Assisted Living/Community Residential Care Facilities, R61-84
General Approach and Recent Developments
The State changed its licensing term to assisted living/community residential care facilities when revised regulations were adopted in July 2001. A Medicaid state plan amendment creating the integrated personal care program in community residential care facilities was implemented in 2002. Criminal background check guidelines were issued in October 2002. The 1976 State Code was amended by adding Section 40-30-980, allowing for the provision of selected prescribed medications by unlicensed persons with documented medication training and a skill competency evaluation.
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Community residential care facility (CRCF). “A facility which offers room and board and which, unlike a boarding house, provides/coordinates a degree of personal assistance for a period of time in excess of twenty-four consecutive hours for two or more persons, eighteen years old or older, not related to the licensee within the third degree of consanguinity. It is designed to accommodate individual residents’ changing needs and preferences, maximize residents’ dignity, autonomy, privacy, independence and safety, and encourage family and community involvement. Included in this definition is any facility (other than a hospital) which offers or represents to the public that if offers a beneficial or protected environment specifically for individuals who have mental illness or disabilities.” These facilities may be referred to as Assisted Living provided they meet the definition of a community residential care facility.
Alzheimer’s Special Care Unit or Program. “A facility or area within a facility providing a secure, segregated special program or unit for residents with a diagnosis of probable Alzheimer’s disease and/or related dementia to prevent or limit access by a resident outside the designated or separated areas, and that advertises, markets, or otherwise promotes the facility as providing specialized care/services for persons with Alzheimer’s disease and/or related dementia or both.”
Bedrooms must offer 100 square feet for single rooms and 80 square feet per resident in multiple occupancy rooms. No more than three residents may share a room. One toilet is required for every six residents and one tub/shower for every eight residents. Pets are allowed.
Facilities may only admit adults and may not admit anyone who is likely to endanger themselves or others, anyone suffering from acute mental illness, anyone needing hospital or nursing home care, or anyone needing continuous daily attention of a licensed nurse. Short term, intermittent nursing needs may be met by a Home Health Agency. Facilities must transfer anyone whose needs cannot be met by the facility in combination with services provided by hospice agencies or home health agencies. In June 2002, a list was issued that clarified who may not be served in CRCFs. The list includes:
- Daily skilled monitoring/observation due to an unstable/complex medical condition;
- Serious aggressive, violent, or socially inappropriate behavioral symptoms;
- Medications that require frequent dosage adjustment, regular intra-muscular and subcutaneous injections;
- Intravenous medications or fluids;
- Care of urinary catheter that cannot be cared for by the resident;
- Treatment of Stage II, III, or IV decubitus, or multiple pressure sores;
- Naso-gastric tube feeding;
- Tracheostomy or sterile care that cannot be managed by the resident;
- Receiving oxygen for the first time, which requires adjustment and evaluation of oxygen concentration;
- Dependency in all ADLs for more than 14 days; and
- Sterile dressing changes.
Nursing Home Admission Policy
Individuals qualify for an intermediate level of care if they need one of four intermediate services or meet two of four functional deficits. The criteria require either monitoring of significant medical conditions; dementia or behavior problems; or impairments requiring extensive assistance with five ADLs. The services include:
- Daily monitoring of a significant medical condition requiring overall care planning to maintain optimum health status;
- Supervision of moderate/severe memory impairment, manifested by disorientation, bewilderment, and forgetfulness which requires significant intervention in overall care planning;
- Supervision of moderately impaired cognitive skills; and
- Supervision of moderate problem behaviors manifested by verbal or physical abusiveness or socially inappropriate/disruptive behavior.
The functional deficits are:
- Requires extensive hands-on assistance with dressing and toileting and eating and physical help in bathing;
- Requires extensive assistance with locomotion;
- Requires extensive assistance to transfer;
- Requires frequent assistance with bladder or bowel care or with daily catheter or ostomy care.
Facilities must provide appropriate assistance with ADLs, meals, special diets, medication assistance, at least one structured recreation activity each day, and transportation. Personal care includes assistance with ADLs; assistance with making appointments and arranging transportation to receive supportive services required in the care plan; being aware of the resident’s whereabouts; monitoring resident activities to ensure health, safety, and well-being, and arranging for routine and emergency health services, podiatry, dental, counseling, and medications.
An assessment of resident needs must be completed by a direct care staff member no later than 72 hours after admission. The facility must develop an individualized care plan with participation by the resident, administrator, and/or the sponsor or responsible party when appropriate, within seven days of admission. The plan must be reviewed and/or revised as changes in resident needs occur, but not less than semi-annually. The rules specify the content of the care plan.
