Each state summary includes the regulatory or statutory citation and category name and includes a description of the state's approach to assisted living or board and care, the definition, unit requirements, tenant admission and retention policy, services that may be provided, the availability of Medicaid reimbursement for low income residents, medication assistance, staffing requirements, training requirements, background checks and monitoring.
This information was abstracted from state statutes, regulations or draft regulations. Copies of each state's summary were sent to appropriate state officials in April 1998 for their review and comment.
The information for each state is based on statutes, regulations, draft legislation, draft regulations and task force reports. Information from states based on draft material is presented to indicate the potential direction of state policy. Final legislation and rules may vary from the source material.
Assisted living Chapter 420-5-4
Regulations for assisted living were effective in 1991. A task force chaired by the state Department of Public Health was appointed in 1996 and held two meetings. A transcript and comments from task force members were submitted for further action. The Department is now developing significant revisions to the regulations. The primary issues being addressed include aging-in-place, admission/retention criteria and serving people with Alzheimer's disease. Draft revisions will be issued for comment in the Spring and final rules by the Spring of 1999. The State Health Coordinating Committee is also reviewing assisted living. The Committee is interested in covering assisted living under Medicaid and determining the number of nursing facility residents that could be served in an assisted living setting.
The current regulations license three categories of facilities. Congregate assisted living facilities serve 17 or more adults, group assisted living facilities serve 4-16 adults and family assisted living facilities serve 2-3 adults. Since 1992 the number of licensed assisted living facilities has grown from 171 to 207 in 1995 and 261 by March 1998. The number of beds has increased from 3,710 in 1992 to 4,840 in 1995 and 6,222 in 1998.
Assisted living facility "means a permanent building, portion of a building, or group of buildings (not to include mobile homes and trailers) in which room, board, meals, laundry, and assistance with personal care and other services provided are for not less than twenty-four hours in any week to a minimum of two ambulatory adults not related by blood or marriage to the owner and/or administrator."
The regulations do not require separate living and sleeping quarters. Private bedrooms without sitting areas must provide 80 square feet and double rooms 130 square feet. If sitting areas are included, private rooms must be 160 square feet and double rooms 200 square feet. Bath tubs or showers must be available for every eight beds, and lavatories and toilets for every six beds. Lockable doors are permitted.
The regulations provide that assisted living facilities may serve "ambulatory adults who do not require acute, continuous or extensive medical or nursing care and are not in need of hospital or nursing home care." Facilities may not serve anyone with communicable or infectious disease, chronic health conditions requiring extensive nursing care and/or daily medication supervision, persons requiring daily professional observation or the exercise of professional judgement by staff. People who need assistance from more than one person to evacuate a building, show severe symptoms of senility, or require restraint or treatment for addiction to alcohol or drugs may not be admitted or retained. Evacuation. Residents must be ambulatory on admission either aided or unaided by prosthesis.
Assisted living facilities must provide personal care for bathing, oral hygiene, hair care and nail care. Facilities may provide for general observation and may arrange or assist residents to obtain medical attention or nursing services when needed. Home health may be provided by a certified agency as long as residents do not require hospital or nursing home care.
Other than SSI, no public financing is available for assisted living.
Assistance is limited to reminders, reading container labels to the resident, checking the dosage and opening containers. Licensed nurses are allowed to administer medications for residents who do not require acute, continuous or extensive medical or nursing care.
The regulations require at least one staff member per six residents 24-hours a day and personal care staff to meet the needs of residents.
Administrators must have 6 hours of continuing education annually on state law and rules, identifying and reporting abuse, neglect and exploitation, special needs of the elderly, mentally ill and mentally retarded, basic first aide/CPR training; business management; human resource management and plant management and safety.
Staff must receive core training that includes but is not limited to: basic first aid; CPR; bathing, grooming, handling of the elderly - 16 hours; infection control; resident's rights; and the survey process. CNAs in good standing are exempt.
Not specified.
Facilities are monitored through licensing review and periodic inspections by the Board of Health depending on funding for inspectors.
Licensure fees are $200 plus $5 per bed over 10 beds.
Assisted living homes, Alaska Statute § 47.33.005 et seq.; 7 Alaska Administrative Code § 75.010 et seq.
The state's assisted living regulations are being reviewed by the state aging office to strengthen license revocation and appeal procedures and other aspects of the program. Proposed revisions are being developed for public comment. No timetable has been set for issuing revised regulations.
In 1997 legislation was passed requiring a criminal background check on all staff. Prior to 1997, criminal background checks were in regulation but not in statute. Rules to implement the amended law are being drafted. A new methodology for reimbursing Medicaid beneficiaries is also being developed.
The states assisted living law was passed in 1994 to encourage the development of assisted living homes to provide a homelike environment for older persons and persons with a mental or physical disability needing assistance with activities of daily living. The law promotes resident participation in the community, recognizes the resident's right and responsibility to evaluate and make choices concerning the services to be provided. The law provides for licensing assisted living homes for elders, people with dementia, and people with physical, mental or developmental disabilities. The Department of Health and Social Services licenses homes for people with mental or developmental disabilities and the Department of Administration licenses homes for older people, people with dementia and people with physical disabilities. The agencies issued joint regulations in 1995 setting additional requirements and standards.
In March 1998, 78 homes with a total of 478 beds had been licensed by the Division of Senior Services. This total does not include the state's Pioneer Homes which are six state operated homes that also provide supportive services. Of the licensed homes, 85% have five or fewer beds. One home has 60 units which are individual apartments. An estimated 50% of the units are private rooms.
The regulations set minimal requirements which are defined in more detail in policies and procedures. Based on their initial experience, state officials are reviewing the regulations governing the overall enforcement and sanctions procedures to expedite action when warranted; to make the criminal check procedures consistent with those used by other agencies; and to clarify liability insurance requirements. To expedite reviews and maximize staff capacity, the licensure staff conduct regular orientation sessions to explain the program and its requirements to interested providers. The sessions are held about every six weeks and have reduced the amount of staff time spent explaining the application process to individual providers or others interested in obtaining a license.
The law creates "Chapter 33. Assisted Living Homes" to emphasize that assisted living serves as the resident's home. The statute applies to residential facilities serving three or more adults who are not related to the owner of the residence by blood or marriage that provide housing, food service, and provide, obtain or offer to provide assistance with activities of daily living, personal assistance (help with IADLs, obtaining supportive services [recreational, leisure, transportation, social, legal, et. al.], being aware of the resident's whereabouts when traveling in the community, and monitoring activities) or a combination of ADL assistance and personal assistance.
No requirements are specified for the type of unit. Shared rooms are allowed. Facilities must meet life safety code requirements applicable for buildings of its size. Homes for six or more people must meet applicable state and municipal standards for sanitation and environmental protection. In view of the vast expanse and geographic variation within the state, the licensing standards are based on community and neighborhood standards rather than a statewide standard. This allows homes to be licensed that are consistent with prevailing local housing standards.
