Supported Residential Care Facilities, Chapter He-P 805
Residential Care Home Facilities, Chapter He-P-804
General Approach and Recent Developments
The State continues to regulate facilities under regulations that have expired while discussions on new regulations drafted in 2003 continue between the licensing agency and provider associations. In 1998 legislation passed that allowed facilities to serve nursing home eligible residents. In effect, the bill was interpreted as superceding more limited admission/retention criteria in the regulations. As a result, the licensing agency has observed increased acuity levels, and an increase in complaints and wandering among residents. A bill setting disclosure requirements for assisted living residences and elderly housing (HB 1220) passed and regulations were issued for comment in October 2002.
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“Residential care facilities, whether or not they are private homes or other structures built or adapted for the purpose of providing residential care, offering services beyond room and board to two or more individuals who may or may not be elderly or suffering from illness, injury, deformity, infirmity, or other permanent or temporary physical or mental disability. Such facilities include those:
- Offering residents home-like living arrangements and social or health services including, but not limited to, providing supervision, medical monitoring, assistance in daily living, protective care or monitoring and supervision of medications; or
- Offering residents social, health, or medical services including, but not limited to, medical or nursing supervision, medical care or treatment, in addition to any services included under subparagraph (1). Such homes or facilities shall include, but not be limited to, nursing homes, sheltered care facilities, rest homes, residential care facilities, board and care homes, or any other location, however, named, whether owned publicly or privately or operated for profit or not.”
The statute indicates that residential care requires a minimum of regulation and reflects the availability of assistance in personal and social activities with a minimum of supervision or health care, which can be provided in a home or home-like setting. Supported residential health care reflects the availability of social or health services, as needed, from appropriately trained or licensed individuals, who need not be employees of the facility, but residents shall not require nursing services complex enough to require 24-hour nursing supervision. Such facilities may also include short-term medical care for residents of the facility who may be convalescing from an illness and these residents shall be capable of self-evacuation (with or without staff assistance). Supportive residential care serves residents who do not need 24-hour nursing care except on a short-term basis. Residents may need help with ADLs but must be able to evacuate with assistance. Residential care homes are a step below supported residential care facilities and provide supervision and some ADL assistance.
HB 1220 defines assisted living residences as any entity that provides housing and holds itself out, through marketing, advertising, or use of the term “assisted living” or a similar designation, as providing or arranging for personal assistance or any health-related or supportive service beyond room and board to one or more adults who are not related to the owner of the residence by blood or marriage.
Units must have at least 80 square feet per one bed room and 140 square feet per room with two beds, exclusive of space required for closets, wardrobe, dressers, and toilet room. Rooms may be shared by two people. Sinks, toilets, tubs, and showers shall be available for every six residents.
Residential care homes can accept only those persons who are 1) mobile and can self evacuate; 2) able to initiate and accomplish most activities of daily living but may require supervision or physical assistance; 3) not in need of licensed or professional nursing or monitoring except for temporary episodic illness.
Persons admitted for short stays must have a health examination conducted within 30 days prior to admission and include any orders and medications required by the resident; an assessment focused on the services needed by the resident; and an admission agreement which lists the services to be provided during the residence.
Persons admitted for more than a short-term stay must have a health exam conducted within 30 days prior to admission which addresses medical requirements; functional activities and limitations; medication needs and orders; and dietary needs. The administrator or designee in conjunction with the resident’s provider and family/guardian must complete an initial assessment prior to admission and the administrator must ensure that assessments are completed at least every six months. The resident must receive a written list of services that will be provided; a list of services for which additional payment is required; rules of the home; information on, and procedures for, reserving a place in the home when the resident is hospitalized or out of the home for a period of time; grounds for termination of agreement; and notification required for involuntary transfer for reasons other than emergency situations.
Residential care homes may not accept any resident whose assessment indicates services are required which the facility cannot provide.
Supported residential care facilities may accept only residents who are mobile and can self-evacuate (with our without assistance); are able to initiate and accomplish some ADLs with help but require physical assistance and prompting from others; require intermittent, short-term, 24-hour nursing care or less than 24-hour nursing care on an ongoing basis; require consultation or direct care for therapeutic services (physical, occupational, recreational therapy, and mental health services); or require administration of medications.
Nursing Home Admission Policy
A person is Medicaid eligible for nursing facility services if the person requires 24-hour care for one or more of the following purposes, as determined by the Department of Health and Human Services:
- Medical monitoring and nursing care;
- Restorative nursing or rehabilitative care;
- Medication Administration (or instruction and supervision of self-medication for discharge purposes only); or
- Assistance with two or more activities of daily living.
