Boarding homes, Chapter 388-78A
Assisted living (Medicaid), Chapter 388-110 WAC
General Approach and Recent Developments
Revisions to the licensing regulations and Medicaid contracting requirements will be effective September 2004 following public hearings in July. The revisions clarify that boarding homes will be allowed, but not required to, provide assistance with ADLs, and intermittent health support. However, facilities that do provide assistance with ADLs will address all ADLs defined by rule and will not be allowed to select among ADLs. Provisions formerly included in the Medicaid contracting requirements, e.g., negotiated service plans, have been included in the general licensing rules.
Separate requirements are used for boarding homes contracting with the Medicaid program as assisted living providers. The State has a grant from the Coming Home Program to expand affordable assisted living in rural areas. Medicaid regulations were issued in 1996 for licensed boarding homes that contract with Medicaid for residential care services that cover assisted living, enhanced adult residential care, and adult residential care. Enhanced residential care facilities provide limited nursing services and personal care while adult residential care facilities provide only personal care.
The Medicaid contracting standards require that contractors ensure that both the physical environment and the delivery of assisted living services are designed to enhance autonomy in ways which reflect personal and social values of dignity, privacy, independence, individuality, choice and decision-making of residents. The contractor shall provide the resident services in a manner which: makes the services available in a homelike environment for residents with a range of needs and preferences; facilitates aging in place by providing flexible services in an environment that accommodates and supports the resident's individuality; supports managed risk which includes the resident's right to take responsibility for the risks associated with decision-making; and develops a formal written, negotiated plan to decrease the probability of a poor outcome when a resident's decision or preference places the resident or others at risk, leads to adverse consequences, or conflicts with other residents' rights or preferences.
|NOTE: The summary below is based on proposed licensing regulations and contracting requirements for dementia facilities.|
Boarding home means any home or other institution, however named, which is advertised, announced, or maintained for the express or implied purpose of providing housing, basic services, and assuming general responsibility for the safety and well-being of the residents, and may also provide domiciliary care, consistent with this chapter, to seven or more residents after July 1, 2000. However, a boarding home that is licensed for three to six residents prior to or on July 1, 2000, may maintain its boarding home license as long as it is continually licensed as a boarding home. “Boarding home” does not include facilities certified as group training homes…nor any home, institution or section thereof which is otherwise licensed and regulated under the provisions of state law providing specifically for the licensing and regulation of such home, institution or section thereof. Nor shall it include any independent senior housing, independent living units in continuing care retirement communities, or other similar living situations including those subsidized by the Department of Housing and Urban Development.
Medicaid. Medicaid covers services in three types of boarding homes: assisted living, adult residential care and enhanced adult residential care. “Assisted living services is a package of services, including personal care, intermittent nursing services and medication administration services, that the department contracts with a licensed boarding home to provide in accordance with Parts I and II of this chapter.” Homes that contract to provide assisted living services must offer private apartment-like units.
“Adult residential care is a package of services, including personal care services, that the department contracts with a licensed boarding home to provide in accordance with Parts I and IV of this chapter.”
“Enhanced adult residential care is a package of services, including personal care services, intermittent nursing services, and medication administration services that the department contracts with a licensed boarding home to provide in accordance with Parts I and III of this chapter.”
Boarding home. Rooms must offer 80 square feet for single occupancy and 70 square feet per person in multiple occupancy rooms. One toilet and sink is required for every eight residents, and one bathing fixture is required for every twelve residents. Two residents may share a sleeping room that has less than 140 square feet if they have an apartment with a total square footage of 220 square feet, excluding the bathroom, and they agree to share the sleeping room.
Medicaid. To contract with Medicaid under the Assisted Living contract, facilities must provide individual units with 220 square feet including counters, closets and built-ins, and excluding the bathroom. Existing facilities may have a minimum of 180 square feet. The kitchen area must have a refrigerator, microwave or stove top, and a counter or table for food preparation. New facilities must also have a sink and counter area and storage area. Units must have lockable entry doors and a living area wired for telephone and television service, where available. Facilities must provide a home-like environment that provides residents with an opportunity for self-expression, and encourages interaction with the community, family and friends.