The home and each resident must sign a residential service contract that describes the services and accommodations to be provided, rates, the rights, duties and obligations of the resident, and the policies and procedures for terminating the contract. Residents who have exceeded the 45 consecutive day limit for receiving 24-hour skilled nursing (see below) may continue to live at the home if the home and the resident or resident's representative have consulted with the resident's physician, discussed the consequences and risks and a revised plan without 24-hour nursing has been reviewed by a registered nurse. Terminally ill residents may continue to reside in the residence if a physician certifies that the person's needs are being met.
Evacuation. These requirements are included in life safety code standards and facility procedures for emergency evacuation drills.
Each resident must have a service plan of care developed within 30 days of move-in that identifies strengths and weaknesses performing ADLs, physical disabilities and impairments, preferences for roommates, living environment, food, recreation, religious affiliation and other factors. The plan also identifies the ADLs with which the resident needs help, how help will be provided by the home or other agencies, and health related services and how they will be addressed. The plan must also identify the resident's reasonable wants and how those will be addressed. If health related services are provided or arranged, the evaluation must be done quarterly. If no health related services are provided, an annual evaluation is required. Assisted living homes may provide intermittent nursing services to residents who do not require 24-hour care and supervision. Intermittent nursing tasks may be delegated to unlicensed staff for tasks designated by the board of nursing. Twenty four hour skilled care may be provided for not more than 45 consecutive days.
In a limited number of cases, room and board and some services are covered by the state's "general relief" program. The payment amounts in the Anchorage area are $30.00 a day for Level I homes, $33.95 for Level II homes and $40.90 for Level III homes.
Services for Medicaid waiver certified individuals in assisted living homes are funded under the state's Choice Program, a Medicaid HCBS waiver. The Senior Services Division is in process of revising the reimbursement methodology which is currently based on levels of care related to the previous licensure categories. Rates vary by area of the state. In the Anchorage area, Level I homes, formerly adult foster care, provide 24-hour awake staff but do not meet unscheduled needs directly and receive $40.38 a day. Level II homes receive $50.89 a day and have staff capacity to meet unscheduled needs, particularly at night. Level III homes receive $61.39 a day. Homes caring for residents needing extra staff (incontinent, skin care, added supervision, help with medication) can receive a $15.76 per day add-on to the rate. If a resident is also attending adult day care three or more days a week, the rate is reduced to between $29 and $51 a day depending upon the level of the facility. A multiplier is applied to the rates which results in higher payments in rural and frontier areas.
The levels of reimbursement were originally based on the size and staffing level of the three licensing levels of facilities. The rate structure will be revised to reflect residents needs and acuity rather than the size of the facility.
A preliminary methodology would develop a payments for low, intermediate and high needs for medical and acute care needs, physical care needs and cognitive needs. See table.
About 30% of the elderly Choice participants, 175 people, reside in assisted living homes. Case managers from local organizations contract with the Division of Senior Services to conduct assessments, determine eligibility and develop a plan of care for Choice participants who reside in assisted living homes.
"Home staff persons" may provide medication reminders, reading labels, opening containers, observing a resident while taking medication, checking self-administered dosage against the label, reassuring the resident that the dosage is correct, and directing/guiding the hand of a resident at the resident's request.
Homes must have the type and number of staff needed to operate the home and must develop a staffing plan that is appropriate to provide services required by resident care plans. Staff must pass a criminal background check. Administrators must be 21 years of age or older and have sufficient experience, training or education to fulfill the responsibilities of an administrator.
No additional training requirements are specified for administrators or staff.
An administrator must provide a sworn statement as to whether the person has been convicted of a felony, a misdemeanor involving drugs or physical or sexual abuse or a misdemeanor involving alcohol. Individuals must also provide the results of a name check, criminal background check and fingerprint investigation conducted by the Alaska Department of Public Safety. Further regulations implementing criminal background checks are being developed.
Both the Department of Health and Social Services and the Division of Senior Services are responsible for screening applicants, issuing licenses and investigating complaints. The departments may delegate responsibility for investigating and making recommendations for licensing to a state, municipal or private agency. Homes must submit an annual self-monitoring report on forms provided by the department. Case managers monitor Choice waiver participants monthly.
Facilities receiving a voluntary license pay a fee of $25, homes serving 3-5 people pay $75 and homes serving six or more residents pay $150.
| ALASKA PAYMENT RATES--ANCHORAGE AREA | |||
| - | Level I | Level II | Level III |
| Room and board | $900.00 | $1018.50 | $1299.77 |
| Waiver services | $1211.40 | $1526.70 | $1841.70 |
| Total | $2111.40 | $2545.20 | $3141.47 |
| Add on | $472.80 | $472.80 | $472.80 |
| Total | $2584.20 | $3018.00 | $3614.27 |
| DRAFT PAYMENT METHODOLOGY | ||||
| Category | Low Impairment Care Service Rate | Intermediate Care Service Rate | High Impairment Care Service Rate | Augmented Service Factor |
| Medicaid and acute care needs | Chronic health problem may be present and treatment may be ongoing. No need for ongoing specialized equipment or procedures. | Chronic health problems are typically present and treatment ongoing. Minimal need for ongoing specialized equipment and/or procedures to intervene. | Acute medical/health care needs typically present and needs ongoing treatment. Need for ongoing specialized medical equipment and procedures to intervene. | Examples of factors which may justify granting an augmented
rate:
|
| Physical care needs | Level of physical impairment minimally impact ability to perform self care. 0-1 ADL dependent. Needs assistance with 1-2 ADLs. | Level of physical impairment adversely affects ability to do self care. 2-3 ADLs. Needs assistance with 3-4 ADLs. | Level of impairment significantly and adversely affects ability to perform self care. 4 or more ADLs. Needs assistance with 5 or more ADLs. | |
| Cognitive needs | Level of cognitive functioning adequate to survive independent of 24-hour supervision. | Level of cognitive dysfunction impacts ability to survive independent of ongoing oversight. (mild dementia) | Level of cognitive functioning significantly and adversely impact ability to survive independent of oversight. Mild to late stage dementia. | |
Assisted living facilities. Comprehensive administrative rules and regulations §R9-10-701 et seq.
Rapid growth in the number and types of home and community based settings serving elderly and adults with physical disabilities, ranging from private homes to facilities providing specialized care to large retirement complexes, has outpaced the regulations developed to guide this development. In the Spring of 1997, the Arizona Department of Health Services' Office of Home and Community Based Licensure established a 28 member task force to help consolidate five of the existing six licensing classifications (adult care homes, supported residential living centers, supervisory care homes, unclassified homes and adult family care) into a single assisted living category. Rules have been issued which are expected to be effective in November, 1998.
