Assisted Care Living Facilities, Rules of the Department of Health, Chapter 1200-8-25 et seq.
Homes for the Aged, Chapter 1200-8-11
General Approach and Recent Developments
Assisted care living facility rules were revised in 2003. Changes were made in the provisions for the reporting of unusual events, policies and procedures for health care decision-making for incompetent residents, and the retention of residents.
Several legislative proposals dealing with fire safety are being considered in the 2004 Legislative session. Legislation requiring sprinklers in all nursing homes, Assisted Care Living Facilities (ACLFs), and Residential Homes for the Aged passed. Most ACLFs already meet the requirement for sprinklers, as the rules and licensing of ACLFs did not go into effect until 1998. ACLFs that were exempted from the requirements now have to submit a plan to come into compliance.
|Assisted care living facilities||184||10,669||178||10,495||160||8,691|
|Homes for the aged||155||3,230||166||3,307||198||3,994|
Assisted care living facility (ACLF) means a building, establishment, complex, or distinct part thereof which accepts primarily aged persons for domiciliary care and which provides on site to its residents room, board, non-medical living assistance services appropriate to the residents' respective needs, and medical services as prescribed by each resident's treating physician, limited to the extent not covered by a physician’s order to a home care organization and not actually provided by a home care organization. An ACLF may directly provide such medical services as medication procedures, topicals, suppositories and injections (excluding intravenous) pursuant to a physician’s order, and emergency response. All other skilled nursing services (part-time or intermittent nursing care, physical occupation and speech therapy, medical social services, medical supplies other than drugs and biologicals, and durable medical equipment) that a home care organization is licensed to provide may be provided in the facility only by a licensed home care organization, except for home health aide services.
Home for the aged means a home which accepts aged persons for relatively permanent, domiciliary care. A home for the aged may be any building, section of a building, or distinct part of a building, a residence, a private home, a boarding home for the aged, or other place, either for profit or not, which provides, for a period exceeding 24 hours, housing, food services, and one or more personal services for one or more aged persons who are not related to the owner or administrator by blood or marriage. Homes for the aged must have agreements with a physician who is available to render care or who will come to the home to visit residents when necessary and with a nursing home that will accept its residents who must be discharged.
Assisted care living facility. A minimum of 80 square feet of bedroom space must be provided for each resident. No more than two residents may share a bedroom. No more than six residents may share a toilet, lavatory, bath, or shower.
Home for the aged. Each resident must have at least 80 square feet of bedroom space. Bedrooms may not have more than two beds, and privacy screens or curtains must be provided and used when requested by the resident. Beds with full side rails, potty chairs, bedpans, or urinals shall not be used routinely in residents' rooms. Residents' rooms must always be capable of being unlocked by the resident.
Assisted care living facilities may not admit or retain anyone who: is in the later stages of Alzheimer's disease, requires physical or chemical restraints, poses a serious threat to self or others, requires nasopharyngeal and tracheotomy aspiration, requires initial phases of a regiment involving administration of medical gases, requires a Levin (or nasogastric) tube, requires arterial blood gas monitoring, is unable to communicate his or her needs, or requires treatment of Stage III or IV decubitus ulcer or exfoliative dermatitis.
Facilities may not admit, but may retain for 21 days, any resident requiring intravenous or daily intramuscular injections or intravenous feedings; gastronomy feedings; insertion, sterile irrigation, and replacement of catheters, except for routine maintenance of Foley catheters; or requiring sterile wound care.
Under regulatory changes adopted in 2003, if a resident’s condition is stable, and the resident is able to care for his or her condition without the assistance of facility personnel or home health care and has a documented history of self-care for their medical condition for at least one year which is documented by a physician and a part of the medical record, a facility may accept for admission and allow the continued stay of a person who has in place a gastrostomy tube or percutaneous endoscopic gastrostomy tube, has in place a catheter that is their sole means of elimination of waste, or requires the routine administration of oxygen. If a person is no longer able to self-care for his or her medical condition(s), the facility must immediately transfer the resident to a licensed nursing home or hospital.
