Adult residential care facilities, NMAC Title 7 Chapter 8 Part 2
Assisted living (Medicaid)
General Approach and Recent Developments
A committee was formed in 2003 to review the current regulations. This committee is in the final stages of its review. The primary issues being addressed include educational requirements for administrators and staff, and redefining ownership. The revisions are expected to be final by the end of 2004.
Assisted living is covered as a Medicaid waiver service. Providers may be licensed as adult residential care homes or as new or innovative programs.
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Adult residential care facility means any congregate residence, maternity shelter, or building for adults, whose primary purpose is to provide to residents, within the facility, either directly or through contract services, programmatic services, room, board, assistance with activities of daily living, in accordance with the program narrative, and/or general supervision to two or more adults who have difficulty living independently or managing their own affairs.
Assisted living is a special combination of housing and personalized health care services designed to respond to the individual needs of Medicaid waiver recipients who require assistance with activities of daily living (e.g., ability to perform tasks that are essential for self care, such as bathing, feeding oneself, dressing, toileting, and transferring) and instrumental activities of daily living (e.g., ability to care for household and social tasks to meet individual needs within the community). Assisted living is based on the following fundamental principles of practice: individuality, independence, privacy, dignity, choice, and a home-like environment. Assisted living services are packaged per individual recipient needs.
Resident rooms may be private or semi-private. Private rooms must have at least 100 square feet of floor area, not including closets and locker areas. Semi-private rooms shared by no more than two people must have at least 80 square feet of floor area per bed, not including closets and locker areas. Facilities serving people with alcohol or drug dependency may offer wards or dormitories that have 60 feet of floor area for each bed. Toilets, sinks, tubs, and showers must be provided in ratios of one for every eight residents. All facilities must have a minimum of 1 toilet and bathing facility which meets requirements for people with disabilities.
Medicaid Services must be provided in “home-like” environments which are defined as:
A minimum of 220 square feet of living and kitchen space (not including bathroom) for newly constructed units (rehabilitated units must provide a minimum of 160 square feet).
Adult residential shelter care homes must provide 100 square feet of floor area in a single bedroom (excluding closet/locker). Recipients must have access to a common living area, kitchen, and bathroom which are handicapped accessible. Eighty square feet is required for semi-private bedrooms.
No resident shall be admitted or retained who is below the age of eighteen or for whom the facility is unable to provide appropriate care. The one exception is maternity shelter facilities. Facilities may not admit or retain anyone requiring continuous nursing care which includes ventilator dependency, Stage III or IV pressure sores, intravenous therapy or injections directly to veins, airborne infectious diseases, conditions requiring physical or chemical restraints, nasogastric tubes/gastric tubes, tracheotomy care, individuals presenting an imminent physical threat or danger to self or others, or individuals whose physician certifies that placement is no longer appropriate. Exceptions are allowed when a team (director, resident, agent, advocate, physician, other health professional) jointly agrees and approves a service plan identifying needs and how they will be met, ensuring maintenance of the facility’s evacuation rating and the well-being of others.
Nursing Home Admission Policy
Medical eligibility is based on nursing facility level of care general criteria and one or more clinical status factors. The general criteria require that two or more activities of daily living (ADLs) cannot be accomplished without consistent, ongoing, daily provision of some or all of the following levels of service: skilled, intermediate, and/or assistance. The functional limitations are secondary to a condition for which general treatment plan oversight of a physician is medically necessary. The clinical factors are medications, respiratory therapy and supplemental oxygen, ventilator care, ostomy care, management of decubitus ulcers, dressings, specialized rehabilitative or restorative care by qualified therapists, and “other” services such as organic brain damage, dementia, and spinal cord injury.
Facilities must supervise and assist residents as necessary with health, hygiene, and grooming needs to include but not be limited to eating, dressing, oral hygiene, bathing, grooming, mobility, and toileting. Recreation/social activities, three meals a day, laundry, and housekeeping must be provided. Facilities must provide or arrange for housekeeping, laundry, and transportation services.
A resident assessment must be completed within 5 days of admission and reviewed every 6 months as part of the individual service plan. The resident assessment must establish a baseline in the resident's functional status and thereafter identify resident changes through periodic reassessments.
An individual service plan, if prompted by the resident assessment, shall be developed and implemented within 14 days of admission, and must address those areas of need as identified in the resident assessment. The individual service plan must be reviewed by a licensed nurse at least every 6 months, and revised as needed at the time of each assessment and consistently implemented in response to the resident's needs. The individual service plan must include the following:
Description of identified need as noted in the resident assessment.
Written description of what services will be provided.
Who will provide the services.
When or how often the services will be provided.
How the services will be provided.
Where the services will be provided.
Goal and outcome of the service.
Documentation of the facilities determination that it is able to meet the needs of the resident.
Medicaid. An inter-disciplinary team develops an individualized service plan (ISP) which is approved by the Department of Health waiver staff. Staff from the facility participate as a member of the team and attend team meetings.