The new assisted living facility category has requirements based on the size of the facility and supplemental requirements depending on the level of service provided. The core requirements address facilities serving 10 or fewer residents, eleven or more residents and adult foster homes which serve 1-6 residents. Facilities will be licensed to provide one of three levels of care supervisory care services, personal care services, and directed care services and must meet supplemental requirements.
The directed care level will serve people with Alzheimer's disease or dementia who cannot selfdirect their care, eg., cannot recognize danger, summon assistance, express need or make basic decisions. Requirements for specialized training, activities, physical plant and services will be established.
The goal of the task force was to develop regulations that are consistent and ensure minimum standards for health, safety and welfare. Regulations will be based on the resident's level of need and promote dignity, independence, self-determination, privacy and choice. Legislation was approved in 1998 authorizing the new category.
AHCCCS, which administers the state's Medicaid managed care program, will retain higher standards (eg., private living units), for providers interested in serving Medicaid beneficiaries.
Pilot program expanded statewide Chapter 163 (1993) authorized a three year supportive residential living centers (SRLC) pilot project, which is the same as assisted living, to test the feasibility of developing additional cost effective alternatives to nursing homes for participants in the Arizona Long Term Care Systems (ALTCS). The pilot was implemented in Maricopa County by the Maricopa Managed Care Systems, a county based HMO which contracts with the state Medicaid agency, AHCCCS, to operate the ALTCS system. In 1996, the legislature approved the statewide expansion of the program and provided funding for 700 ALTCS members and no restrictions on the number of private pay residents. After 1997, there is no limit on the number of members who can be served through Supportive Residential Living Centers (to be renamed assisted living facilities).
As required by legislation, Maricopa Managed Care Systems issued a report in December 1995. The report recommended a statewide expansion of the program based on three primary findings: cost effectiveness, high satisfaction level among participants and the ability to meet resident needs in a less restricting environment.1 The study found annual savings of $2 million based on the continuous enrollment of 100 participants.
The evaluation collected data on resident satisfaction, number of residents, length of stay, level of care, emergency room utilization, urgent care visits, number of days of hospitalization and cost, average daily cost of supportive residential living, service levels, demographic information, functional information, and medical information. The study identified three areas for further study: building codes, public versus private pay criteria and level of care.
The following information is based on the new proposed regulations.
Assisted living facility means a residential care institution, including adult foster care, that provides or contracts to provide supervisory care services, personal care services or directed care services on a continuing basis.
Supervisory care services mean general supervision, including daily awareness or resident functioning and continuing needs, the ability to intervene in a crisis and assistance in the selfadministration of prescribed medications.
Personal care services mean assistance with activities of daily living that can be performed by persons without professional skills or professional training and include the coordination or provision of intermittent nursing services and the administration of medication and treatments by a nurse who is licensed pursuant to Title 32, Chapter 15 or as otherwise provided by law.
Directed care services means programs and services, including personal care services, provided to persons who are incapable of recognizing danger, summoning assistance, expressing need or making basic care decisions.
The ALTCS program will contract with assisted living homes (10 or less) and assisted living centers but only centers that offer residential units (apartments).
Assisted living centers (11+ residents) may provide residential units or bedrooms. Residential units must have at least 220 square feet of floor space, excluding bathroom and closet for one person with an additional 100 square feet for a second person. Units must have a keyed entry, bathroom, resident controlled thermostat and a kitchen area with sink, refrigerator, cooking appliance that may be removed or disconnected and space for food preparation.
Assisted living centers and homes providing bedrooms must have 80 square feet in single rooms and 60 square feet per resident in double rooms. No more than two residents may share a room. Rooms occupied by residents receiving personal care services or directed care services must have a bell, intercom or other mechanical means to contact staff. At least one toilet, sink and shower is required for every eight residents
ALFs providing supervisory care services may serve residents who need health or health related services if these services are provided by a licensed home health or hospice agency.
ALFs with a personal care service license may not accept or retain any resident who is unable to direct self-care; requires continuous nursing services unless the nursing services are provided by a licensed hospice agency or a private duty nurse; residents with a stage III or IV pressure sore or someone who is bed bound due to a short illness unless the primary care physician approves, the resident signs a statement and the resident is under the care of a nurse, a licensed home health agency, or a licensed hospice agency.
ALFs licensed to provide direct care services may admit residents who are bedbound, need continuous nursing services or have a stage III or IV pressure sore if the requirements for facilities providing personal care services are met.
Residents must receive an assessment and a service plan within 14 days of acceptance. Plans must be reviewed every 12 months for residents receiving supervisory care services, every six months for residents receiving personal care services and every three months for residents receiving directed care services. Services must meet scheduled and unscheduled needs. Facilities must provide general supervision; promote resident independence, autonomy, dignity, choice, self-determination and the resident's highest physical, cognitive and functional capacity; help utilizing community resources; encouragement to preserve outside supports; individual attention and social interaction and activities.
Facilities providing personal care services also provide skin maintenance, sufficient fluids to maintain hydration, incontinence care, an assessment by a primary care provider for residents needing medication administration or nursing services.
Facilities providing directed care must provide cognitive stimulation and activities to maximize functioning; encouragement to eat meals and snacks; and an assessment by a primary care provider.
ALTCS Services are grouped into three types: hotel services, personal care services and nursing care services. Hotel services include meals, linen and personal laundry, housekeeping and social and recreational services. Personal care includes assistance with ADLs, managing functional and behavior problems, assisting with medication and oversight. Nursing services cover observation and assessment, routine nursing tasks, intermittent nursing care and terminal care delivered by hospice providers.
Prior to move in, an interdisciplinary team (manager, staff, RN if nursing services are provided, resident and/or representative and case manager if applicable) conducts an assessment. A plan of care is developed with the resident or their representative that identifies the services needed, the person responsible for providing the service, method and frequency of services, measurable resident goals and the person responsible for assisting the resident in an emergency.
Assisted living facilities can contract with ALTCS program contractors to serve beneficiaries meeting the nursing home criteria. Program administrators used rates set for adult foster care, nursing facilities, the Oregon assisted living program and the Arizona HCBS program as guidelines in setting the rates paid to what were formerly called Supportive Residential Living Centers. (ALTCS will use the new terms contained in the assisted living regulations.) Administrators also consider the package of services provided and ask each Center to submit a budget. Three classes of rates are negotiated based on the level of care: low, intermediate and high skilled. The rates include room and board which is paid by the resident. The monthly room and board amount is the resident's "alternative share of cost" (spend down) or 85% of the current SSI payment, whichever is greater. For residents who receive SSI, the payment rate is $470 a month of which $403.10 is paid to the residence to cover room and board charges and $66.90 is retained by the resident.
| ARIZONA RATES BY PROGRAM CONTRACTOR | |||
| - | Class I | Class II | Class III |
| APIPA | $46.67 | $56.67 | $66.67 |
| Ventana | $50.00 | $56.67 | - |
| MMCS | $47.33 | $60.42 | $73.88 |
| Pima | $46.45 | $59.30 | $72.51 |
An evaluation of the SLRC program found that the average cost of SRL was 58.7% of the cost of a nursing facility in FY 95 - $1567 a month compared to $2669 for nursing facility residents, for a savings of $1102 a month. Ancillary health costs (inpatient, physician, transportation, emergency rooms etc.) were 30% lower for SRL participants than nursing home residents.
