State Residential Care and Assisted Living Policy: 2004. North Carolina

03/31/2005

Citation

Assisted living residences, NCAC Title 10A Chapter 13 Subchapters F and G; General statute 131D-2

General Approach and Recent Developments

Licensing requirements adopted in 1995 and 1996 established the umbrella term of “assisted living residences” for three types of long-term residential care settings: (1) adult care homes, formerly called domiciliary homes, which must be licensed by the State, (2) group homes for developmentally disabled adults, and (3) multi-unit assisted housing with services which are not licensed, but must be registered with the State. Adult care homes are divided into different types based on size. Family care homes provide care to no more than 6 residents and adult care homes provide care to 7 or more residents. The legislative intent behind licensure for adult care homes is to ensure that facilities provide services that assist the residents in such a way as to assure the health and safety of residents, quality of life, and maximum flexibility in meeting individual needs and preserving individual autonomy.

Several pieces of legislation were enacted in 2001 requiring the following changes: (1) the state licensing agency must develop an adult care home quality improvement consultation program; the Department of Health and Human Services, Division of Facility Services must develop an assessment tool to measure quality of care; and facilities with special care units must file separate cost reports for special care and non-special care units. All legislation was implemented except for the adult care home quality improvement consultation program which has not been formalized to date.

In 2002, the Legislature gave temporary rulemaking authority to the Division of Facility Services through July 2004. The Division formed a rules review committee to receive advice. This committee includes representatives from state and local government, provider associations, and advocacy groups whose charge is to review regulations for all licensure categories and make recommendations for rule amendments, repeals or adoptions. Recommendations are submitted from the Department of Health and Human Services to the Medical Care Commission, the formal rulemaking body for the State of North Carolina.

Changes made through temporary rulemaking are clarification of the discharge rules and compliance requirements, updating food service rules to bring menu requirements in line with current dietary recommendations, food service training, modification of tuberculosis-related rules to assure consistency with state TB control measures, and the reorganization and updating of physical plant requirements. Legislation was passed in 2003 requiring licensure fees for assisted living residences.

Supply
  Category   2004 2002 2000
Facilities Units Facilities Units Facilities Units
Adult care homes 629 35,247 631 34,776 610 32,995
Family care homes 648 3,642 682 3,814 743 4,134
Multi-unit assisted housing with services   23 1,853 20 1,538 NR NR

Definition

Assisted living residence means any group housing and services program for two or more adults, by whatever name it is called, which makes available, at a minimum, one meal per day and housekeeping services, and provides personal care services directly or through a formal written agreement with one or more licensed home care agencies. The Department may allow nursing service exceptions on a case by case basis. Settings in which services are delivered may include self-contained apartment units or single or shared room units with private or area baths. Assisted living residences are to be distinguished from nursing homes subject to the provisions of G.S. 131E-102. There are three types of assisted living residences: adult care homes, group homes for developmentally disabled adults, and multiunit assisted housing with services.

Adult care home is a type of assisted living residence in which the housing management provides 24-hour scheduled and unscheduled personal care services to two or more residents, either directly or through formal written agreement with licensed home care or hospice agencies. Some licensed adult care homes provide supervision to persons with cognitive impairments whose decisions, if made independently, may jeopardize the safety or well-being of themselves or others and therefore require supervision. Medication in an adult care home may be administered by designated, trained staff.

There are three types of adult care homes.

  1. Adult care homes licensed for seven or more beds;
  2. Family care home: an adult care home licensed for 2 to 6 beds; and
  3. Group home for developmentally disabled adults: an adult care home which is licensed for two to nine beds for developmentally disabled adult residents.

Note: Almost all group homes for developmentally disabled adults were transferred to licensure under mental health regulations (G.S.122C) in 2000. There are only a few remaining under adult care home licensure (13D-2).

Multi-unit assisted housing with services is defined as “an assisted living residence in which hands-on personal care services and nursing services, which are arranged by housing management, are provided by a licensed home care or hospice agency through an individualized written care plan.” The resident has a choice of any provider, and the housing management may not combine charges for housing and personal care services. All residents, or their compensatory agents, must be capable, through informed consent, of entering into a contract and must not be in need of 24-hour supervision. It is important to note that multi-unit assisted housing with services facilities are only required to register with the Division of Facility Services and to provide a disclosure statement. They are not licensed. The information provided below, unless it specifically references multi-unit assisted housing with services facilities, applies only to licensed facilities.

