Residential Facilities for Groups, Nevada Revised Statutes §449.017 et seq.; Nevada administrative code §449.156-2766
General Approach and Recent Developments
Effective January 2004 Nevada amended their HCBS waiver for the Elderly in Group Care Homes to include an assisted living service. Legislation has passed that requires licensed facilities to obtain an endorsement on its license authorizing it to operate as a residential facility which provides “assisted living services.” Facilities may not market themselves as providing assisted living services unless they obtain an endorsement from the State. Facilities will provide to any potential resident a full written disclosure describing what personalized care services will be available and the amount charged for those services. Physical plant standards will require independent units to contain toilet facilities and a sleeping area or bedroom. In facilities with 11 or more residents, units will be able to be shared by consent only. New care principles are described including the promotion of resident quality of life, individualized needs, and personal choice; creative and innovative service provision; resident autonomy; fostering a community atmosphere; and facility operations that minimize the need for residents to move out of the facility as resident needs change over time. Application fees will be $200. Revised minimum staff training requirements for residential facilities which provide services to persons with Alzheimer’s disease are being proposed.
|Residential care facilities for groups||300||4,021||374||NR||326||4,581|
Residential facility for groups means an establishment that furnishes food, shelter, assistance and limited supervision to an aged, infirm, mentally retarded or handicapped person. The term includes, without limitation, an assisted living facility. The term does not include an establishment which provides care only during the day, persons providing care for no more than two persons in their home, persons providing care for one or more persons related to him within the third degree of consanguinity or affinity, a halfway house for recovering alcohol and drug abusers, or facilities funded by a division or program of the Department of Human Resources.
Residential facilities for groups may specialize in care for different groups: elderly and disabled, mentally ill, Alzheimer’s and related dementia, hospice care, mentally retarded adults, and persons with chronic illnesses. In order to specialize in care for different groups, a facility must obtain an endorsement on its license authorizing it to operate as a residential facility which provides care to a specific population, e.g., persons with Alzheimer’s disease.
A residential facility for elderly or disabled persons means a residential facility which provides care to persons requiring assistance and protective supervision due to infirmity or disability.
A residential facility which cares for persons with Alzheimer’s disease means a residential facility which provides care and protective supervision for persons with Alzheimer’s disease or a related disease, including, without limitation, senile dementia, organic brain syndrome, or other cognitive impairment.
Single occupant rooms must have 80 square feet of floor space and multiple resident rooms must have 60 square feet of floor space per resident. No more than three residents may share a room. One toilet and lavatory is required for every four residents. A tub or shower is required for every six residents. However, new legislation provides that units may be shared “with another occupant only upon consent of both occupants and all units must include toilet facilities. Doors of bedrooms may be equipped with locks for use by residents if the doors may be unlocked from the corridor and keys are readily available. Provisions must be made for privacy in all bathrooms and for all toilets located in bedrooms for use by more than one resident.
Facilities serving people with Alzheimer’s disease must be have sprinklers and have 24-hour awake staff. Exit doors must have alarms or time-delay locks. Local audible alarming units must be installed. Facilities serving people with Alzheimer’s disease must have a secure yard, completely fenced and gated with locking devices.
Residents are considered Care Category 1 (ambulatory) and Care Category 2 (non-ambulatory). Ambulatory residents are physically and mentally capable of moving from an unsafe area to an area of safety within four minutes unassisted. Non-ambulatory residents require the assistance of at least one other person to move to a safe area within four minutes. Facilities licensed prior to January 1, 1997, are not required to meet requirements for installing automatic sprinkler systems unless they seek to serve Category 2 residents. Sprinklers must be installed prior to a change of ownership, an increase in licensed beds, or admission of non-ambulatory residents. Requirements for hard-wired smoke detectors with battery back up are also waived for small homes unless the above changes are proposed.
People who are bedfast, require 24-hour skilled nursing or medical supervision, and/or require restraints or confinement in locked quarters may not be admitted. The rules do not allow facilities to admit or retain residents with a lengthy list of health conditions with some exceptions. Residents with (or needing) catheters, colostomies or ileostomies, contractures, pressure ulcers, diabetes, unmanageable incontinence, enemas/suppositories, oxygen, injections, protective supervision, or wound care may not be admitted or retained unless the resident is physically and mentally capable of performing the required care or if the care is provided or supervised by an appropriately skilled medical professional. Residents needing gastronomy care, naso-gastric tubes, or have staph or other serious infections or tracheotomies cannot be admitted or retained unless a written request is submitted by the administrator documenting the resident’s condition and how care can be provided and the request is approved by the licensing agency. A resident who is suffering from an illness or injury from which the resident is expected to recover within 14 days after the onset of the illness or the time of the injury may be cared for in the facility. A resident may reject medical care. This rejection must be recorded and signed by the resident.