Residents with these conditions may be retained longer than 21 days if the Health Department is notified and does not object. However, residents may not be retained after 21 days if they require four or more skilled nursing visits per week for any other condition.
Home for the aged. Residents who need continual professional medical/nursing observation and/or care cannot be admitted or retained. Residents who require more technical nursing care or medical care than the personnel and the facility can lawfully provide shall be transferred to a hospital or nursing home. Homes for the aged cannot admit a person whose primary diagnosis is a mental health condition which clearly endangers himself or others and/or who is receiving active treatment from a mental health facility for a condition which clearly endangers himself and others. Homes for the aged may serve people with mental health conditions, but these residents may not make up more than 50 percent of the home’s residents. Persons in the early stages of Alzheimer’s disease and related disorders may be admitted if an interdisciplinary team made up of a physician who is experienced in the treatment of Alzheimer’s disease, a social worker, registered nurse, and a family member (or patient care advocate) determines that care can appropriately and safely be given in the home for the aged. Such residents must be reviewed at least quarterly as to the appropriateness of placement in the home.
Nursing Home Admission Policy
Care must be expected to improve or ameliorate the individual’s physical or mental condition, prevent deterioration in health status, or delay progression of a disease or disability. Individuals must have a condition that requires daily in-patient nursing care and need help with one or more of the following: transfer to and from bed, chair or toilet; mobility; eating; toileting (including use of toilet or incontinence care); expressive or receptive communication; orientation; medication administration; behavior; or skilled nursing or rehabilitative services at a greater frequency, duration, or intensity than can practically be provided through a daily home health visit. Assistance with ADLs must be daily or multiple times per week. Nursing care includes observation and assessment, administration of legend drugs, supervision of nurses aides, and other skilled nursing therapies performed by LPNs or RNs.
Assisted care living facility. Personal services include supervision and assistance with ADLs (but not nursing or medical care). Medical services such as medication procedures, administration of medications, emergency response services, and home care organization services prescribed by a physician and as allowed by law may be offered.
Home for the aged. Assistance and supervision with medications is allowed and medications may be administered by a licensed nurse. Homes for the aged may not care for residents who require restraint, and so must not use restraints. Homes may provide personal care such as bathing, dressing, and grooming of hair, fingernails, and toenails. Laundry and linen services, food service, and recreational activities are also provided.
Dietary services must be directed and staffed by adequate qualified personnel. An outside company may provide food services if they have a dietician available. An employee who is qualified by experience or training must serve as director of food and dietetic services. The facility must have access to a qualified dietician. Three meals a day are required that constitute an acceptable and/or prescribed diet. Therapeutic diets must be prescribed by a practitioner.
Agreements must include the procedure for handling transfers or discharges. Accurate written statements regarding fees and services must be provided upon admission but are not part of the agreement.
Changes in 2003, require that each facility maintain and establish policies and procedures governing the designation of a health care decision-maker for making decisions on behalf of a resident who is incompetent or who lacks decision-making capacity, including but not limited to allowing the withholding of CPR measures from individual residents. The facility must inform the resident and/or the resident’s decision-maker of these policies and procedures upon admission or at such time as is appropriate. Rules also require a facility to identify who the decision-maker will be for a person who is incompetent or who lacks decision-making capacity.
Provisions for Serving People with Dementia
Residents in all but the latter stages of Alzheimer’s disease may be admitted only after determination by an interdisciplinary team that care can be safely and appropriately provided. This determination must be reviewed quarterly. Facilities with secure units must report on a series of items normally included in disclosure provisions such as: assessments by multi-disciplinary teams and reviews; number of deaths, hospitalizations and incidents; staffing pattern and ratios; daily group activities; and staff training.
Assisted care living facility staff may assist with self-administration of medications. A licensed professional may administer medications within the scope of his or her license.
