Assisted living, OAR Division 56: 411-056-0000
Residential care facilities, OAR Division 56:411-55-000
General Approach and Recent Developments
Oregon has two types of residential care and separate licensing and regulatory requirements for each: Residential Care Facilities (RCFs) and Assisted Living Facilities (ALFs). The major distinction between ALFs and RCFs is that ALFs have private apartments whereas RCFs have both private and shared rooms and private and shared baths. The State does not allow providers to market themselves as assisted living unless they offer residents private apartments and are licensed as assisted living. The rules for assisted living and residential care facilities establish standards that promote the availability of appropriate services for elderly and disabled persons in a home-like environment that enhances the dignity, independence, individuality, privacy, choice, and decision making ability of the resident. Language about the philosophy is also contained in sections dealing with management responsibilities and service planning.
In February 2004, the State extended the moratorium on the licensing of new assisted living and residential care facilities until June 30, 2005 and changed the requirements within the moratorium rule. Licenses may be issued to: applicants who submitted construction plans prior to August 16, 2001; facilities applying for a renewal license or changing ownership, but are not increasing capacity; facilities that are relocating within the service area; or a Continuing Care Retirement Community that provides care to residents within its closed system. New applicants requesting licensure must demonstrate that the proposed facility will serve a population for whom insufficient services exist in the service area. The rule now allows facilities to request an increase in capacity by ten percent.
Effective August 1, 2004, assisted living and residential care facilities are required to develop and implement policies on the possession of firearms and ammunition within the facility. Such policies must be disclosed to residents.
Assisted Living Facilities. The State amended the assisted living rules regarding criminal background checks, changing the compliance code references in the regulations, which became effective August 1, 2004.
Residential Care Facilities. Substantial revisions to the residential care facility regulations became effective in April 2004. The revisions make the residential care facility regulations more like the assisted living facility regulations. The State will initiate another series of rule changes for residential care facilities this summer, with an expected implementation date of early Fall. Issues to be addressed include increased staff to resident ratios and required additional nurse involvement in facilities.
A consumer guide (http://www.dhs.state.or.us/seniors/publications/oregon_consumer_guide.pdf) is available and a uniform disclosure form (http://afsforms.hr.state.or.us/Forms/Served/SE9098A.pdf) has been developed.
|Assisted living facilities||190||12,566||180||11,998||138||8,661|
|Residential care facilities||236||8,504||220||8,227||187||6,805|
“Assisted living facility means a building, complex or distinct part thereof, consisting of fully self-contained individual living units where six or more seniors and persons with disabilities may reside. The facility offers and coordinates a range of supportive personnel available on a 24-hour basis to meet the ADL, health services, and social needs of the residents described in these rules. A program approach is used to promote resident self-direction and participation in decisions that emphasize choice, dignity, privacy, individuality, independence and home-like surroundings.”
No facility may use the term assisted living unless it is licensed as such.
“Residential care facility means a building, complex or distinct part thereof, consisting of shared or individual living units in a home-like surrounding where six or more seniors and adult persons with disabilities may reside. The facility offers and coordinates a range of supportive services available on a 24-hour basis. Facility services address the residents’ activities of daily living, health, and social needs in a way that promotes choice, dignity, individuality and independence.”
No facility may use the term residential care facility or present itself as providing residential care services unless it is licensed as such. A residential care facility may not be operated in combination with other facilities unless it is licensed, maintained, and operated as a distinct part.
Assisted living facility. Each unit consists of individual adaptable and accessible apartments with a lockable door, private bathroom, and kitchenette facilities which include a sink, refrigerator, and cooking appliance that can be removed or disconnected. Units must provide 220 square feet of space, not including a private bathroom. Buildings must meet applicable zoning and building codes. Pre-existing structures must provide 160 square feet excluding the bathroom.
