Assisted living residence, R23-17.4 RCAL
General Approach and Recent Developments
In 2002, the rules changed the licensing category from residential care and assisted living facilities to assisted living residence, added a new section for the resident agreement, increased training requirements for administrators, and made other changes. Legislation was passed in 1997 authorizing the Rhode Island Housing and Mortgage Finance Agency (HMFA), working in collaboration with the Department of Human Services and the Department of Elderly Affairs, to serve up to 200 low- and moderate-income chronically impaired or disabled adults who are eligible for or at risk of entering a nursing home in facilities certified and financed by the HMFA.
The revised regulations were effective February 2004. The changes included a philosophy of care, new quality assurance requirements, staff training, additional requirements for Alzheimer dementia care units, reporting requirements, and a full functional assessment prior to admission, completed by a Registered Nurse.
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Assisted living residence is “a publicly or privately operated residence that provides directly or indirectly by means of contracts or arrangements personal assistance to meet the resident’s changing needs and preferences, lodging, and meals to two (2) or more adults. Assisted living residences include sheltered care homes, and board and care residences, or any other entity by any other name providing the above services which meet the definition of assisted living residence.” There are levels of licensure for residential care and assisted living facilities based on fire code requirements and need for assistance with medications. A residence may have areas within the facility that are licensed separately. The levels are:
Fire code classification:
- Level F1: licensure for residents who are not capable of self preservation; and/or
- Level F2: licensure for residents who are capable of self preservation; or
- Level M1: licensure for residents who require central storage and administration of medications; or
- Level M2: licensure for facilities which only assist residents with self-administration of medications.
Alzheimer’s special care unit/program means any assisted living residence that locks, secures, segregates, or provides a special program or a special unit for residents with a diagnosis of probable Alzheimer or a related disorder, to prevent or limit access by a resident outside the designated or separated areas; and that advertises or markets the residence as providing specialized Alzheimer/dementia care. Facilities must be licensed as an “F1-M1” residence.
The State’s Medicaid waiver defines assisted living as “personal care and services, homemaker, chore, attendant care, companion services, medication oversight (to the extent permitted under state law), therapeutic social and recreational programming, provided in a home-like environment in a licensed community care facility. This service includes 24-hour, on-site response staff to meet unscheduled or unpredictable needs in a way that promotes maximum dignity and independence, and to provide supervision, safety and security.”
Resident rooms may have no more than two beds. Single rooms must have at least 100 square feet in area, and double bedrooms must be at least 160 square feet in area. There must be at least one bath per 10 beds and one toilet per eight beds or fraction thereof on each floor where residents’ rooms are located and not otherwise serviced by bathing facilities within the resident’s room. There must be an area within the resident’s bedroom and/or facility to be under lock for the safe keeping of personal possessions.
The Medicaid waiver allows sharing of units only by the consent of the residents.
Legislation authorizing the demonstration defines a unit as “an apartment, condominium, bed or other dwelling quarters in an assisted living facility as defined by this statute.”
A resident must not require medical or nursing care as provided in a health care facility but who as a result of choice and/or physical or mental limitation requires personal assistance, lodging and meals and may require the administration of medication. A resident must be capable of self-preservation in emergency situations, unless the residence meets a more stringent life safety code. Persons needing medical or skilled nursing care, including daily professional observation and evaluation and/or persons who are bedbound or in need of the assistance of more than one (1) person for ambulation are not appropriate to reside in assisted living residences. However, an established resident may receive daily skilled nursing care or therapy from a licensed health care provider for a condition that results from a temporary illness or injury for up to twenty-one days or if the resident is under the care of a licensed hospice agency provided the assisted living residence assumes responsibility for ensuring that care is received.
Nursing Home Admission Policy
Nursing home residents must require the services of professional and/or qualified technical health personnel such as registered nurses, licensed practical nurses, physical therapists, occupational therapists, speech pathologists, audiologists, or require assistance with activities of daily living including walking, bathing, dressing, feeding, and toileting. The facility must provide these services under the supervision of licensed nursing personnel. Documentation of the nurse review is required monthly. Residences with a full time nurse may conduct the formal nurse reviews quarterly.
A comprehensive assessment, on a form approved by the licensing agency (see http://www.health.ri.gov), is required prior to or during admission covering health, physical, social, functional, activity and cognitive needs and preferences. The form demonstrates that the resident meets the residency criteria and that the residence is able to meet their needs. A written service plan is required within a reasonable time after admission.
Services include twenty-four hour awake adult staffing; personal services; assistance with self-administration of medication or administration of medications by appropriately licensed staff; assistance with arranging for supportive services that may be reasonably required; monitoring health, safety, and well-being; housekeeping; laundry; medication assistance; and reasonable recreational, social services. Nurse review is necessary under all levels of medication licensure. A registered nurse must visit the facility at least once every 30 days to monitor the medication regimen for all residents; evaluate the health status of residents; make necessary recommendations to the administrator; follow up on previous recommendations; and provide signed, written reports to the facility documenting the visit.
Services covered by the demonstration waiver project include: personal care; homemaker; chore; attendant care; companion services; medication oversight; therapeutic, social, and recreational programming; transportation; 24-hour, on-site response staff to meet scheduled or unpredictable needs; and nursing and skilled therapy services which are incidental to the provision of supportive services.
Facilities provide three balanced, varied meals each day and provide a diet that is appropriate to the resident’s medical regimen. The rules reference requirements in other state laws.
Facilities are required to disclose the name of the owner and operator; the level of license with an explanation; admission and discharge criteria; services available; financial terms; terms of the residency agreement and contact information for the department, attorney general fraud and abuse unit, ombudsperson and local police offices.