Unit Requirements

Residential building codes apply to adult care homes serving six or fewer residents and institutional building codes to adult care homes serving more than six residents. Adult care homes may serve up to four residents per bedroom. Bedrooms must be a minimum of 100 square feet, excluding vestibule and closet, for single rooms and 80 square feet per person for multiple occupancy rooms, excluding vestibule, closet or wardrobe space. One bathroom must be provided for every five residents and a tub or shower for every ten residents. Bathroom requirements include hand grips and non-skid surfacing.

Admission/Retention Policy

Adult care homes. Unless a physician determines otherwise, adult care homes may not care for people who are ventilator dependent or require continuous licensed nursing care. They may also not serve individuals whose physician certifies that placement is no longer appropriate, individuals whose health needs cannot be met in the specific adult care home as determined by the residence, and individuals with medical and functional care needs that the Social Services Commission has determined cannot be properly met.

Multi-unit assisted housing with services. Except when a physician certifies that appropriate care can be provided on a temporary basis to meet the resident's needs and prevent unnecessary relocation, multiunit assisted housing with services shall not care for individuals with any of the following conditions or care needs: ventilator dependency; dermal ulcers III and IV, except those stage III ulcers that are determined by an independent physician to be healing; intravenous therapy or injections; airborne infectious disease in a communicable state that requires isolation of the individual or requires special precautions by the caretaker to prevent transmission of the disease; psychotropic medications without appropriate diagnosis and treatment plans; nasogastric tubes; gastric tubes except when the individual is capable of independently feeding himself and caring for the tube, or as managed by a home care or hospice agency licensed in the State; requires continuous licensed nursing care; individuals whose physician certifies that placement is no longer appropriate; is total dependent in four or more of the seven ADLs as determined by a uniform assessment instrument; and individuals whose health needs cannot be met in the specific multiunit assisted housing with services as determined by the residence.

Nursing Home Admission Policy

Level of care decisions are made by nurses employed by the State’s prior authorization fiscal agent. The following factors frequently indicate the need for an intermediate level of nursing home care: services needed by a licensed professional for a minimum of eight hours a day or other personnel working under the supervision of a licensed nurse; daily observation and assessment; restorative measures (e.g., teaching self-care, transfer, and ambulation activities); assistance with ADLs; need for administration and/or control of medications; colostomy-ileostomy care; dressings requiring prescription medications and/or aseptic or sterile techniques; and diabetes.

Other combinations of conditions may also indicate need for an intermediate level of care: minimal assistance with a tracheotomy; need for teaching and counseling; ancillary therapies; injections; treatments; psycho-social considerations; behavioral problems (wandering, verbal disruptiveness, combativeness); verbal or physical abusiveness or inappropriate behavior); frequent falls; or chronic recurrent medical problems that require daily observation.

Services

All licensed facilities are required to provide three meals a day, transportation, activities, and housekeeping services. Licensed facilities may provide personal care directly or through contracts. The Medical Care Commission has the authority to limit what medical and functional care needs cannot be met in adult care homes. Nursing services may be provided by the residence on a case-by-case exception basis approved by the Department of Health and Human Services, or through licensed home care agencies. The resident of an assisted living facility has the right to obtain services from providers other than the housing management, at their own cost. Facilities may provide respite services, but provision of this service is not a condition for licensure. If respite services are provided, the facility must specify the rates for services and accommodations.

Residents in all licensed facilities must receive an assessment within 72 hours of admission using the Resident Register. The facility must complete a functional assessment of each resident within 30 days after admission and at least annually thereafter using an assessment instrument approved by the Department. The assessment is used to determine residents’ functional level, and includes measures of psychosocial well-being, cognitive status, and activities of daily living. Assessments must be completed within 10 days following a significant change in a resident’s condition. The facility must complete a care plan based upon the resident’s assessment within 30 days following admission. The care plan is an individualized written program of personal care for each resident and must include a statement of the care or service to be provided based on the assessment or reassessment, as well as the frequency of service provision.

Assessments and care plans are reviewed during oversight visits to determine whether residents are appropriate for the facility, whether the assessment was appropriately done, whether the plan of care is appropriate, and whether the facility has the capacity to meet the residents’ needs.

Dietary

Licensed facilities must provide three meals a day, snacks, and modified or therapeutic diets ordered by a physician. Menus for modified and therapeutic diets must be planned or reviewed by a registered dietician. The rules describe the content of daily menus.

Agreements

Adult care homes. At admission, the facility must give the resident a contract that specifies rates for accommodations and services, and the period of notice that will be provided for rate changes. Facilities must also provide a copy of house rules, including conditions for discharge or transfer; refund policies; policies on smoking and alcohol consumption; visitation policies; resident rights; grievance procedures; and a statement as to whether the facility complies with the Civil Rights Act.