Boarding homes may accept and retain an individual as a resident in a boarding home only if:
- The boarding home can meet the individual's needs, including providing any specialized training to resident-care staff persons that may be required;
- The individual's health care condition is stable and predictable, as determined jointly by the boarding home and the resident or the resident's representative if appropriate. When residents require services of a licensed nurse, the registered nurse must specifically assess, determine and document in the resident's record if the resident's health care condition is stable and predictable. Residents who do not require the services of a licensed nurse on the boarding home premises are assumed to have stable and predictable conditions;
- The individual is ambulatory, unless the boarding home is approved by the Washington state director of fire protection to care for semi-ambulatory or non-ambulatory residents; and
- The individual meets the acceptance criteria the boarding home described in the boarding home's disclosure information.
Nursing Home Admission Policy
Individuals eligible for admission to a nursing home and COPES waiver services must meet one of four criteria.
- Require care provided by or under the supervision of a registered nurse or a licensed practical nurse on a daily basis;
- Have an unmet need requiring substantial or total assistance with at least two or more of the following ADLs: eating, toileting, ambulation, transfer, positioning, bathing and self-medication;
- Have an unmet need requiring minimal, substantial or total assistance in three or more of the above ADL; or
- Have a cognitive impairment and require supervision due to one or more of the following: disorientation, memory impairment, impaired judgment, or wandering and have an unmet or partially met need with at least one or more of the ADLs.
Boarding homes. Residents receive a preadmission assessment that covers medical history; necessary and contraindicated medications; a licensed medical or health professional's diagnosis; significant known behaviors or symptoms that may cause concern or require special care; mental illness diagnosis, except where protected by confidentiality laws; level of personal care needs; activities and service preferences; and preferences regarding other issues important to the applicant, such as food and daily routine. An initial service plan is prepared to identify the resident's immediate needs and provide direction to staff and caregivers relating to the resident's immediate needs, capabilities, and preferences. Assessors must have a master’s degree and two years experience or a bachelor’s degree and three years experience, or be a registered nurse, physician or have three years successful experience completing assessments in a boarding home. Comprehensive assessments must be completed within 14 days following the date the resident moves in, and are required annually. The regulations identify the topics that must be included in the assessment.
Negotiated service agreements must be developed based upon discussions with the resident and the resident's representative, and the preadmission assessment of a qualified assessor. The service agreement includes the care and services necessary to meet the resident's needs, defined roles and responsibilities of the resident, the boarding home staff, and resident's family or other significant persons in meeting the resident's needs and preferences; the times services will be delivered, including frequency and approximate time of day, as appropriate; the resident's preferences for activities and how those preferences will be supported; appropriate behavioral interventions, if needed; a communication plan, if special communication needs are present; the resident's ability to leave the boarding home premises unsupervised; and a prohibition against waiving resident rights, or holding resident’s liable for loss of personal property or injury.
Boarding homes must provide activities, housekeeping, laundry, meals and nutritious snacks and provide for the general safety and well being of the resident, which means providing prescribed low sodium diets, diabetic diets, mechanical soft foods, emergency assistance, monitoring, arranging health care appointments; coordinating health care services with outside providers; and assisting residents to obtain and maintain eye glasses, hearing aids, dentures and other devices. Boarding homes may provide optional services such as assistance with ADLs (bathing, dressing, eating, personal hygiene, transferring, toileting, mobility) and health support services (blood glucose testing, puree diets, calorie controlled diabetic diets, dementia care, mental health care and developmental disabilities care). Homes that do not provide assistance with ADLs may only admit residents who are independent.
Intermittent nursing services (medication administration, administration of health treatments, diabetic management, non-routine ostomy care, tube feeding and nurse delegation) may be provided and any limitations, additional services or conditions must be disclosed. Facilities must implement systems that support the safe practice of nursing.
Homes may also provide adult day care services for non-residents.
Medicaid. A formal written negotiated plan, which involves the resident, appropriate staff, the Aging and Disability Services Administration (ADSA) case manager and family members, must be completed. The contractor must provide the services agreed upon in the resident's negotiated service agreement and approved by the department case manager, including any reasonable accommodations required; and provide the resident and case manager with a copy of the negotiated service agreement.
The State's nurse practice act was amended and allows RNs to delegate tasks to nursing assistants in licensed boarding homes. Nursing assistants must complete a core training program and may perform the following delegated nursing tasks: oral and topical medications and ointments; nose, ear, eye drops, and ointments; dressing changes and catheterization; suppositories, enemas, and ostomy care; blood glucose monitoring; and gastronomy feeding in established and healed condition. Delegation is at the discretion of the nurse and only for people whose conditions are stable and predictable.