Residential care homes. Services include supervision; arrangement of appointments; crisis intervention; supervision in activities of daily living, nutrition, and medications and provision of or arrangement for transient medical care with licensed home health care providers; access to community services; and room and board.
If a resident's health status changes permanently to non-mobile or the resident requires medical or nursing care on an ongoing basis, the home must either provide medical or nursing care from a licensed home health care provider on a contract basis; seek licensure to provide a higher level of care; or transfer the resident to another facility where medical and nursing care are available.
The home is responsible for arranging the provision of additional services to residents requiring care during a temporary episodic illness or convalescence following acute hospital care.
Supported residential care facilities provide housekeeping; verbal and physical assistance with ADLs; nutrition monitoring; meals; personal supervision when required to offset cognitive deficits that pose a risk to self or others; assistance with medications (verbal prompting, reminding, and some physical assistance); and provision for administration of medications by appropriately licensed persons directly or by contract with a licensed home health agency and for treatments ordered by a physician. Facilities shall provide or arrange with a licensed home health agency for short-term intermittent nursing care and less than 24-hour nursing or other medical monitoring care on an ongoing basis.
Staff responsible for food service must have knowledge of nutritional requirements and planning and preparation of prescribed diets. Facilities must provide three or more meals a day and snacks between meals and before retiring that meet the recommended dietary allowances of the National Research Council.
Agreements must list the service provided, additional services available and their cost, house rules, bed hold policy, grounds for termination of the agreement, and the notification required for involuntary transfer for emergency situations.
New Hampshire implemented legislation in 2003 requiring disclosure of information to allow residents to compare assisted living residences, independent retirement communities and elder housing and make informed choices. Regulations and a standard form were issued by the licensing agency. The rules require disclosure of whether the facility is licensed, the amount of the basic rate, the services included in the rate (e.g., assistance with specific ADLs, monitoring and supervision of medications, administration of mediations, personal laundry services (number of loads per week), housekeeping services; meals provided, transportation services, recreation and leisure activities, amenities in the living unit, and staffing (24-hour availability, licensed nurse, personal care attendant, nursing assistant and maintenance staff availability; deposits/advance payment requirements and refundability; and services not included in the basic rate and their cost.
Provisions for Serving People with Dementia
Disclosure requirements for all licensed facilities apply to those serving people with dementia. The revised regulations will contain provisions for serving people with dementia.
Administration of medications by licensed staff is allowed.
A Medicaid waiver was approved in 1999 that includes assisted living. The State also has provided a state SSI supplement for residential care facilities since the 1980s that currently totals $758 a month (federal and state) to pay for room and board, which includes a PNA of $50. Assisted living coverage is available in both non-licensed subsidized housing sites and licensed facilities. The State uses a flat Medicaid payment of $1,250 a month for services in residential care facilities and $50 per day in non-licensed elderly housing programs, including room and board paid by the resident. Family supplementation is allowed. Five of the 42 participating facilities are licensed and they serve 36 residents. The rest are elderly housing buildings.
Administrators must be at least 21 and never convicted of a misdemeanor or felony. Administrators of facilities licensed for four to sixteen beds must have a high school diploma or GED plus one year of work experience in a health field or an associate’s degree from an accredited college or university in a health field.
Administrators of residential care homes licensed for 17 or more residents must have a high school diploma plus five years of direct care experience; an associate’s degree from an accredited college or university, plus three years of experience in a health or human services field; or a bachelor’s degree in a health field.
Residential care homes do not require medical directors or directors of nursing. Other staff must be at least 18 years old if they provide direct care.
Administrators must have 12 hours of continuing education each year.
Staff. Personnel shall have orientation and training in the performance of their duties and responsibilities which includes job description requirements, fire safety and evacuation, medical emergency protocol, resident rights, and facility tour and familiarization. Ongoing in-service training or continuing education must be provided to address areas of weakness identified during annual performance review. In-service training shall also address new or special needs of residents and shall include training in medication supervision or administration; first aid; behavior management; personal care; fire safety and evacuation; socialization; and resident rights.
Staff may not have been convicted of a felony and never have been convicted of abuse, assault, neglect, or exploitation of any person. A signed statement by the employee is acceptable documentation for conviction of abuse, assault, neglect, or exploitation. As of July 1, 2003 prior to a final offer of employment being made, the facility must have received and reviewed the results of criminal conviction record the division of state police.
The licensing agency conducts annual inspections of facilities.
$2.50 per bed.
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