A resident may be discharged from a residential facility without his approval if he fails to pay his bill within 5 days after it is due; he fails to comply with the rules or policies of the facility; or the administrator of the facility or the bureau determines that the facility is unable to provide the necessary care for the resident.
Nursing Home Admission Policy
Individuals are nursing home eligible if the individual’s condition requires the level of services provided by either a skilled nursing facility or intermediate care facility with at least three deficits identified in the following areas: (1) self-administration of medications; (2) treatments/special needs such as oxygen, tracheostomy, suctioning, ventilator dependent, IV, central line, feeding tube, wound care, glucose monitoring, insulin coverage, as examples; (3) activities of daily living; (4) need for supervision; and (5) instrumental activities of daily living.
Services provided include personal care; at least ten hours of activities a week; three meals a day; protective supervision; laundry; and assistance with access to dental, optical, social, and related services as needed by residents. Assistance with medical needs described in the Admission/Retention Policy section may be provided through a contract with a community agency or directly by staff hired by the facility. Assessments are completed by a physician.
Three meals a day and snacks that meet the recommended dietary allowance of the Food and Nutrition Board must be provided. Meals must be nutritious, served in an appropriate manner, suitable for the residents and prepared with regard for individual preferences and religious requirements. At least three meals a day must be served at regular intervals. The times at which meals will be served must be posted. Not more than 14 hours may elapse between the meal in the evening and breakfast the next day. Snacks must be made available in between meals for the residents who are not prohibited by their physicians from eating between meals. A resident must be served meals in his bedroom for not more than 14 consecutive days if he is temporarily unable to eat in the dining room because of an injury or illness. The facility may serve meals to other residents in their rooms upon request. Special diets may be provided if ordered by a physician or dietician. Facilities with more than ten residents must consult at least quarterly with a registered dietician concerning development and review of weekly menus, training for kitchen employees, compliance with nutritional program of the facility, and other observations regarding preparation and serving of meals.
Agreements include basic rate and the services included, schedule of payment, charges for optional services, and the refund policy.
Provisions for Serving People with Dementia
Facilities serving people with Alzheimer’s disease must obtain an endorsement on its license to do so. Administrators must have three years’ experience caring for residents with Alzheimer’s disease or a combination of education and training. The facility’s policies and procedures must include a description of the basic services, activities, the manner in which behavioral problems will be addressed, medication management, steps to encourage family involvement, criteria for admission and discharge, and steps that have been developed to prevent and respond to wandering. Facilities must offer activities related to gross motor skills, social activities, sensory enhancement activities, and outdoor activities. At least one awake staff must be on duty at all times. Within three months of employment, staff must complete eight hours of training in providing care to residents with Alzheimer’s disease and providing support to family members. Exits must have warning devices. The grounds must be secure.
Facility staff may administer medication and assist with self-administration of medications when the resident’s condition is stable and following a predictable course, the amount of medication is at a maintenance level and does not require daily assessment, and a written plan of care has been prepared by a physician or registered nurse. The staff assisting with self-administration must complete a training program in medications.
Amendments effective January 2004 to the HCBS Waiver changed the name from Elderly in Group Care Homes to the Adult Residential Care Waiver and added an assisted living service. Participants must meet the criteria for placement in a group care home or assisted living facility and meet the 300% SSI eligibility criteria. To participate in this waiver, individuals must be placed from a nursing facility, hospital, or have been a participant in one of three other waivers serving the Frail Elderly, People with Physical Disabilities, and Persons with Mental Retardation and Related Conditions.
Under this waiver, there are two service packages: assisted living and personal care. The assisted living service package provides a greater level of choice and provides for care in a more individual apartment/studio setting that includes a kitchenette, a sleeping/living room, and private bath. Rooms may be dually occupied only by choice. The personal care package provides more direct supervision, allows individual choices but is operated in a more group format. Each package has three levels of service based upon the recipient’s functional need, determined through a comprehensive assessment process by a registered nurse or licensed social worker. Assessments are completed annually or upon a significant change in condition. A plan of care is developed from the comprehensive assessment by a social worker or a case manager, and must include the input of the recipient or the recipient’s representative.
The assisted living and personal care services packages provide for assistance with ADLs, 24-hour in-home supervision, assistance to engage in the facility’s social and recreational programming, and transportation to appointments. Services must be provided in a way that fosters independence and aging in place, and routines of service provision must be consumer-driven to the maximum extent possible, with consumers treated with dignity and respect. Caregivers must be trained in the functional care skills needed to care for each unique recipient. Training must include, but not be limited to, techniques such as transfers, mobility, positioning, use of special equipment, identification of signs of distress, First Aid, and CPR.