Residents may be discharged under the following conditions only: for the resident’s welfare and when the resident’s needs cannot be met in the facility; the resident’s condition has improved sufficiently so the resident no longer needs the services provided by the facility; the health or safety of other individuals in the facility is endangered; failure to pay charges for services and accommodations; or discharge is mandated under other rules. All health or safety-related reasons for discharge must be documented by a physician, physician’s assistant, or nurse practitioner.

Multi-unit assisted housing with services programs are required to provide a disclosure statement as part of the annual rental contract. The disclosure statement must include a description of the following: emergency response system; charges for services offered; limitations of tenancy; limitations of services; resident responsibilities; financial/legal relationship between housing management and home care or hospice agencies; a listing of all home care or hospice agencies and other community services in the area; an appeals process; and procedures for required initial and annual resident screening and referrals for services.

Provisions for Serving People with Dementia

Facilities that market themselves as providing a special care unit for persons with dementia must be licensed as such. Facilities that are licensed as a special care unit, or have a section that is so designated on the license are required to provide written disclosure statements. Written disclosure statements must include, but are not limited to the following: a statement of the overall philosophy and mission of the licensed facility and how it reflects the special needs of residents with Alzheimer's disease or other dementias, a mental health disability, or other special needs disease or condition; the process and criteria for placement, transfer, or discharge to or from the special care unit; the process used for assessment and establishment of the plan of care and its implementation, including how the plan of care is responsive to changes in the resident's condition; staffing ratios and how they meet the resident's need for increased care and supervision; staff training that is dementia-specific; physical environment and design features that specifically address the needs of residents with Alzheimer's disease or other dementias; frequency and type of programs and activities; involvement of families in resident care, and availability of family support programs; and additional costs and fees to the resident for special care. Facilities that serve residents with dementia but do not market themselves as special care units are not required to comply with the disclosure provisions.

Special Care Units must have policies that describe their philosophy including the mission and objectives of the unit that address: an environment that promotes mobility and minimal use of restraints; that provides a structured but flexible lifestyle through a well developed program of care that includes activities; individual care plans; methods of behavior management that preserve dignity through design of the physical environment, physical exercise, social activity, appropriate medication administration, proper nutrition, and health maintenance.

Locking devices that meet special requirements may be used. Facilities must provide direct access to a secured outside area and avoid or minimize the use of potentially distracting mechanical noises.

Staffing. At least one staff person is required for every eight residents on the first and second shift and one staff person for every ten residents on the third shift. A care coordinator must be on duty in the unit at least 8 hours a day, 5 days a week. The care coordinator may be counted in the minimal staffing requirements. In units with more than 16 units, the care coordinator must be on staff as described in regulation, but is not counted in determining the minimal staffing requirement. Administrators must have at least 20 hours of training specific to the population served. Employees must have six hours of orientation within one week and 20 hours within six months. Six of the twelve hours of continuing education must be dementia specific.

Medication Administration

Multi-unit assisted housing with services. Assistance with self-administration of medications may be provided by appropriately trained staff when delegated by a licensed nurse according to the home care agency's established plan of care.

Adult care homes. The facility must ensure the development and implementation of written policies and procedures for the ordering, receiving, storage, discontinuation, disposition, and administration of medications, including self-administration of medications. The facility must contact a resident’s physician or prescribing practitioner for verification or clarification of medication orders.

Only staff meeting the medication aide training specified in regulations may administer and prepare medications for administration. Residents are permitted to self-administer medications as long as they are competent and physically able to do so. Self-administered medications must be prescribed by a physician or other person legally authorized to do so and specific instructions for administering medications must be contained on the medication label. Residents may store self-administered medications in their room in a safe and locked area.

Effective October 2000, medication aides who administer medications and staff supervising the administration of medications must successfully pass a written examination prior to or within 90 days of completing a clinical skills validation portion of a competency evaluation. Medication aides and their supervisors must complete 6 hours of continuing education related to medication administration annually. A licensed pharmacist, prescribing practitioner, or registered nurse must perform at least a quarterly review of each resident’s medications and the facility’s medication policies and procedures, or more frequently as identified by the Department based on documentation of specific medication problems in the facility.

Public Financing

Personal care in adult care homes is reimbursed as a state plan service through Medicaid for persons aged 65 and older, and working age adults with disabilities, mental retardation and other developmental disabilities, and mental illness. The program currently serves approximately 24,000 beneficiaries living in 2,200 adult care homes.