Core services provide minimum to moderate assistance and include at a minimum: bathing, dressing, eating, personal hygiene, behavior management, opportunities for individual and group interaction, housekeeping, laundry, transportation, meal preparation and dining, 24-hour response capability to meet routine scheduled care as well as unscheduled, unpredictable needs of the recipients, capacity to provide on-going supervision of the waiver recipient within a 24-hour period, service coordination capability to arrange access to services not provided directly, provider participation in the interdisciplinary team meetings for development of the individualized service plan, and demonstrated capability to address the most common dementia related problems (e.g., memory loss, depression, sleep disorders).
In addition to the above core services, providers may provide personal services (specialized bowel and bladder program and catheter care); private duty nursing (medication management, nursing services such as injections, wound care, health status monitoring and assessment); skilled maintenance therapies (physical therapy, occupational therapy, speech); emergency response services; and other support services authorized by the Department of Health designed to maintain independence.
Services may be provided by the facility or another approved waiver provider.
Facilities must provide three nutritionally balanced meals and evening snacks in accordance with the recommended daily dietary allowances from the basic food groups. Therapeutic diets and prescribed vitamin and mineral supplements may be given according to physician orders. Training must be appropriate to staff responsibilities.
The agreement covers the scope of services to be provided, the cost of services and method of payment, circumstances under which the agreement can be terminated, and the bed-hold policy. A new agreement is required when services, costs, or other material terms change. An admission/discharge agreement may provide for termination by the facility when the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility. Termination of an admission agreement by the facility is permitted in emergency situations for the following reasons: the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; the safety or health of individuals in the facility is endangered; the resident has failed to pay for a stay at the facility, as defined in the admission agreement; the facility ceases to operate or is no longer able to provide services to the resident; and due to sanctions or remedies imposed by the Department.
Provisions for Serving People with Dementia
Medications may be administered by licensed health care professionals. Staff who have completed an approved training program may assist with medications if given permission by the resident or resident representative. Facilities must have a consulting pharmacist who reviews medications at least quarterly.
The HCBS Disabled and Elderly Waiver serves elders and people with disabilities. Facilities receive a flat rate of $50.50 per day (excluding room and board). Room-and-board charges are the responsibility of the recipient. The waiver sets eligibility at 300 percent of the federal SSI payment. Income supplementation is allowed.
Adult residential facilities. The facility must employ staff capable and trained to provide the basic care and resident assistance and supervision required, based on the assessment of the residents needs, and must employ an administrator. Direct care staff must be at least eighteen years of age. When residents are awake, all facilities must have at least one direct care staff person on-duty and awake for each 15 residents. During resident sleeping hours, facilities with 15 or fewer residents must have at least one direct care staff person on duty and responsible for the care and supervision when residents are in the facility. Facilities with 16 to 60 residents: at least one direct care staff person awake at all times and at least one additional staff person available on the premises while residents are sleeping. Facilities with 61 to 120 residents: two direct care staff persons awake at all times and at least one additional staff person immediately available on the premises when residents are sleeping. Facilities with more than 120 residents: at least 3 direct care staff persons awake at all times and one additional staff person immediately available on the premises for each additional 40 residents or fraction thereof in the facility.
The waiver guidelines require staffing ratios and patterns that will meet the individual recipient's needs as identified in the ISP.
Administrators must be 21, demonstrate respect for residents, have a high school diploma or equivalent and have proven their ability to administer a facility through education or experience. Administrators must be able to communicate with the residents and other staff members in the language spoken by the majority of the residents and other employees.
Staff training, appropriate to staff responsibilities, includes, at a minimum, an orientation and an on-going, but at least annual, program which includes: fire safety; first aid; safe food handling practices; confidentiality of records and resident information; infection control; resident rights; reporting requirements on abuse, neglect, and exploitation; transportation safety for assisting residents and operating vehicles to transport residents; and providing quality resident care based on current resident needs.
Qualifications of personal care assistants. Each personal care assistant shall have completed:
- A nurse aide training course approved by the Department and shall have passed the Nurse Aide Certification exam; or
- A homemaker-home health aide training program approved by the Board of Nursing and shall be so certified; or
- Other equivalent training program approved by the Department.
Each personal care assistant shall receive orientation prior to or upon employment and ongoing in-service education regarding the concepts of assisted living.
Applicants for the administrator position must comply with the requirements of the New Mexico Caregivers Criminal History Screening Act.
The Licensing Authority must perform on-site survey/monitoring visits at all adult residential care facilities to determine compliance with the regulations, to investigate complaints, or to investigate the appropriateness of licensure for any alleged unlicensed facility. If violations of the regulations are cited, the licensee or facility designee is provided with an official written report of the findings at the completion of the survey/monitoring visit or within ten working days following the visit. The Licensing Authority may utilize a committee comprised of interested parties including but not limited to advocacy, provider, consumer and state agency representation. The committee shall advise the state agency on facilities’ written requests. The licensee or facility designee shall submit a plan of correction at the time of the survey/monitoring visit or within ten working days of receipt of the official written report citing the violations. The plan of correction must: address how all violations identified in the official written report will be corrected; how the facility will identify other residents having the potential to be affected by the same deficient practice; how the facility will monitor its corrective action; specify a date upon which the corrective action will be completed. Cited violations must be corrected within thirty days from the date the survey was completed, unless the Licensing Authority approves otherwise. The Licensing Authority may accept, reject, or negotiate modifications to the plan of correction.
$30 per facility.
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