The Department of Health developed medication guidelines that outline 3 levels: (1) medication observation/assistance includes reading of labels and verbal prompting; (2) self-administered medication means that a resident is independent with medications; (3) medication administration is allowed by licensed professional staff only.
Assisted care living facilities. The licensing law does not authorize Medicaid coverage for medically necessary home care services provided in an assisted care living facility. The State recently received approval to expand its Medicaid waiver statewide. Although assisted living is not a covered service, facilities are reimbursed for respite care. Eligible waiver beneficiaries may receive up to nine days of respite care per year at a rate of $91.93 per day. There is no state supplement to the federal SSI payment for assisted living.
Home for the aged. Personal care is not funded by Medicaid either as a state plan service or as a waiver service. An SSI pilot program called the Quality Enabling Program provides $525,100 annually to supplement what a facility receives from a resident. The program pays up to $9 a day per resident. This program is only available in 20 counties.
Assisted care living facilities. There must be sufficient staff to meet the needs, including medical services, of residents. Facilities must have a licensed nurse available.
Assisted care living facility administrators. Administrators must be certified biannually. Certification requires 24 classroom hours of continuing education courses approved by the board that includes instruction in the following: state rules and regulations for homes for the aged/ACLFs; health care management; nutrition and food service; financial management; and healthy lifestyles.
Homes for aged administrators. The licensee of a home for the aged must be at least 18 years old. The chief administrator of the home must be certified by the Board as a residential home administrator, unless the administrator is currently licensed in Tennessee as a nursing home administrator. The licensee must have a high school diploma or equivalent; persons serving as a chief administrator of a licensed home for a continuous period of at least nine months prior to January 1990 are exempt from this requirement. Licensees must have at least 24 hours of continuing education each year. Personal care attendants must be at least 18 years old. Facilities with five or more residents whose level of evacuation capability is classified as “slow” must have a responsible attendant on duty and awake at all times.
Assisted care living facility staff. No continuing education is required for direct care staff.
Homes for aged staff must attend any training program which may be required by the Department when such programs are offered without charge in each of the three regions of the State, and no more frequently than annually.
The administrator must not have been convicted of a criminal offense involving abuse or intentional neglect of an elderly or vulnerable individual. Facilities may not employ any person listed on the Department’s abuse registry.
Revised rules in 2003 added language concerning the reporting of unusual events. A facility must report the abuse of a patient or unexpected occurrence or accident that results in death, life threatening or serious injury to a patient to the Department of Health within 7 business days. Circumstances which could result in an unusual event are outlined in regulation. Specific incidents that may result in a disruption of the delivery of health care services at the facility shall also be reported within 7 business days. The facility must file with the Department of Health a corrective action report within 40 days of the identification of the event.
Inspections are conducted each year. The state inspection and monitoring process serves as a regulatory function only. However, when the State develops policy or interpretive guidelines, they do request the input of industry providers. If through the oversight process a particular problem area is identified, the State will work with the assisted living association to provide training and education at association meetings, rather than provide one on one consultation and training to individual providers.
Deficiencies must be addressed by plans of correction. Homes must comply with local fire safety authority regulations.
The Department of Health develops interpretive guidelines for regulations. Department policy was issued to all ACLFs in January 2004 to provide criteria for hospice waivers in ACLFs. Another policy bulletin was issued concerning T.C.A. 68-11-20(5)(A)(i) which prohibits residents with latter stages of Alzheimer’s disease or related disorders from being admitted or retained in an ACLF.
Fees for assisted care living facilities vary with the number of beds:
- Fewer than 25 beds ($600);
- 25 to 50 beds ($800);
- 50 to 74 beds ($950);
- 75 to 99 beds ($1,100);
- 100 to 124 beds ($1,250);
- 125 to 149 beds ($1,400);
- 150 to 174 beds ($1,550); and
- 175 to 199 beds ($1,700).
Facilities with over 200 beds are charged $1,700 plus $150 for every 25 beds or fraction thereof.
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