Residential care facility. Resident units may comprise individual apartments with private bathroom and kitchenette facilities or be limited to a bedroom only, with bathroom facilities centrally located off common corridors. Facilities must include a minimum of 80 square feet per resident and limit occupancy to two residents per unit. Centralized bathing facilities must be provided for every 10 residents who do not have private bathing. Toilets must be provided for every six residents. Facilities licensed, constructed or renovated after April 1, 2004 will meet accessibility requirements of the Americans with Disabilities Act under Title III as a public accommodation and the Oregon Structural 30 Specialty Code, as enforced by the Oregon Building Codes Division and local jurisdictions having authority.
Assisted living facility. An initial screening is conducted to determine whether a potential resident meets the facility’s admission requirements. Based on the initial screen, an initial service plan is developed before the resident moves in to the facility and is reviewed within 30-days of move-in to ensure the services accurately reflect the resident’s needs and preferences. Facilities may, but are not required to, ask residents to move, with a 30-day notice, if their needs exceed the level of ADL services available; the resident exhibits behaviors or actions that repeatedly interfere with the rights or well being of others; the resident, due to cognitive decline, is not able to respond to verbal instructions, recognize danger, make basic care decisions, express need, or summon assistance; the resident has a complex, unstable, or unpredictable medical condition; or for non-payment of charges. Facilities are allowed to ask residents to leave with less than a 30-day notice, but not less than a 14-day notice if the resident exhibits behavior that is an immediate danger to self or others; has a sudden change in condition that requires medical or psychiatric treatment outside the facility and it is determined that the resident’s level of care exceeds the level of care of the facility; the facility is unable to accomplish resident evacuation according to the Life Safety Code rules; or the resident requires 24 hour, seven days a week nursing supervision.
Resident care facility. No residential care facility will admit individuals whose care needs exceed the classification on its license without prior written consent of the relevant department.
Two levels of licensure are available for residential care facilities based upon the qualifications and number of staff in the residential care facility. A Class I license is needed to serve residents who only require assistance with ADLs. These facilities cannot serve anyone who require full assistance in any activity of daily living. Class II facilities provide care to residents who may require full assistance in activities of daily living; and, in addition, serve people who have an increase in medical acuity.
A Class I facility may retain a resident who requires full assistance in an ADL if the provider establishes that the following criteria are met: the provider is able to provide appropriate care to the resident in addition to the care of the other residents; staff are available to meet the additional care requirements of all residents in the facility; and the fire evacuation standard for all residents and staff members can be met.
Nursing Home Admission Policy
Regulations set priorities for services based on the amount of assistance needed with a specified ADL or combination of specified ADLs and cognition. Due to recent budget constraints, the priority thresholds have been changed. Eligibility had been limited to levels 1-11 but was expanded to levels 12 and 13 July 1, 2004.
- Dependent in mobility, eating, toileting, and eating;
- Dependent in mobility, eating, and cognition;
- Dependent in mobility or cognition or eating;
- Dependent in toileting;
- Substantial assistance with mobility, assistance with toileting and eating;
- Substantial assistance with mobility and assistance with eating;
- Substantial assistance with mobility and assistance with toileting;
- Assistance with eating and toileting;
- Substantial assistance with mobility;
- Minimal assistance with mobility and assistance with toileting;
- Minimal assistance with mobility and assistance with eating;
- Assistance with mobility;
- Assistance with eating;
- Minimal assistance with mobility;
- Dependent in bathing and dressing;
- Assistance in bathing or dressing.
Residential care facilities and assisted living facilities. A service planning team (including a registered nurse if the resident receives nursing services, state or Area Agency on Aging case manager, facility administrator or designee, and the resident or legal representative) conducts an assessment with each resident and develops a service plan that responds to his or her needs and reflects the principles of dignity, choice, individuality and independence, and home-like environment.
Required services include three nutritional meals and snacks a day; personal and other laundry services; a program of social and recreational activities; services to assist with ADLs; and household services. Facilities must provide or arrange for social and medical transportation, ancillary services for related medical care (physicians, pharmacy, therapy, podiatry), and maintenance of a personal fund account. Required health services include accessing first payor benefits, providing a licensed registered nurse to conduct health assessments and periodic monitoring, assigning the basic tasks of nurse delegation, providing intermittent nursing services for residents with stable and predictable medical needs, and oversight and monitoring of residents’ health status. Facilities also coordinate the provision of health services with outside service providers such as hospice, home health, physicians’ offices, etc. Other health services include health care teaching and counseling, and emergency response systems that respond to health and medical needs 24-hours a day.