Three meals and snacks that meet dietary needs must be provided. Tray service is not permitted unless the resident is medically unable to go to the dining room or occasionally if the resident prefers. There must be trained staff/volunteers supervising food services who have a knowledge of food values to make appropriate substitution. If special diets are provided, the menus must be prepared by a professionally qualified dietician or reviewed by the physician or other qualified medical provider. The rules contain required servings by food group.
The written agreement explains the specific care/services/equipment provided by the facility (administration of medications, special diets, assistance with ADLs), the fees for care/services/equipment, notice requirements for changes in fees, the dates a resident will receive their personal needs allowance, transportation policy, discharge/transfer provisions, and a statement of resident rights and the grievance procedure.
Provisions for Serving People with Dementia
Legislation passed in 1996 requires facilities advertised as special care facilities serving residents with Alzheimer’s disease to disclose the form of care and treatment that distinguishes it as being suitable for people with Alzheimer’s disease, the admission/transfer and discharge criteria, care planning process, staffing and training, physical environment, activities, the role of family members, and the cost of care. Staff must receive training in the care of persons with dementia, communication techniques, understanding and coping with behaviors, safety, activities, and other related topics.
Facilities may administer medications and are responsible for ascertaining that medications are taken by residents in accordance with physicians’ orders. Non-licensed staff may administer medications if they have been trained by appropriately licensed individuals. Administration of medications has been expanded to include oral and topical medications, regularly scheduled insulin anaphylactic treatments under established medical protocols in addition to insulin and epinephrine injections. Flu injections and TB screening are performed by licensed nurses. Staff must verify orders for self-administration of medications.
The “integrated personal care program,” implemented in 2002, provides coverage of personal care in residential settings under the Medicaid state plan. The program serves elders, adults with disabilities, MR/DD, and individuals with mentally illness. To be eligible for coverage, beneficiaries must already receive the optional state supplement to the SSI program, which is available to persons residing in community residential care facilities, and require assistance with two ADLs, or need assistance with one ADL and have a cognitive impairment, be unable to live alone due to inadequate support, and need assistance to sustain maximum functional level. Facilities must contract with a licensed nurse at least one day a week who is responsible for providing personal care training to staff, and developing and monitoring care plans of individuals served by the integrated personal care program. Facilities participating in the integrated personal care program must be able to provide medical monitoring, medication administration, personal care and also be ADA compliant. The program contracts with 35 facilities serving 600 participants. Facilities receive $1,055 per participant per month, on average. This rate is calculated using a standard formula, and is comprised of a reduced optional state supplement payment, resident funds, and an integrated personal care program daily rate of $12.80 per participant per day. The optional state supplement is reduced by a calculated amount in order to draw down Medicaid match for the daily rate.
The optional state supplement program cap is $912 per month. The facility receives $865 per month for room, board and services and the resident retains a $47 personal needs allowance. Family supplementation is not allowed.
At least one staff member shall be available for every eight residents during the day and one per 30 residents at night. Facilities with more than eight residents must have one staff member awake and dressed at night. Awake staff are required in facilities of less than eight if there are residents with dementia. In multi-story buildings, staff must be on each floor at all times that residents are present.
Administrators must be licensed by the South Carolina Department of Labor, Licensing and Regulation, and be mentally and emotionally capable of meeting the responsibilities involved in operating the facility in order to ensure the facility is in compliance with the regulations and shall demonstrate adequate knowledge of the regulations.
Staff. In-service training programs shall be planned and provided for all personnel and shall include at least: basic first aid; procedures for checking and recording vital signs; care of persons with communicable diseases; use of restraints; medication management; care for persons with dementia (if applicable); CPR; confidentiality and residents’ rights; OSHA standards for blood borne pathogens; and fire response training. Staff receive basic information on these topics during orientation. Training shall be provided on a continuous basis and not less than annually.
Staff must not have any prior convictions or pleas of nolo contendere for child or adult abuse, neglect, or mistreatment, and facilities must check appropriate registries.
Facilities are inspected prior to licensure and at least every three years or more frequently as needed. Facilities must submit a plan of correction to the State licensing agency when issues of noncompliance are documented. A schedule for monetary penalties is included in regulation. Consultations are available as requested by facilities or as deemed appropriate by the State.
Facilities must have a written quality improvement program. The program must establish desired outcomes and the criteria by which effectiveness is accomplished; identify and evaluate the causes of deviation from desired outcomes; develop action plans to prevent future deviations; establish quality indicators; analyze appropriateness of care plans; review all incidents and accidents including resident deaths, and infection or other occurrences that threaten the health and safety of residents; and create a systematic method of obtaining feedback from residents and other interested parties on the level of satisfaction with care and services received.
$10 per bed or $75 whichever is greater.
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