Medicaid Participation
2004 2002 2000
Facilities Participants Facilities Participants Facilities Participants
2,200 24,000 2,389 18,533 2,241 Not reported

The maximum State/County Special Assistance (SA) payment for room and board (this is a state SSI supplemental benefit standard that is based on the federal SSI payment and any other sources of income according to established eligibility requirements) is $1,066 a month plus a $46 personal needs allowance. The Medicaid payment varies with the needs of the residents. The payment methodology was modified in January 2004. Medicaid pays for personal care, transportation, and therapeutic leave for all eligible residents. The payment includes a basic amount for personal care (the amount varies for small and large facilities) and an additional “enhanced” payment for residents with heavy care needs. Heavy care means a resident needs extensive assistance or is totally dependent in eating or toileting, or both, and/or ambulation/ locomotion. Eligibility for the additional payment is based on the adult care home’s assessment, which is verified by a county case manager. Medicaid also provides payment for transportation services.

North Carolina Medicaid Rates (per Day)
Factor Per Diem
Basic personal care
   1-30 beds $16.74
   More than 30 beds   $18.34
Eating +$10.33
Toileting +$3.69
Eating and toileting +$14.02
Ambulation/locomotion +$2.64
Transportation +$.60

The State is in the process of reviewing a new case-mix payment system.

Staffing

At all times there must be one administrator or supervisor-in-charge who is directly responsible for assuring that all required duties are carried out and for assuring that at no time are residents left alone without a staff member. Other staffing requirements vary by the size of the facility and shift. Facilities serving between 20 and 30 residents must have 16 hours of aide time on the first and second shifts and eight on the third shift. The amount of aide hours increases with the size of the facility and reaches 96 hours for facilities with 131 to 140 residents. A supervisor is required for facilities with 31 or more residents.

Training

Administrators. Administrators must be certified. Certification is available for people who are 21 years or older; pass a criminal background check; have completed the equivalent of two years of course work at an accredited college or university, or have successfully completed one year of college and two years of related supervisory experience. Administrators desiring to work in a home with 7 or more beds must complete a 120-hour administrator-in-training course including course work and140 hours of on-the-job training in a facility. Exceptions to this requirement include individuals with a current nursing home administrator’s license or certification from a state requiring comparable certification standards.

Staff. Staff who directly provide personal care or who directly supervise those who do, must complete an 80-hour personal care training and competency evaluation program established by the State. Family care home staff must have a 25-hour training program. Training must be completed within 6 months after hiring for staff hired after September 2003. Licensed health professionals, staff listed on the Nurse Aide Registry, or staff who document completion of a 40-45 hours or 75 - 80 hour training program or competency evaluation program since 1996 are exempt from this training requirement.

The 80-hour training program includes at least 34 hours of classroom instruction and 34 hours of supervised practical experience. The competency evaluation includes observation and documentation, basic nursing skills including special health-related tasks, personal care skills, cognitive and behavioral skills including interventions for individuals with mental disabilities, basic restorative services, and resident’s rights. Experienced staff may take the competency exam without undergoing training.

Facilities must assure that non-licensed and licensed personnel not practicing in their licensed capacity complete a one-time competency evaluation for specific personal care tasks (specified in regulation) before performing these tasks. Facilities must also assure training in the following areas: (1) care of residents with diabetes for unlicensed staff prior to the administration of insulin; and (2) care of residents with medical symptoms that warrant restraints regarding the use of alternatives to physical restraint use, and the care of residents who are physically restrained. Additionally, at least one staff person on the premises at all times must have completed, within the last 24 months, a course on CPR and choking management. Staff designated by the administrator must complete assessment training according to an instruction manual on resident assessment established by the Department.

Background Check

Family care home administrators must provide written documentation about any convictions for criminal offenses from the clerk of court in the county in which the conviction was made, including driving offenses. Administrators of adult care homes of 7+ beds must have a state fingerprint check. Facilities must perform state criminal background checks on all staff, who must have no findings of abuse or neglect listed on the North Carolina Health Care Personnel Registry.

Monitoring

County Departments of Social Services monitor adult care homes at least every other month. State staff provide consultation, technical assistance, and training to the county monitors. State staff also provide monitoring oversight and perform selected surveys of homes based on compliance history or lack of previous county monitoring.

Counties with at least one licensed adult care home must establish a community advisory committee that serves all licensed homes in the county. The committee is responsible for ensuring that residents’ rights are respected and that the overall quality of care is maintained. Rules further specify the function, size, and composition of the committees.

Fees

Adult care homes with 6 or fewer beds: $125.00/year. Adult care homes with 6 or more beds: $175.00/year plus an annual per bed fee of $6.25/bed. The State recently imposed a one-time, per project fee for the review of health care facility construction projects to ensure that the project plans and construction comply with state law. The fee shall not exceed $12,500 for any single project. Adult care homes with more than 7 beds are charged $87.00 plus .05/square foot of project space. Family care homes are charged an $87.00 flat fee.

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