The service plan describes who provides services, what, when, how, and how often services are provided and, if applicable, the desired outcome. The resident shall actively participate in the development of the service plan to the extent of his/her ability to do so. The service plan is reviewed and updated at least quarterly.
A managed risk process is used when a resident exhibits high-risk behavior or choices. The process includes presenting to the resident alternatives to and consequences of the behavior. The resident’s decision to modify the behavior or accept the consequences is documented. The resident’s preferences take precedence over those of family member(s). A managed risk plan cannot be entered into or continued with or on the behalf of a resident who is unable to recognize the consequences of his/her behavior or choices. The plan is reviewed at least quarterly.
Residential care facility and assisted living facility. Three meals a day and snacks in accordance with the recommended dietary allowances of the USDA Food Guide Pyramid and modified special diets appropriate to the residents’ needs and choices are provided.
Residential care facility and assisted living facility. Agreements/disclosure statements are reviewed by the licensing agency and include the terms of occupancy; payment provisions (basic rental rate and what it includes, additional services costs, billing method, payment system and due dates, and deposits/fees if applicable); policy for rate changes; refund/proration conditions; a description of the scope of services available; a description of the service planning process and the relationship to costs; additional available services; the philosophy of how health care and ADL services are provided; resident rights; the system for packaging medications and the resident’s right to choose a pharmacy; move-out policy; notice that the licensing agency has the right to review records; and the staffing plan.
Provisions for Serving People with Dementia
Residential care facility and assisted living facility. Oregon has a separate set of rules for Alzheimer’s Care Units (Chapter 411, Division 057) which apply to nursing facilities, residential care facilities, and assisted living facilities with the exception of adult foster homes.
Any facility that offers or provides care for residents with Alzheimer's disease or other dementia in an Alzheimer's Care Unit must obtain an endorsement on its facility license. The Alzheimer's Care Unit must be designed to accommodate residents with dementia in a home-like environment. The design and environment of a unit should assist residents in their activities of daily living; enhance their quality of life; reduce tension, agitation, and problem behaviors; and promote their safety. The rules further clarify physical plant standards.
Staffing. Every effort must be made to provide residents with familiar and consistent staff members in order to minimize resident confusion. All direct care staff assigned to the Alzheimer's Care Unit must be specially trained to work with residents with Alzheimer's disease and other dementias. Staffing must be sufficient to meet the needs of the residents and outcomes identified by the individual care plan and sufficient to implement the full day and evening care program. Staffing levels on the night shift depend on the sleep patterns and needs of residents (without control of sleep by medications).
Training. Facilities must provide an orientation program to all new employees assigned to the unit. Orientation must include the facility's philosophy related to the care of residents with Alzheimer's disease and other dementias in the Alzheimer's Care Unit; a description of Alzheimer's disease and other dementias; the facility's policies and procedures regarding care provided in the unit, including therapies provided and general approach; treatment modalities; admission, discharge and transfer criteria; basic services provided within the unit; policies regarding physical restraints, wandering/egress control, and medication management; staff training; and family activities; and common behavior problems and recommended behavior management. Ongoing in-service training shall be provided to all medical and non-medical staff who may be in direct contact with residents of the unit. Staff training shall be provided at least quarterly. The rules further identify the required content of the in-service trainings.
Admission/Retention Policy. Facilities with Alzheimer's Care Units must have a written policy of preadmission screening, admission and discharge procedures. Admission criteria shall require, at a minimum, a physician's diagnosis of Alzheimer's disease or other dementia. The policy shall include criteria for moving residents from within the facility, into or out of the unit. When moving a resident within the facility or transferring a resident to another facility or placement, the facility shall take into account the resident's welfare.