The residency agreement has been modified and includes resident rights, admission criteria, discharge criteria, discharge policies, the unit to be rented, shared space and facilities, services to be provided or arranged, financial terms (basic rates, extra charges at admission or in the future, deposits and advanced fees and the rate increase policy), special care provisions, resident responsibilities and house rules, initial and ongoing assessment and service plan, and the grievance procedure.
Provisions for Serving People with Dementia
Facilities offering special care must disclose the form of care or treatment provided. The disclosure explains the philosophy and mission, the criteria for occupancy, transfer and termination; the process used for assessment and establishing the plan of service and its implementation, including the method by which the plan of service evolves and is responsive to changes in condition; staff training and continuing education practices; the physical environment and design features appropriate to support the functioning of cognitively impaired adult residents; the frequency and types of resident activities; the involvement in families and family support programs; and the cost of care and any additional fees.
A license for dementia is required when one or more resident's dementia symptoms impact their ability to function as demonstrated by any of the following: safety concerns due to elopement risk or other behaviors; inappropriate social behaviors that adversely impact the rights of others; inability to self preserve due to dementia; a physician's recommendation that the resident needs dementia support consistent with this level; or if the residence advertises or represents special dementia services or if the residence segregates residents with dementia. In addition to the requirements for the basic license, licensing requirements for the “dementia care” level shall include the following: staff training and/or requirements specific to dementia care as determined by the relevant state department; a registered nurse with special training must be on staff and available for consultation at all times; the residence shall provide for a secure environment appropriate for the resident population.
New direct service employees must receive at least twelve (12) hours of orientation and training in understanding various dementias; communicating effectively with dementia residents; managing behaviors.
In M2 level facilities, unlicensed staff may only remind residents to take their medications and observe. M1 level facilities may administer medications including removing medication containers from storage, assisting with removal of a medication from a container, and/or directly administering the medication. Staff must have four hours of training by an RN regarding policies and procedures and have passed an exam based on the training.
The State has two waivers covering assisted living. One waiver covers a broad range of services and includes assisted living for residents who are relocating from nursing homes. Thirteen facilities contract with Medicaid and were serving 30 beneficiaries in 2002. Facilities receive a prospective Medicaid payment based on their customary rate not to exceed $1,400 a month, including room and board covered by SSI. The room and board charge is set by the facility. The SSI benefit, including the state supplement, standard is $1,159 in 2004. Beneficiaries retain $100 a month as a personal needs allowance. Income supplementation is not permitted. Nursing home residents receive case management to assist with relocation to the community. Case managers use community resources to address transitional expenses.
A second 1915 (c) waiver covers case management and assisted living services for elderly and adults with physical disabilities in a demonstration program involving the Department of Elderly Affairs and the Rhode Island Housing Mortgage and Finance Agency to develop affordable projects. Twenty-two facilities were serving 200 beneficiaries. The maximum payment from Medicaid is $37.00 per day for services. The room and board charge, usually between $800 and $900 a month, is separate from the Medicaid payment. The program will only reimburse facilities with single occupancy rooms with private baths. An additional 180 slots have been approved but not yet funded.
SSI beneficiaries that do not receive waiver services retain a PNA of $55 a month.
Facilities must have a responsible adult on the premises at all times, who is in charge of the operation of the facility and who is physically and mentally capable of communication with emergency personnel. All facilities must provide staffing which is sufficient to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psycho-social well being of the residents, according to the appropriate level of licensing.
Administrators must be at least 21 years old and obtain certification as a residential care/assisted living facility administrator or have equivalent training. Certification requirements include a training program covering topics referenced in the regulations. The course work must take place in a college, vocational training, state or national certification program which is approved by the Director of Health. Licensed nursing home administrators are considered certified. Administrators must complete at least 16 hours of continuing education annually.
Staff. New employees receive at least two hours of orientation and training in fire and emergency procedures; recognition and reporting of abuse, neglect, and mistreatment; assisted living philosophy (goals/values: dignity, independence, autonomy, choice); resident's rights; and confidentiality. Employees who have regular contact with residents and provide residents with personal care receive at least ten hours of orientation and training in: basic sanitation and infection control (i.e., universal precautions); food service; medical emergency procedures; basic knowledge of aging-related behaviors; personal assistance; assistance with medications; safety of residents; record-keeping; service plans; reporting; and where appropriate, basic knowledge of cultural differences. In-service training in appropriate topics is also required.
The Medicaid waiver requires a minimum one hour of orientation and twelve hours of annual in-service training for staff. Personal care services for “waiver” certified residents must be provided by Nursing Assistants.
All employees are subject to a nationwide criminal records check through state or local police.
The licensing agency may inspect and investigate facilities as it deems necessary but at least once a year. Representatives of the licensing agency have the right to enter facilities any time without prior notice to inspect the premises and services. Every facility is given notice by the licensing agency of all deficiencies reported as a result of an inspection or investigation. A consultation/collaboration model may be implemented when additional staff are available. The licensing agency noted the importance of having registered nurses and pharmacy consultants available to monitor the assessment process, appropriateness of admission and medication issues.
The new rules require that residences develop, implement and maintain a documented, ongoing quality assurance program to attain and maintain a high quality assisted living residence through an on-going process of quality improvement that monitors quality, identifies areas to improve, methods to improve them, and evaluates the progress achieved. Areas subject to quality assurance review shall include at least personal assistance and resident services; resident satisfaction; and incidents (for example, resident complaints, medication errors, resident falls, and injuries of unknown origin).
The administrator is responsible for maintaining a written plan that includes three areas for quality assurance/improvement review and describe the monitoring, identification, and evaluation processes; tracking methods; and the person responsible for it.
$250 plus $50 per bed. Further increases are proposed for Fiscal Year 2005.
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