Facilities must have policies and procedures governing the procurement, administration, storing and disposal of medications. Staff may supervise self-administration by opening bottle caps, reading labels, checking the dosage and observing the resident taking the medication. Medications which cannot be self-administered must be administered by an RN or "as otherwise permitted." The phrase as otherwise permitted was included to accommodate any future statutory changes in the state's nurse practice act. Medication organizers can be prepared a month in advance by an RN or family member.
Facilities are required to ensure that sufficient staff are available to provide services consistent with the level of care for which the facility is licensed, services established in a care plan, service to meet resident needs for scheduled and unscheduled needs, general supervision and intervention in a crisis 24-hours a day, food services, environmental services, safe evacuations and ongoing social and recreational services.
Managers must be 21, certified and have a minimum of 12 months of health related experience.
Staff must complete an orientation that includes the characteristics and needs of residents; the facility's philosophy and goals; promotion of resident dignity, independence, self-determination, privacy, choice and resident rights; the significance and location of service plans and how to read and implement a service plan; facility rules, policies and procedures; confidentiality of resident records; infection control; food preparation, service and storage if applicable; abuse, neglect and exploitation; accident, incident and injury reporting; and fire, safety and emergency procedures.
Managers and staff must complete 12 hours of ongoing training annually covering promoting resident dignity, independence, self-determination, privacy, choice, and resident rights/fire, safety and emergency procedures; infection control; abuse, neglect and exploitation. Staff in facilities licensed to provide directed care services must receive a minimum of four hours of training in providing services to residents.
In addition to the above topics, training may include providing services to residents; nutrition, hydration and sanitation; behavioral health or gerontology; social, recreational or rehabilitative services; personnel management, if applicable; common medical conditions, medication procedures, medical terminology and personal hygiene; service plan development, implementation or review and other needs identified by the facility.
Staff must also maintain current CPR certification and complete six hours of continuing education annually pursuant to §36-448.11(D). Nurses aides in good standing are deemed to meet the initial training requirements.
Certificate of training Staff must obtain a certificate of training. Facilities may develop their own training and certificate program with approval from the department. Department approved training programs have requirements for instructors and the method of instruction. The competency based approach sets standards for supervisory care services, personal care services, directed care services, and manager training.
Supervisory care services: 20 hours or the amount of time needed to verify a person demonstrates skills and knowledge in assisted living principles; communication; managing personal stress; preventing abuse, neglect and exploitation; controlling the spread of disease and infection; documentation and record keeping; implementing service plans; nutrition, hydration and food services; assisting with self-administration of medications; providing social, recreational and rehabilitative activities; and fire, safety and emergency procedures.
Personal care services: 30 hours (50 total) or the amount of time needed to verify a person demonstrates skills and knowledge in additional skills areas such as the aging process, common medical conditions associated with aging or physical disabilities and medications; assisting with ADLs and taking vital signs.
Directed care services: 12 hours (75 total) or the amount of time needed to verify a person demonstrates skills and knowledge of Alzheimer's disease and related dementia; communicating with residents with residents w ho are unable to direct care; providing services including problem solving, maximizing functioning and life skills training for those unable to direct care; managing difficult behaviors; and developing and providing social, recreational and rehabilitative activities for such persons.
Staff must comply with fingerprint requirements under A.R.S. 36-411. Legislation requiring federal criminal background checks is likely to be passed and implemented in 1998.
The licensing agency conducts annual renewal inspections. Licenses may be renewed for two years for facilities that are free of deficiencies.
Facilities are monitored by ALTCS program contractors and the Arizona Department of Health Services. Sites are recertified annually by the Department of Health Services. During the pilot phase, MMCS monitored resident care on a quarterly basis, provided technical assistance and conducted meetings of providers to obtain feedback on the program. With statewide expansion, participants are visited at least quarterly by their ALTCS case manager. Annual operating and financial reviews of ALTCS contractors (HMOs) are conducted annually by AHCCCS. The reviews also include case management and provider records and claims data. AHCCCS also reviews a random sample of residents, including assisted living residents, to evaluate the appropriateness and quality of care. The review found no unmet needs or quality of care problems.
Residential long term care facilities Arkansas Annotated Code §§20-76-201 (b)(3), 2010-203 and 20-10-224.
Rules were revised and updated in 1996. State agencies are exploring reimbursement for an assisted living model.
Residential long term care facility means a building or structure which is used or maintained to provide, for pay on a 24-hour basis, a place of residence and board for three or more individuals whose functional capabilities may have been impaired, but who do not require hospital or nursing home care on a daily basis, but could require other assistance with activities of daily living.
A minimum of 100 square feet is required for single rooms and 80 square feet per resident in shared rooms. Rooms may be shared by two residents. A minimum of one toilet/lavatory is required for every six residents and one tub/shower for every 10 residents.
Tenants must be 18 or older; independently mobile (physically and mentally capable of vacating the facility within 3 minutes); able to self-administer medications; be capable of understanding and responding to reminders and guidance from staff; do not have a feeding or intravenous tube; are not totally incontinent of bowel and bladder; do not have a communicable disease that poses a threat to the health or safety of others; do not need nursing services which exceed those that can be provided by a certified home health agency on a temporary or infrequent basis; do not have a level of mental illness, retardation or dementia or addiction to drugs or alcohol that requires a higher level of medical, nursing or psychiatric care or active treatment than can safely be provided in the facility; does not require religious, cultural or dietary regimens that cannot be met without undue burden; and do not require physical restraints, or have current violent behavior.
Facilities may provide personal care; supportive services (occasional or intermittent guidance, direction or monitoring for ADLs); activities and socialization; assistance securing professional services; meals; housekeeping; and laundry. Residents have a choice of providers for receiving personal care services and they may use an agency that is not the facility. RCFs may not provide medical or nursing services. Home health services may be provided by a certified home health agency when ordered by a physician.
Personal care services are reimbursed as a state plan service under Medicaid based on a plan of care. Facilities are reimbursed fee for service. A maximum of 64 hours of care per month may be covered without prior authorization. About 1,000 residents are covered each month.
RCFs may remind residents to take medications, read label instructions and remove the cap or packaging.