The regulations require three meals a day at regular intervals and no more than 14 hours between the evening meal and breakfast the next day unless a nutritious snack is provided. Menus must be written at least one week in advance and delivered to residents' rooms or posted where residents can see them. Menus provide a variety of foods and are not repeated for at least three weeks, except that breakfast menus in boarding homes that provide a variety of daily choices of hot and cold foods are not required to have a minimum three-week cycle.
Provisions regarding agreements are contained in the State’s resident rights statute. This law requires that facilities inform residents or their representative of the services, items, and activities customarily available in or arranged by the facility; the charges, including charges for items that are not included in the per diem rate; and the rules of operation. Facilities must also fully disclose to potential residents their service capabilities.
Boarding homes are required to complete a thorough disclosure forms that includes required a description of required services, level of ADL assistance, intermittent nursing services, help with medications, policy on services arranged by residents, care for residents with dementia, developmental disabilities and mental illness, transportation, ancillary services, smoking policy, payments, “bed hold” policy, Medicaid support, fire protection and security features and the licensing status.
Potential residents must be informed of their rights regarding health care decision making consistent with applicable state and federal laws and rules, before or at the time the individual moves into the boarding home.
Provisions for Serving People with Dementia
All boarding homes that serve residents with dementia must obtain information about the resident’s significant life experiences; ability to articulate personal needs and initiate activity; patterns of behavior that express concerns such as wandering, agitation, resistance to care, social isolation and aggression. Egress control may not restrict resident’s who are able to leave the home safely. Appropriate sprinkler and fire alarm systems are required for areas of restricted egress. Control devices must automatically de-activate when the fire alarm or sprinkler activates.
The training regulations require that staff receive training on: introduction to the dementias; dementia, depression, and delirium; resident-based caregiving; dementia caregiving principles; communicating with people who have dementia; sexuality and dementia; re-thinking “problem” behaviors; hallucinations and delusions; helping with activities of daily living (ADLs); and working with family and friends.
Homes that contract with Medicaid to provide enhanced adult residential-specialized dementia care have to meet additional standards. “Enhanced adult residential care-specialized dementia care services” is a package of services, including specialized dementia care assessment and care planning, personal care services, intermittent nursing services, medication administration services, specialized environmental features and accommodations, and activity programming. Contractors must complete a full re-assessment of residents on a semi-annual basis; and maintain awake staff twenty-four hours per day. The contractor must provide staffing that is adequate to respond to the assessed sleeping and waking patterns and needs of residents; and develop and implement policies and procedures. The contractor must have a plan that identifies the professional who will provide the consultation, and when and how the consultation will be utilized to manage residents who may wander; and outline actions to be taken in case a resident elopes.
Each staff who works directly with residents must have at least six hours of continuing education per year related to dementia, including Alzheimer's disease, that include but are not limited to the following topics: aggressive behaviors and catastrophic reactions; agitation and caregiving strategies; delusions and hallucinations; dementia problem-solving strategies; depression and dementia; fall prevention for dementia; personal care as meaningful activity; promoting pleasant and purposeful activity; and resistance to care.
On a daily basis, the contractor must provide residents access to opportunities for independent, self-directed activities and offer opportunities for activities that accommodate variations in a resident's mood, energy and preferences. Multiple common areas must be available, at least one of which is outdoors, that vary by size and arrangement such as: various size furniture groupings that encourage social interaction; areas with environmental cues that may stimulate activity, such as a resident kitchen or workshop; areas with activity supplies and props to stimulate conversation; a garden area; and paths and walkways that encourage exploration and walking.
Boarding homes must provide medication assistance and may provide medication administration. Medication Administration means the direct application of a prescribed medication whether by injection, inhalation, ingestion, or other means, to the body of the resident by a person legally authorized to do so. Medication assistance means assistance with self-administration of medication rendered by a non-practitioner to a resident of a boarding home in accordance with chapter 246-888 WAC.
The State reimburses for assisted living services, enhanced adult residential care and adult residential care under an HCBS waiver and the Medicaid State plan. All three levels of services are provided by licensed boarding homes that contract with Medicaid. Enhanced adult residential care and assisted living services are provided to HCBS waiver participants. Adult residential care services are provided under the Medicaid state plan.
Assisted living services is a package of services, including personal care and limited nursing services, that the department contracts with a licensed boarding home to provide. The regulations require that assisted living services be provided to a resident in a private apartment-like unit.
Enhanced adult residential care is a package of services, including personal care and limited nursing services, that the department contracts with a licensed boarding home to provide.
