administration of medications, is not considered an ADL.

Three categories of facilities are defined based on the needs of residents. Category A means the residents can self medicate, need assistance with no more than 3 ADLs, and are generally in good health. Category B means residents may be in need of nursing services; be consistently and totally dependent in more than four ADLs, but may not require chemical, physical, or medical restraint or be a danger to self or others. Category C facilities serve residents with cognitive impairments who are not capable of expressing needs or making basic care decisions, who may be at risk of leaving the facility without regard to personal safety, but who may not be a danger to self or others (except for risk of leaving) and may not require physical or chemical restraint.

Unit Requirements

New facilities must limit rooms to 2 residents. Existing facilities may serve four residents in a single bedroom. Each single bedroom must contain 100 square feet and each multi-bedroom must contain at least 80 square feet per bed, excluding toilet rooms, closets, lockers, wardrobes, alcoves, or vestibules. Each resident must have access to a toilet room without entering another resident's room or the kitchen, dining, or living areas. There must be one toilet room for every four residents and one bathing facility for every twelve residents.

Kitchens or kitchenettes in resident rooms are permitted if the resident's service plan permits unrestricted use and the cooking appliance can be removed or disconnected if the service or health care plan indicates the resident is not capable of unrestricted use.

Admission/Retention Policy

Category A facilities may not serve residents needing physical or chemical restraint, stage 3 or 4 pressure sores; gastronomy or jejunostomy tubes; require skilled services on a continual basis (except administration of medications); residents who are a danger to self or others; dependent in 4 or more ADLs as a result of cognitive or physical impairment; or residents incapable of expressing needs or making basic care decisions. Category A residents may receive skilled medical services for no longer than 30 continuous days per occurrence, not to exceed 120 days in a 12-month period.

Category B facilities may serve people who are consistently and totally dependent in 4 or more ADLs; require skilled services for more 30 days per episode and more than 120 days a year if the services are provided or arranged by the facility or the resident; are not a danger to self or others; do not require physical or chemical restraints; and have a signed health care assessment by a licensed healthcare professional that is renewed quarterly.

Category C facilities serve residents who have severe cognitive impairments. Such a person is incapable of recognizing danger, self-evacuating, summoning assistance, expressing needs or making basic care decisions, are at risk of leaving the facility without regard to personal safety, and may not be a danger to self or others.

Nursing Home Admission Policy

Applicants can meet criteria in either of two areas to be eligible. The first area includes one of the following: comatose; ventilator dependency; respiratory problems requiring constant treatments, observation or monitoring under direction of registered nurse; unstable medical conditions requiring 24-hour availability of services; nasopharyngeal aspiration; cognitive impairment requiring a structured, professionally staffed environment; tube feedings; or maintenance of a tracheostomy, gastrostomy, colostomy, ileostomy, or other indwelling tubes. The second area requires two of the following: constant supervision to total human assistance in two ADLs; administration of daily medications; physical, mental, or medical needs which are deteriorating or will continue to deteriorate in the absence of monitoring or supervision; restorative nursing or therapy treatments; care of extensive decubitus ulcers or other widespread skin diseases; or requires regular intervention by a case manager.

Services

Each resident receives an initial needs assessment, prior to move in, to determine the prospective resident's needs that includes: cognitive patterns such as short-term memory, long term memory, memory recall, decision making change in cognitive status/awareness or thinking disorders; sensory patterns; activities of daily living functional performance; mood and behavior patterns such as sadness or anxiety displayed by resident, wandering, verbally abusive, physically abusive and socially inappropriate/disruptive behavior; health problems/accidents; weight/nutritional status; skin problems; medication use; and use of restraints, safety or assistive devices. A follow-up needs assessment is performed again 60 days after move in date, as needed at a significant change of condition, and no less than annually for category A residents

Facilities must provide or make provisions for personal services such as laundry, housekeeping, food service and local transportation; assistance with ADLs, as provided for in the admission agreement and service plan, and that do not require the use of licensed health care professional or licensed practical nurses; recreational activities; assistance with self-medication; 24-hour on site supervision by staff; and assistance in arranging policy-related services such as medical appointments and appointment related to hearing aids, glasses and dentures. Facilities may provide, make provisions for or allow residents to obtain third party services for administration of medications and skilled nursing or other skilled services for temporary, short-term acute illness for up to 30 consecutive days per episode up to 120 days per year.