The number of direct care staff needed is scaled for daytime, evening and night shifts based on the number of residents. Staffing must be sufficient to meet the needs of residents.
Administrators must have a current certification as a residential care facility administrator, or complete a course of instruction and training prescribed by the Department.
Staff An orientation covering, at a minimum, job duties, resident rights, abuse/neglect reporting requirements and fire and tornado drills is required. Four hours of in-service training or continuing education a year covering resident rights, evacuation of a building, safe operation of fire extinguishers, incident reporting and medication supervision are required for direct care staff.
Background check Administrators may not have any prior conviction pursuant to Arkansas Code Annotated §20-10-401 or relating to the operation of a long term care facility nor any conviction for abusing, neglecting or mistreating individuals.
$5 per bed.
Residential care facilities for the elderly Title 22, Division 6, Chapter 8.
California licenses 5,900 residential care facilities for the elderly with 123,238 residents. About 70% of the facilities serve fewer than six residents. These facilities account for between 25-30% of all residents. As in other states, nursing facilities are concentrating on providing specialty, subacute and rehabilitative care, many through contracts with HMOs. Nursing homes have not expressed interest in converting to assisted living facilities, however, many nursing homes are adding assisted living to free beds for higher need residents and to provide referrals as assisted living residents age.
At the direction of the state legislature, a study of state approaches to assisted living was conducted by the Department of Health and filed in 1997. Informal discussions among state agencies, assisted living providers and legislative staff were to discuss the definition of assisted living and where it fits or how it compares to the current residential care facilities for elderly model. The discussion has focused on if assisted living is different, what services should be allowed and whether assisted living should be considered a bundle of services that is provided without regard to the building. Other issues addressed included the definition, information needed by consumers, the scope of services to be covered and the needs of clients that can be met, the place of assisted living in the continuum of care and whether a new licensure category was needed or appropriate.
The 18 member group has discussed financing for low income elders but believes Medicaid waiver financing would lead to a medical model. The Department of Health has concerns about residents meeting the nursing home level of care criteria being served in settings that are not licensed. The aging community believes there are too many licensure categories already and new ones only serve providers seeking higher levels of reimbursement without really increasing the services provided.
During 1995, legislation (Chapter 550 of the Acts of 1995) was passed that allows RCFEs that serve people with Alzheimer's Disease to develop secure perimeters. Based on the results of a pilot project, the law allows facilities that meet specific additional requirements to secure exterior doors or perimeter fences, or to install delayed egress devices on exterior doors and perimeter fence gates. Resident supervision devices, wrist bracelets which activate a visual or auditory alarm when a resident leaves the facility may also be used. Facilities must provide interior and exterior space for residents to wander freely, receive approval from the local fire marshal and conduct quarterly fire drills. Facilities with delayed egress devices must be sprinklered and contain smoke detectors and the devices must deactivate when the sprinkler system or smoke detectors activate. The devices must also be able to be deactivated from a central location and deactivate when a force of 15 pounds is applied for more than two seconds to the panic bar. In addition facilities shall permit residents to leave who continue to indicate such a desire and staff must ensure continued safety. Reports must be submitted when residents wander away from the facility without staff. Delayed egress devices may not substitute for staff.
A voluntary disclosure process has been adopted under which facilities offering special services for people with Alzheimer's Disease disclose information concerning their program. A consumer's guide has been developed which alerts family members to several key questions that should be asked. The areas include the philosophy of the program and how it meets the needs of people with Alzheimer's, the pre-admission assessment process used by the facility, the transition to admission, the care and activities that will be provided, staffing patterns and the special training received by staff, the physical environment and indicators of success used by the facility.
Residential care facility for the elderly means a housing arrangement chosen voluntarily by the resident, or the resident's guardian, conservator or other responsible person, where 75% of the residents are 60 years of age or older, or, if younger, have needs compatible with other residents and where varying levels of care and supervision are provided, as agreed to at time of admission or as determined necessary at subsequent times of reappraisal.
Occupancy is limited to two residents per bedroom which must be large enough to accommodate easy passage between beds, required furniture and assistant devices such as wheelchairs or walkers. One toilet and sink is required for every six residents and a bath tub or shower for every 10 residents.
Facilities may admit or retain residents who are capable of administering their own medications; receive medical care and treatment outside the facility or from a visiting nurse; residents who need to be reminded to take medications; and people with mild dementia, or mild temporary emotional disturbance resulting from personal loss or change in living arrangement. Facilities may not admit or retain anyone with a communicable disease; anyone who requires 24-hour skilled nursing or intermediate care or is bedridden more than for more than 14 days including residents who are unable to transfer independently to and from bed and are unable to leave the building unassisted in an emergency. The regulations allows residents with health conditions requiring incidental medical services which are specified in the rules to be admitted and retained (eg., intermittent positive pressure breathing, indwelling catheter, management of incontinence, colostomy/ileostomoy, contractures, healing wounds). Residents who will be bedridden more than 14 days may be retained if the facility submits a physician's statement to the Department of Health stating that the condition is temporary and an estimated date upon which the resident will no longer be confined to bed is provided.
Alzheimer's projects Facilities may admit and retain people with Alzheimer's Disease who are not able to respond to verbal instructions to leave a building without assistance provided they have:
Services are divided into basic services and care and supervision. Basic services include safe and healthful living accommodations; personal assistance and care; observation and supervision; planned activities; food service; and arrangements for obtaining incidental medical and dental care. Care and supervision covers assistance with ADLs and assumption of varying degrees of responsibility for the safety and well being of residents. The tasks include assistance with dressing, grooming, bathing and other personal hygiene; taking medications; and central storing and distribution of medications.
Facilities may assist with self-administration of medications and, if staff is authorized by law, administer injections.
Sufficient staff must be employed to deliver services required by residents. On the job training or experience is required in the principles of nutrition, food storage and preparation, housekeeping and sanitation standards, skill and knowledge to provide necessary care and supervision, assistance with medications, knowledge to recognize early signs of illness and knowledge of community resources.
Requirements for awake staff vary by the size of the facility. For 16 or less, staff must be available in the facility; 16-100, at least one awake staff; 101-200, 1 on call and 1 awake with an additional awake staff for each additional 100 residents.
Administrators Individuals shall complete an approved certification program prior to be being employed as an administrator. The program must include 40 hours of classroom training which covers laws, rights, regulations and policies (12); business operations (3); management and supervision (3); psycho-social needs of the elderly (5); physical needs of the elderly (5); community and support services (2); use, misuse and interaction of drugs (5); and admission, retention and assessment procedures (5). All administrators shall be required to complete at least 20 clock hours of continuing education per year in areas related to aging and/or administration.