Agreements. Prior to admission into the Alzheimer's Care Unit, the facility shall provide the resident or the resident's legal guardian and a member of the resident's family (if appropriate), with a copy of the disclosure statement.
Services. Within seven working days of admission, the interdisciplinary staff must review the care needs of the new resident. Within 14 days of admission, the interdisciplinary staff must develop an individualized care plan which shall describe the resident's needs, choices, problems to be worked on, the desired outcomes or interventions, and the names of the staff who are to be primarily responsible for implementing the care plan. The care plan must reflect the resident as a person, with family, history and interests. Individual care plans must be developed and written by the interdisciplinary staff and signed by each member of the staff. Each care plan must be reviewed, evaluated for its effectiveness, and updated at least quarterly or more frequently if indicated by changing needs of the resident. Outcomes for the individual care of each resident shall include: promoting remaining abilities for self-care; encouraging independence while recognizing limitations; providing safety and comfort; maintaining dignity by respecting the need for privacy, treating the resident as an adult and avoiding talking as if the resident is not present; and at least one issue of a psychosocial nature related to the resident's preferred manner of living and receiving care.
All facilities with Alzheimer's Care Units must provide for activities appropriate to the needs of the individual residents. Activities which must be offered to the residents at least weekly include:
- Gross motor activities; e.g., exercise, dancing, gardening, cooking, etc.;
- Self care activities; e.g., dressing, personal hygiene/grooming;
- Social activities; e.g., games, music;
- Crafts; e.g., decorations, pictures, etc.;
- Sensory enhancement activities; e.g., distinguishing, pictures and picture books, reminiscing, and scent and tactile stimulation, etc.; and
- Outdoor activities; e.g., walking outdoors, field trips, etc.
A social worker or an assigned staff shall provide social services to both the resident and support to family members.
Residential care facility and assisted living facility. The regulations allow residents to keep over-the-counter and prescription medications in their unit if they are capable of self-administration. Residents who self-administer prescription medications must have a physician’s or other legally recognized practitioner’s written order of approval. Facilities are allowed to administer medications, and they must have policies and procedures that assure all administered medications are reviewed every 90 days. Residents who self-administer medications are encouraged to have their medications reviewed every 90 days. Medication and treatment administration systems must be approved by a pharmacist consultant, registered nurse, or physician.
The State contracted with 170 assisted living facilities and served 3,731 beneficiaries in December 2003, compared to 172 facilities and 3,600 beneficiaries in the spring of 2002. The program also contracted with 165 residential care facilities and served 1,127 residents in December 2003. The State has an active program to identify and relocate nursing home residents to assisted living and other community settings. Beneficiaries relocating from nursing homes may receive cash grants or may be granted income exemptions to pay for transition expenses.
Assisted living. For residents who meet the nursing home level of care criteria, the State provides five levels of payment. The levels are assigned based on a service priority score determined through an assessment. (See table below.) ADLs include eating/nutrition, dressing/grooming, bathing/personal hygiene, mobility, bowel and bladder control, and behavior. Critical ADLs are toileting, eating, behavior.
The State uses the 300 percent option to determine financial eligibility, and residents are permitted to retain $565.70 as a maintenance allowance; the remainder is the residents’ cost sharing amount. Residents pay $455.70 for room and board, and keep $110 for personal needs. Supplementation is not permitted. The average monthly service costs are $1,643 a month. The distribution of residents by level is: Level 1--2 percent; Level 2--1 percent; Level 3--6 percent; Level 4--59 percent; and Level 5--32 percent.