Adult residential care is a package of services, including personal care services, that the department contracts with a licensed boarding home to provide.” WAC 388-110-120 et seq. The contracting regulations set standards in addition to the licensing rules.
The State replaced a four tiered payment methodology with 12 classifications for residential settings that include regional variations. The rates are based on components for provider staff, operations, and capital costs. The rates include an amount ($505.16 a month) paid by residents for room and board costs. The SSI payment standard is $564 a month in 2004 and therefore, the PNA would be $58.84. In addition to the service amounts, a capital add-on is available for newly constructed facilities whose capital costs exceed the room and board allowance. Criteria for allowing family supplementation of resident income for room and board are being revised. The pending changes may allow supplementation in limited circumstances.
|Assisted living services||205||4,404||206||3,762||168||2,919|
|Enhanced adult residential care||163||888||166||NR||NR||NR|
|Adult residential care||158||443||167||NR||NR||NR|
|NOTE: Facilities may contract for more than one level of service.|
Staff must be sufficient to furnish services and care needed by residents consistent with the negotiated service agreements, maintain the home free of safety hazards, and implement fire and disaster plans.
Boarding home administrators must be 21 and qualify under a number of provisions. Individuals may serve as an administrator if they were actively employed as a boarding home administrator and met existing qualifications on September 1, 2004; hold a current state nursing home administrator license; obtained a certificate for completing administrator training; or have other combinations of education and experience. Administrators must complete training in the statutes covering boarding homes; criminal history background checks; abuse of vulnerable adults; resident rights; and long-term care services training.
Boarding home staff receive orientation and training on the organization of the boarding home; its physical boarding home layout; their specific duties and responsibilities; how to report resident abuse and neglect consistent with chapter 74.34 RCW and boarding home policies and procedures; policies, procedures, and equipment necessary to perform duties; needs and service preferences identified in the negotiated service agreements of residents with whom the staff persons will be working; and resident rights, including without limitation, those specified in chapter 70.129 RCW. Managers must develop and implement a process to ensure caregivers have information from the preadmission assessment, on-going assessment and negotiated service agreement relevant to providing services to each resident with whom the caregiver works; are informed of changes in the negotiated service agreement of each resident with whom the caregiver works; and are given an opportunity to provide information to responsible staff regarding the resident when assessments and negotiated service agreements are updated for each resident with whom the caregiver works.
Direct care staff must also complete a basic training program that covers core knowledge and skills that caregivers need in order to provide personal care services effectively and safely and pass a competency test. DSHS must approve basic training curricula.
The boarding home must ensure that staff have a criminal history background and homes may not hire individuals convicted of a crime against persons as defined in RCW 43.43.830; financial exploitation as defined in RCW 43.43.830; found in any disciplinary board final decision to have abused a vulnerable adult under RCW 43.43.830; the subject in a protective proceeding under chapter 74.34 RCW; convicted of criminal mistreatment; or found by the department to have abused, neglected, or exploited a vulnerable person in any matter in which an administrative hearing due process right is offered and the finding is upheld through the hearing process or the individual failed to timely appeal the finding.
The licensing agency makes periodic inspection and survey visits. The licensing agency dropped “quality improvement consultation” because of budget reductions. The service, provided upon request, helps facilities understand regulatory requirements and share best practices. Funds to continue the program have not been approved.
Case managers are a primary source of monitoring for quality assurance for Medicaid beneficiaries. During regular visits, the case manager checks to see if the client is satisfied, the negotiated service plan is being carried out, and that the plan is appropriate for the resident.
Homes may maintain a quality assurance committee that includes a licensed registered nurse, the administrator and three other members from the staff of the boarding home. When established, committees meet at least quarterly to identify issues that may adversely affect quality of care and services to residents and to develop and implement plans of action to correct identified quality concerns or deficiencies in the quality of care provided to residents. To promote quality of care through self-review without the fear of reprisal, and to enhance the objectivity of the review process, the department shall not require, and the long-term care ombudsman program shall not request, disclosure of any quality assurance committee records or reports, unless the disclosure is related to the committee's compliance with this section, if: the records or reports are not maintained pursuant to statutory or regulatory mandate; and the records or reports are created for and collected and maintained by the committee.
Facilities are charged $79 annually per licensed bed. An additional $150 is payable for facilities receiving a third site visit because of failure to respond adequately to deficiencies or facilities receiving a full out-of-sequence inspection resulting from information gathered during a complaint investigation.
|January 1, 2004 Adsa Community Residential Daily Rates|
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