Staff Personnel must be given on the job training or have related experience in: the principles of good nutrition, good food preparation and storage and menu planning; housekeeping and sanitation procedures; skill and knowledge required to provide necessary resident care and supervision including the ability to communicate with residents; knowledge required to safely assist with prescribed medications which are self-administered; knowledge necessary in order to recognize early signs of illness and the need for professional help; and knowledge of community services and resources.
Facilities licensed for 16 or more must have a planned on the job training program in the above areas including orientation, skill training and continuing education.
The licensing agency conducts a criminal background check of officers of the organization, adults responsible for administration and direct supervision, persons providing direct care and employees having frequent contact with residents and others and may approve or deny a license or employment based on its findings. A fingerprint clearance shall be received by the licensing agency on all persons subject to criminal record review prior to issuing a license.
Facilities must be inspected annually. Three levels of penalties are allowed for violations with an (A) immediate, (B) potential and (C) technical impact. $50 per day civil penalties are allowed for A and B violations increasing to $100 per day if the same violation is repeated 3 times in a 12 month period. Consultation is provided for Type C violations.
Licensing fees required at initial licensure and annually thereafter, are adjusted by facility size: 16 - $300; 7-15 - $450; 16-49 - $600 and 50+ - $750.
Personal Care Boarding Homes Chapter VII, §1.1 et seq.
Colorado licenses assisted living under personal care boarding home rules. Rules were revised in 1993. The number of licensed facilities has risen from 238 in 1990 to 385 in 1995 and 469 in 1998. Nursing home beds occupied by Medicaid recipients have remained stable over the past 10 years at 10,400. State respondents attributed the stable census to the expansion of home and community based programs, including reimbursement of personal care boarding homes. In 1995, the legislature revised the Medicaid rate for alternative care facilities (personal care boarding homes) and participation rose from 70 facilities to 179 by March 1998. The number of HCBS waiver participants in ACFs rose from 600 to 960 by June 1996 and 1,400 by March 1998.
While the regulations allow double occupancy and shared bathrooms, the majority of new construction provide private rooms or apartments, including homes that contract with the state to serve Medicaid recipients. The supply of personal care boarding homes is expected to increase. The licensing agency notes that many nursing facility owners are developing their own personal care boarding homes and few nursing home operators have complained about the level of care offered.
Personal care boarding home is "a residential facility that makes available to three or more adults not related to the owner of such facility, either directly or indirectly through a provider agreement, room and board and personal services, protective oversight, and social care due to impaired capacity to live independently, but not to the extent that regular 24-hourmedical or nursing care is required."
The rules allow no more than two people to share a room for facilities built after July 1, 1986. Single occupancy rooms must have at least 100 square feet and double occupancy rooms at least 60 square feet per person. Cooking is not allowed in bedrooms and facilities must provide access to a food preparation area for heating or reheating food or making hot beverages subject to "house rules." Cooking may be allowed in facilities which provide apartments rather than bedrooms. Facilities must provide at least one bathroom for every six residents.
Personal care boarding homes may not admit or retain residents who are:
Each facility develops their own admission criteria based on the capacity of the facility. A review of Medicaid pre-admission screening assessment forms showed that Medicaid waiver participants in ACFs had fewer skilled needs than nursing home residents.
Facilities must provide a physically safe and sanitary environment, room and board, personal services (transportation, assistance with activities of daily living and instrumental activities of daily living, individualized social supervision), protective oversight and social care. Written "board and care plans," which must be reviewed at least annually, are required for each resident and include a list of current prescribed medications (dosage, time and route of administration, whether self-administered or assisted), dietary restrictions, allergies and any physical or mental limitations or activity restrictions.
Nursing and therapies may be received if provided by a home health agency.
Medicaid rules limit room and board charges for Medicaid recipients to $448 a month. Effective July 1998, the Medicaid rate for services is $29.88 a day. The rate covers oversight, personal care, homemaker, chore and laundry services. The state is interested in developing tiered rates.
| MONTHLY RATES | |
| Room and board | $488.00 |
| Service | $864.40 |
| Total | $1344.60 |
Most larger facilities have hired LPNs to administer or manage medications and ensure that physician's order have been received and recorded. Unlicensed staff may assist with selfadministration but they cannot take physicians' orders over the phone.
Facilities must employ sufficient staff to ensure provision of services necessary to meet resident needs.
Administrators must meet the minimum education, training and experience requirements by successfully completing a program approved by the department. Acceptable programs may be conducted by an accredited college, university or vocational school, or a program, seminar or inservice training program sponsored by an organization, association, corporation, group or agency with specific expertise in that area. The curriculum includes at least 30 actual clock hours of which at least 15 are comprised of a discussion of each of the following topics: resident rights; environment and fire safety, including emergency procedures and first aid; assessment skills; identifying and dealing with difficult behaviors, and nutrition.
The remaining 15 hours shall provide emphasis on meeting the personal, social and emotional care needs of the resident population served.
Staff All staff, including volunteers, must be given on the job training or have related experience in the job assigned to them and shall be supervised until they have completed on the job training appropriate to their duties and responsibilities or had previous related experience evaluated. Training and orientation in emergency procedures shall be provided to each new staff member, including volunteers, within three days of employment.
Staff members not serving as an operator who have direct responsibility for the provision of personal care, i.e. hygiene, of residents or for the supervision or training of residents in the resident's own personal care, shall provide documentation of either successful completion of course work in the provision of personal care or previous and related job experience in providing personal care to residents.
The facility shall provide adequate training and supervision for staff comprised of a discussion of each of the following topics: resident rights, environment and fire safety, including emergency procedures and first aid; assessment skills; and identifying and dealing with difficult situations and behaviors.
The owner or licensee may have access to and shall obtain any criminal history record information from a criminal agency for all persons responsible for the care and welfare of residents.
The regulations require that facilities provide access to the ombudsman program to the facility and residents at reasonable times.
Assisted living services agency. Connecticut General Statutes §19a-490; Connecticut Agency Regulations §19-13-D105.
Assisted living regulations were issued by the Health Department and approved by the Legislative Review Committee in December, 1994. The regulations take a unique approach by allowing "managed residential communities" (MRCs) to offer assisted living services through assisted living services agencies (ALSAs). MRCs may obtain a license to also serve as an ALSA.
Twenty two assisted living service agencies have been licensed. About 115 homes for the aged have been licensed. The supply, which declined for several years, seems to be increasing as more multi-facility, for-profit companies enter the market and small owner operated homes decline.
The ALSA regulations focus on the licensing of agencies to provide services rather than the building and services as an entity. MRCs have to notify the health department of their intention to provide assisted living services. The ALSA, either the MRC or another agency, must be licensed by the Department of Public Health and Addiction Services to provide services. The MRC is not licensed by the Department of Public Health and Addiction Services. MRCs must show evidence of compliance with local zoning ordinances and building codes.