Medicaid payment is not available for room and board, items of comfort or convenience, or the costs of facility maintenance, upkeep and improvement. Family supplementation has been discussed but not implemented. The SSI and state supplement payment standard is $914 a month which includes a personal needs allowance of $88. For individuals who are on the Adult Residential Care Waiver, room and board fees are determined by the facility. The Medicaid service payment is $20, $45, or $60 a day (about $600, $1,350, or $1,800 a month) depending on the assessment of the level of service.
|Supervision to minimal assistance with an ADL and a score a 3 on the Total Level of Care (LOC) Score line.||Personal Care
|Supervision to minimal assistance with an ADL and a score a 3 on the Total Level of Care (LOC) Score Inc.||$20.00|
|Moderate assistance with both critical ADLs* or moderate assistance with any 4 ADLs or dependent with 1-2 ADLs or score of 2 in at least 1 critical behavior.**||Personal Care
|Moderate assistance with both critical ADLs* or moderate assistance with any 4 ADLs or dependent with 1-2 ADLs or score of 2 in at least 1 critical behavior.** Minimal physical assistance with ADLs, with some self care tasks requiring moderate levels of assistance.||$45.00|
|Maximum assistance to dependent with both critical ADLs or maximum assistance with any 4 ADLs or dependent for 3 or more ADLs or score of 3 in at least one critical behavior area.||Personal Care
|Maximum assistance to dependent with both critical ADLs or maximum assist with any 4 ADLs or dependent for 3 or more ADLs or score of 3 in at least one critical behavior area. Moderate physical assistance with ADLs, with some self care tasks requiring maximal levels of assistance.||$60.00|
|* Critical ADLs include eating/feeding, bladder and bowel continence
** Critical behaviors include wandering, resists care, self-abusive behavior, abusive to others, and memory/cognition
Facilities must maintain staffing patterns that are sufficient to meet the care needs of residents and to enable residents to achieve and maintain their functioning, self care, and independence. Facilities with more than 20 residents must have at least one awake staff member and an additional person available within 10 minutes. Staff of all facilities must receive annually eight hours of training that is directed toward meeting the needs of group-care residents. Facilities licensed for 20 to 49 residents must have one staff member designated to organize, conduct, and evaluate activities. Facilities with 50 or more beds must have a full-time person for activities. Volunteers may be used to supplement the services and programs of a residential facility, but may not be used to replace members of the staff of the facility.
Administrators must have the necessary skills to meet or direct staff to meet the needs of residents unless such skills are met by appropriately skilled medical professionals who are employed by or contract with the facility. Administrators must receive annually eight hours of training that is directed toward meeting the needs of group-care residents.
All staff must possess the necessary skills to meet the needs of the residents in the residential facility with the exception of those needs/skills which are to be met in a contract with other service providers. Within 60 days after being employed by a residential facility for elderly or disabled persons, a caregiver must receive not less than 4 hours of training related to the care of those residents. Staff must receive annually eight hours of training that is directed toward meeting the needs of group-care residents.
Within 30 days after an administrator or caregiver of a residential facility is employed at the facility, the administrator or caregiver must be trained in first aid and cardiopulmonary resuscitation. The advanced certificate in first aid and adult cardiopulmonary resuscitation issued by the American Red Cross or an equivalent certification will be accepted as proof of that training.
Caregivers must have no prior convictions or history of previous findings of abuse, neglect, or exploitation or other serious convictions relating to the ability to care for dependent persons. All other staff must not have any convictions or history of abuse, neglect, or exploitation. Reference checks may be used for documentation.
Facilities are subject to on-site inspections and complaint investigation. The State views the oversight process as less structured than nursing facility oversight, although the focus on compliance and quality of care is still paramount. They provide on-site education during the survey process, which has been more effective than a plan of correction-only approach.
Under the Adult Residential Care Waiver, case managers are required to have monthly contact and quarterly face to face contact with the recipient or the recipient’s family, in addition to supervisory home visits to conduct a random sampling of 10% of consumers quarterly and a supervisory review of a sample of case files at a minimum, annually.
Initial fees are $2,400 plus $184 per bed. Renewal fees are $1,182 plus $92 per bed. Residential facilities for groups with low-income beds have an initial fee of $2,400 plus $100 per bed. Renewal fees are $1,182 plus $35 per bed. Residential facilities for groups with less than 11 beds have an initial fee of $1,085 plus $95 per bed and renewal fees of $35 per bed for low- income beds. Residential facilities for groups with less than 11 beds that have 75% or more low-income beds pay an initial fee of $500 plus $92 per bed, and renewal fees of $35 per bed for low-income beds. Facilities that wish to increase their bed capacity must pay a flat fee of $250 and $184 for each additional bed. For beds that will serve the low-income, the fee is $100.
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