Services include required personal care services such as: personal grooming (bathing, hand washing, shampoo, shaving, and hair care); oral hygiene and denture care; toileting and toilet hygiene; eating; use of crutches and other assistive devices; and assistance with self-medication. Other services include laundry, housekeeping, recreation activities, and food service. They also include providing or making available provision for local transportation, personal assistance with ADLs, recreational activities, and supervision of self-medication. Personal care assistance is provided while encouraging residents to maintain independence and a sense of self-direction. Administration of medications is not considered an ADL.

Licensed health care professionals conduct assessments covering specific topics in Category B facilities. Requirements are specified for incontinence care and skin care.

Category B facilities shall employ or contract with a registered nurse to provide or supervise nursing services to include: general health monitoring on each category B resident; performing a nursing assessment on category B residents when and as required; assistance with the development of the resident health care plan and, as appropriate, the development of the resident service plan; and routine nursing tasks, including those that may be delegated to licensed practical nurses (LPN) and unlicensed assistive personnel in accordance with the Montana Nurse Practice Act.

Dietary

Facilities establish and maintain policies addressing the preparation and serving of meals in amount and variety sufficient to meet the nutritional needs of each resident. Therapeutic diets must be provided when ordered by a physician. Meals must offer an alternative food or drink to give residents a choice. Staff receive training in food, nutrition, and diet planning.

Agreements

A written resident agreement is required and includes at least the following items: the criteria for requiring transfer or discharge of the resident to another level of care; a statement explaining the availability of skilled nursing or other professional services from a third party provider to a resident in the facility; the extent that specific assistance will be provided by the facility as specified in the resident service plan; a statement explaining the resident's responsibilities including but not limited to house rules, the facility grievance policy, facility smoking policy and policies regarding pets; a listing of specific charges to be incurred for the resident's care, frequency of payment and facility rules relating to nonpayment of services and security deposits, if any are required; a statement of all charges, fines, penalties or late fees that shall be assessed against the resident; a statement that the agreed upon facility rate shall not be changed unless 30 day advance written notice is given to the resident and/or their legal representative; and an explanation of the facility's policy for refunding payment in the event of the resident's absence, discharge or transfer from the facility and the facility's policy for refunding security deposits.

Provisions for Serving People with Dementia

Category C facilities must disclose the facility's overall philosophy, transfer and discharge criteria, resident assessment processes, processes for implementation and updating of health care plans, staff training, physical environment, resident activities, family involvement and costs of care. Staff must be awake and available to provide supervision and care to the resident.

Category C administrators must have three or more years experience in working in the field of geriatrics or caring for disabled residents in a licensed facility; ora documented combination of education and training that is acceptable to the Department of Health. At least eight of the 16 hours of the annual continuing education requirement must cover caring for persons with severe cognitive impairments.

Category C direct care staff must receive additional documented training in: the facility or unit's philosophy and approaches to providing care and supervision for persons with severe cognitive impairment; the skills necessary to care for, intervene with and direct residents who are unable to perform activities of daily living; techniques for minimizing challenging behavior including: wandering, hallucinations, illusions and delusions; impairment of senses; therapeutic programming to support the highest possible level of resident function (large motor activity; small motor activity; appropriate level cognitive tasks; and social/emotional stimulation); promoting residents' dignity, independence, individuality, privacy and choice; identifying and alleviating safety risks to residents; identifying common side effects and untoward reactions to medications; and techniques for dealing with bowel and bladder aberrant behaviors.

Medication Administration

Staff may assist with self-administration of medications. In Category B and C facilities, medications may be administered by licensed health care professionals or individuals delegated to do so.

HB 681 allows the board of nursing to establish qualifications for licensure of medication aides, including but not limited to educational requirements. The board may define levels of licensure of medication aides consistent with educational qualifications, responsibilities, and the level of acuity of the medication aides' patients. The board may limit the type of drugs that are allowed to be administered and the method of administration. A medication aide may perform services requiring basic knowledge of medications and medication administration under specific circumstances as determined by the board; practice only in a licensed assisted living facility; and practice only under the general supervision of a licensed professional nurse.