A bill authorizing a pilot project in three cities with up to 300 units was signed that provides Medicaid reimbursement for assisted living services in elderly housing complexes. The pilot will be developed by the Department of Social Services and the Connecticut Housing Finance Agency. Another bill passed that repeals the certificate of need requirement.
Assisted living services: nursing services and assistance with ADLs provided to clients living within a managed group living environment having supportive services that encourage clients primarily age 55 or older to maintain a maximum level of independence. Routine household services may be provided as assisted living services or by the managed residential community. These services provide an alternative for elderly persons who require some help or aid with ADLs and/or nursing services.
To qualify as a managed residential community and a setting in which assisted living services may be provided, units are defined as a living environment belonging to a tenant(s) that includes a full bathroom within the unit including water closet, lavatory, tub or shower bathing unit and access to facilities and equipment for the preparation and storage of food.
Each ALSA agency will develop its own admission criteria but the regulations do not allow the ALSAs to impose unreasonable restrictions and screen out people whose needs may be met by the ALSA. Assisted living services may be provided to residents with chronic and stable health, mental health and cognitive conditions as determined by a physician or health care practitioner.
Services may only be provided by organizations licensed as an assisted living services agency. Nursing services delivered under the regulations and include client teaching, wellness counseling, health promotion and disease prevention, medication administration and delegation of supervision of self-administered medications and provision of care and services to clients whose conditions are chronic and stable.
Registered nurses may also perform quarterly assessments, coordination, orientation, training and supervision of aides.
The Health and Education Facilities Authority provides loans for the development of assisted living settings. As yet, no specific program has been developed to subsidize services for low income residents but a bill authorizing a Medicaid demonstration was passed and awaiting action by the Governor.
The regulations allow for administration of medications by licensed staff. Assisted living aides may supervise the self-administration of medications which includes reminding, verifying, and opening the package.
ALSAs must have at least one RN and an on-site supervisor 20 hours a week for every 10 or fewer RNs and aides and a full time supervisor for every 20 RNs and aides. A sufficient number of aides must be available to meet residents' needs. All aides must be certified Nurses Aides or Home Health Aides and complete 10 hours of orientation and one hour of in-service training every two months.
Twenty-four hour awake staff are not required since the needs will vary among managed residential communities. However, 24-hour staffing could be required if indicated by resident plans of care. An RN must be available on-call 24-hours a day.
Each agency must have an orientation policy and procedure for all employees which shall include but not necessarily be limited to the following:
Each agency shall have an in-service education policy that provides an annual average of at least one hour bimonthly for each assisted living aide.
The in-service training shall include but not be limited to current information regarding specific service procedures and techniques and information related to the population being served.
ALSAs are required to establish a quality assurance committee that consists of a physician, a registered nurse and social worker. The committee meets every four months and reviews the ALSA's policies on program evaluations, assessment and referral criteria, service records, evaluation of client satisfaction, standards of care and professional issues relating to the delivery of services. Program evaluations are also to be conducted by the quality assurance committee. The evaluation examines the extent to which the managed residential community's policies and resources are adequate to meet the needs of residents. The committee is also responsible for reviewing a sample of resident records to determine whether agency policies were followed, whether services are provided only to residents whose level of care needs can be meet by the ALSA, and whether care is coordinated and appropriate referrals are made when needed. The committee submits an annual report to the ALSA summarizing findings and recommendations. The report and actions taken to implement recommendations are made available to the state Department of Public Health.
Agencies are inspected biennially. Penalties include revocation, suspension or censure; letter of reprimand; probation; restrict acquisition of other entities; consent order compelling compliance; and civil monetary penalties.
Fees are not required for ALSAs.
Homes for the aged provide personal care and a maximum of two people to a room. One toilet is required for every six residents per floor and bathing facilities are required for every eight residents. Residents may receive temporary nursing services from a community agency.
Assisted living agencies: Title 16 Health and Safety, Part II, Chapter II, § 63.0 et seq.
Rest residential homes Delaware code, Part II §59.0 et seq.
Regulations governing assisted living were adopted in 1998. The philosophy of the regulations is stated in the opening "purpose" section and directs that the "services are provided based on the social philosophy of care and must include oversight, good, shelter and the provision or coordination of a range of services that promote quality of life of the individual. The social philosophy of care promotes the consumer's independence, privacy, dignity and is provided in a home-like environment."
Assisted living is a residential arrangement for fee for dependent elderly and adults with disabilities which provides assistance with activities of daily living and other services that promote the consumer's quality of life.
Rest residential home is an institution that provides resident beds and personal care services for persons who are normally able to manage activities of daily living. The home should provide friendly understanding to persons living there as well as appropriate care in order that the resident's self-esteem, self-image and role as a contributing member of the community may be reinforced.
Assisted living The rules do not allow agencies to provide services to people who have conditions that exceed the agency's capabilities or who present a danger to self or others or engage in illegal drug use. Two other groups of consumers cannot be served--unless the attending physician certifies that despite the presence of the following factors, the consumer's needs may be safely met by a service agreement developed by the agency, the attending physician, a registered nurse, the consumer or his/her representative if the consumer is incapable of making decisions and other appropriate health care professionals:
Facilities may not serve residents who need transfer assistance from more than one person and a mechanical device, unless special staffing arrangements have been made, or residents who present a danger to self or others or engage in illegal drug use.
Rest residential homes No specific requirements are stated other than in the definition of a resident.
Assisted living The rules require individual living units. Consumers must have access to a readily available central kitchen if one is not provided in the unit. Bathing facilities must be provided in the unit or in a readily accessible area. Sharing of a bedroom is limited to two consumers and only with their consent.
Rest residential homes provide 100 square feet for single occupancy and 80 square feet per resident for multiple occupancy. No more than four people may share a room. One bath tub or shower and one toilet and wash basin are required for every four residents.
Assisted living Services are based on an assessment of the consumer completed 30 prior to admission and reviewed and revised within 14 days of admission, if appropriate, and a medical evaluation completed within 30 days prior to admission. A service agreement describes the scope, frequency and duration of services and monitoring. A managed risk process may be part of the service agreement. The agreement must address the need for personal services; nursing services; food services; environmental services including housekeeping, trash removal, laundry and safety; social/emotional services; financial management; transportation; individual living unit furnishings; assistive technology and durable medical equipment; rehabilitation services; qualified interpreters; and reasonable accommodations for persons with disabilities. The agreement includes shared responsibility and bounded choice except for people who are bedridden or have unstable medical conditions.
The regulation require that each agency shall develop policies to prevent cognitively impaired residents from wandering away from safe areas and the safe storage of medications.
Rest residential homes provide shelter, housekeeping, board, personal surveillance or direction in activities of daily living.