|Service Policy||Service||R&B||Total Rate|
|Level 5||Dependent in 3 to 6 ADLs OR dependent in behavior and 1 to 2 other ADLs.||$1,944.02||$455.70||$2,399.72|
|Level 4||Dependent in 1 to 2 ADLs OR assistance in 4 to 6 ADLs plus assistance in behavior.||$1,574.64||$455.70||$2,030.34|
|Level 3||Assistance in 4 to 6 ADLs OR assistance in toileting, eating, and behavior.||$1,204.07||$455.70||$1,659.77|
|Level 2||Assistance in toileting, eating and behavior or behavior AND eating or toileting||$910.23||$455.70||$1,365.93|
|Level 1||Assistance in 2 critical ADLs or assistance in any 3 ADLs or assistance in 1 critical ADL and 1 other ADL||$688.36||$455.70||$1,144.06|
Residential Care Facilities. Medicaid also pays for services for persons who meet the nursing home level of care criteria in Level 2 residential care facilities. In the State’s 2003 budget, the RCF base service rate for all clients was $917.00 per month. Depending on impairment level, there are 3 add-on levels. Base plus 1 add-on is $1,142.00; base plus 2 add-ons is $1,367.00; base plus 3 add-ons is $1,592.00. The add-on is based primarily on how dependent a person is with ADLs.
Residents eligible for Medicaid have the same cost sharing requirements and personal needs allowance as those residing in assisted living facilities.
Assisted living. Each facility must have sufficient staff to meet the 24-hour scheduled and unscheduled needs of each resident and to respond in emergency situations.
Residential care. The regulations contain staff ratio for Class I and Class II facilities that vary by time of day and the number of residents. Irrespective of minimum number of staff stated in the rules, the licensee and administrator are responsible for assuring that an adequate number of qualified staff are available at all times to meet the unique care, health and safety needs of the residents including fire safety and evacuation.
Assisted living administrators shall be at least 21 years of age, have a high school diploma or equivalent and two years of professional or management experience in a health or social service field, or have a combination of experience and education; or a bachelor’s degree in a health or social service field. They must also complete 40 hours of approved classroom training, or complete a classroom training of less than 40 hours and a 40-hour internship in a licensed facility and obtain 20 hours of continuing education credits each year.
Residential care administrators shall be at least 21 years of age, have a high school diploma or equivalent and two years of professional management experience in a health or social service-related field, or have a combination of experience and education or a bachelor’s degree in a health or social service field. Administrators hired on or after January 1, 2003 must complete 40 hours of approved classroom training, or complete a classroom training of less than 40 hours and a 40-hour internship in a licensed facility and obtain 20 hours of continuing education credits each year.
Assisted living. Each facility administrator must document that staff have received assisted living training as prescribed by the State. The facility administrator is accountable for training all facility staff. That training includes: the principles of assisted living; changes associated with the aging process, including dementia; resident rights; how to perform direct ADL care; location of service plans and how to implement them; fire safety/emergency procedures; responding to behavior issues; infection control; food preparation and storage; and observation/reporting skills.
Residential care. Direct care staff must complete six hours of job related pre-service orientation covering the philosophy of residential care, review of residents’ unique needs, use of the service plan, nurse delegation, fire evacuation plans, and instruction in universal precautions. Training in the abdominal thrust, CPR and basic first aid training is recommended but not required. Twelve hours of in-service training must be completed annually.
Non-direct care staff must complete four hours of job related pre-service training that will include a review of the philosophy of residential care, 24 fire safety and fire evacuation plan, emergency procedures and instructions in universal precautions.
Assisted living and residential care owners, administrators, and staff must satisfy a criminal records clearance under OAR Chapter 410, Division 007, and sign a criminal record authorization, Form SDS 303. A fingerprint check may be required.
Assisted living. State or Area Agency on Aging staff conduct periodic monitoring visits at least every two years. The facility must develop and conduct an ongoing quality improvement program that evaluates services, resident outcomes and resident satisfaction.
Residential care. Facilities are inspected at least every two years. Facilities not in compliance with the rules will submit a plan of correction that satisfies the Department within 10 days of receipt of the inspection report. In addition, the Department may impose sanctions for failure to comply with the licensing rules. Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment and other areas of operation.
$60 per facility.
For Alzheimer’s Care Units, there is a non-refundable endorsement fee that must accompany each application and upon license renewal. Fees are as follows:
- 16 or fewer residents: $50
- 17-50 residents: $75
- 100 or more residents: $100
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