Public Financing

An HCBS waiver program covers elders, people with disabilities, and people with mental illness in assisted living facilities. Eligible residents receive $625 in federal SSI payment and a state supplement. Residents retain a personal needs allowance of $100 and pay $525 to the facility for room and board. Family supplementation is allowed by state policy for room and board only.

The Medicaid waiver reimburses adult foster care homes and assisted living facilities between $520 and $1,800 a month depending on the level of care needed by residents. HCBS case managers complete the assessment and determine the payment rate in accordance with state policy. In addition to the room-and-board component, the basic service payment for residents is $520 a month. Additional payments are calculated based on ADL and other impairments. Points are calculated for each impairment. The functions measured are: bathing, mobility, toileting, transfer, eating, grooming, medication, dressing, housekeeping, socialization, behavior management, cognitive functioning, and other. Each function is rated as follows:

  • With aides/difficulty: needs consistent availability of mechanical assistance or expenditure of undue effort;
  • With help: requires consistent human assistance to complete the activity, but the individual participates actively in the completion of the activity; or
  • Unable: the individual cannot meaningfully contribute to the completion of the task.

Each point equals $33 a month. For example, a resident consistently needing help with toileting would be scored a two and would earn $66 a month for that impairment. Residents with severe impairments, totally dependent in more than three ADLs, can receive $44 a month for each point. The total payment (services and room and board) ranges from $1,045 to $2,325 a month although very few participants have been approved at the highest rate. The average payment is $44 a day.

Medicaid Participation
2004 2002 2000
  Facilities     Participants     Facilities     Participants     Facilities     Participants  
165 475 111 400 NR 200

Staffing

Facilities must have a sufficient number of qualified staff on duty 24 hours a day to meet the scheduled and unscheduled needs of each resident, to respond in emergency situations, and provide all related services, including, but not limited to: maintenance of order, safety and cleanliness; assistance with medication regimens; preparation and service of meals; housekeeping services and assistance with laundry; and assurance that each resident receives the supervision and care required by the service or health care plan to meet their basic needs.

Category B facilities must employ or contract with a registered nurse.

Training

Administrator. Administrators must be licensed as a nursing home administrator in Montana or another state; or have successfully completed all of the self study modules of “The Management Library for Administrators and Executive Directors”, a component of the assisted living training system published by the Assisted Living University (ALU) or be enrolled in and complete the self study course within six months of employment.

The annual training requirement was raised from six to 16 hours covering: accounting and budgeting, basic principles of supervision, basic and advanced emergency first aid, characteristics and needs of residents, community resources, pharmacy and medication dispensing, resident and provider rights, and skills for working with residents.

Staff. The orientation and training topics covered for direct care staff have been expanded. They cover the facility’s policies and procedures manual; job description; services provided; how to perform ADL care; basic techniques in observation and reporting; changes associated with the aging process including dementia; residents’ rights; assisting with mobility and transfer; lifting techniques; food and nutrition; location of resident records and implementation of services and healthcare plans; assistance with medications; adverse and desired medication reactions; emergency procedures; safety hazards; food preparation; and abuse reporting; and the Montana resident bill of rights. Category B and C staff must receive 16 hours of training specific to direct care requirements for these facilities.

Background Check

All staff may not have convictions for a crime involving violence, fraud, deceit, theft, other deception, or a violation of 52-3-825 MCA for which the person is still under state supervision. Facilities must check with the Montana Nurse Aide Registry for any adverse actions taken against a CNA or any individual who was a CNA. Facilities are required to develop and follow policy and procedures for hiring qualified staff to ensure resident safety and well-being.

Monitoring

Unannounced on-site surveys are conducted annually, biannually, or triennially depending on whether the facility has been granted an extended license. Individuals served under the HCBS program are reassessed every six months or more frequently if needed.

Fees

$20 per bed for up to 20 beds, plus $1 per bed for each bed over 21.

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