Beneficiaries with income below 250% of the SSI level will be eligible for waiver services. The room and board payment from the beneficiary will be $548 and three levels of reimbursement for services are planned. The payment levels were devised based on an analysis of spending for HCBS waiver clients living in their own homes and participants in the adult foster care program.
| REIMBURSEMENT LEVELS | |||
| - | Level I | Level II | Level III |
| Room and board | $538 | $538 | $538 |
| Services | $770 | $970 | $1190 |
| Total | $1308 | $1508 | $1728 |
Assisted living The assisted living agency shall provide appropriate training to staff to meet the needs of the consumers. The content and attendance of staff training programs shall be documented.
Rest residential homes Nurse aide/nurse assistant staff must complete a training course approved by the State Board and Nursing and the Board of Health. Aides/assistants must be certified prior to employment. Section 609 describes the curriculum and the competencies that must be measured in the following areas: nurse aide role and function; environmental needs; psycho- social needs; and physical needs. Section 59.610 describes the qualifications of instructors and the training instructors must receive.
Community Residence Facilities: DC Law 5-48; DC Code § 32-1301 et seq.; Chapter 34, § 3400 et seq.
A Long Term Care Coalition has been reviewing assisted living and is expected to make recommendations during 1998.
A facility providing safe, hygienic sheltered living arrangements for one or more individuals aged 18 years or older (except in the case of group homes for mentally retarded persons, no minimum age limitation shall apply), not related by blood or marriage to the residence director, who are ambulatory and able to perform the activities of daily living with minimal assistance. The definition includes facilities, including halfway houses and group homes for mentally retarded persons, which provide a sheltered living arrangement for persons who desire or require supervision or assistance within a protective environment because of physical, mental, familial, or social circumstances, or mental retardation. The definition does not include facilities providing sheltered living arrangements to persons who are in the custody of the Department of Corrections of the District of Columbia.
No more than 4 persons may share a bedroom. Minimum square footage and bathing and toilet facilities requirements are specified in the DC Housing Code (14 DCMR).
Prospective residents, the residence director and the resident's physician must agree that the prospective resident does not need professional care and can be assisted safely and adequately within a community residence facility. Residents must be able to perform ADLs with minimal assistance, generally be oriented as to person and place and capable of exercising proper judgement in taking action for self-preservation under emergency conditions. By special permission of the mayor, persons who are not generally oriented or who are substantially ambulatory but need minimal ADL assistance may be admitted if sufficient staff resources are available.
Meals, housekeeping, laundry, dietary services are provided. Short term nursing care, 72 hours, may be provided or arranged by the facility
Facilities must provide each resident a means of storing medications. Assisting with selfadministration is listed as an activity of daily living.
The licensing agency may conduct background checks on the licensee which include contacts with the police to determine criminal convictions.
Assisted living facilities. Florida Statute chapter 400 Part 3; Florida Administrative Code Chapter 58A-5 et seq.
Chapter 97-82, passed in 1997, revised training requirements and added new provisions for facilities serving people with Alzheimer's disease. An earlier law requires that such facilities disclose in its advertising or other documents how its services are especially applicable to people with Alzheimer's disease. Facilities serving more than 17 persons must have awake staff 24 hours a day, or if serving under 17 residents, either awake staff or mechanisms to monitor and ensure the safety of residents. These facilities must also offer special activities, maintain a physical environment that provides for the safety and welfare of residents and employ staff who have completed appropriate training. The law also removes a barrier to admitting residents who need a higher level of care.
Florida's original legislation (1975) was amended in 1987, 1989, 1992, 1995 and 1997. The 1997 legislation transferred rule authority for assisted living from the Department of Health and Rehabilitative Services to the Department of Elderly Affairs, renamed adult congregate living facilities to assisted living facilities. Extended congregate care (ECC) was created as a higher level of assisted living and new requirements were added for providing mental health services and staff training. The law and rules apply a different philosophy and training for ECC facilities than standard ALFs. Licensing authorization for ALFs remained with the Agency for Health Care Administration.
In November, 1995 there were approximately 5400 units of assisted living in 1900 facilities. About 120 of the 1900 facilities also hold a license to provide ECC services. In March 1998, 2,056 facilities with a total of 66,293 beds were licensed. This includes 235 ECC beds, 110 limited nursing services beds and 152 limited mental health beds.
"Assisted living facility means any building or buildings, section of a building or distinct part of a building, residence, private home, boarding home, home for the aged or other place, whether operated for profit or not, which undertakes to provide through its ownership or management, for a period exceeding 24 hours, housing, food service, and one or more personal services for four or more adults, not related to the owner or administrator by blood or marriage, who require such services; or to provide extended congregate care, limited nursing services, or limited mental health services, when specifically licensed to do so pursuant to s. 400.407, unless the facility is licensed as an adult family care home."
"Extended congregate care means acts beyond those authorized in subsection 16 that may be performed pursuant to chapter 464 by persons licensed thereunder while carrying out their professional duties; and other supportive services which may be specified by rule. The purpose of such services are to enable residents to age in place in a residential environment despite mental or physical limitations that might otherwise disqualify them from residency in a facility licensed under this part." This definition creates a higher level of care in assisted living which requires an additional license.
Facilities with a limited nursing services license can provide nursing assessments, assessment of the physical and mental status of residents, administration of medications, supervision of selfadministration, applying heat, routine changes of colostomy bags, passive range of motion exercises, ice caps, urine tests and routine dressing that no require packing or irrigation, replacement of self-maintained indwelling catheters, enemas and digital stool removal therapies, and care of casts, braces or splints.
Facilities with an ECC license must develop policies which allow residents to age in place and which maximize the independence, dignity, choice and decision making; specify the personal and supportive services that will be provided; specify the nursing services to be provided and describe the procedures to ensure that unscheduled service needs are met.
Facilities licensed to provide extended congregate care must provide private rooms or apartments, or semi-private room or apartment shared with a roommate of choice, with a lockable entry door. Facilities that offer rooms rather than apartments must have bathrooms shared by no more than three residents.
Facilities that do not have the ECC license may offer shared rooms, maximum four per room, a bathroom for every six residents and bathing facilities for every eight residents.
Admission The regulations for "admissions" to all assisted living facilities are very detailed. New residents must:
Continued residency Additional criteria affect continued residency. In regular assisted living facilities, people who are bedridden more than seven days or develop a need for 24-hour nursing supervision may not be retained.
In ECC facilities, residents may not be retained if they are bedridden for more than 14 days. Residents may stay if they develop stage 2 pressure sores but must be relocated for stage 3 and 4 pressure sores. Residents who are medically unstable, become a danger to self or others or experience cognitive decline to prevent simple decision making may not be retained. People who became totally dependent in 4 or more ADLs (exceptions for quadraplegics, paraplegics and victims of muscular dystrophy, multiple sclerosis and other neuro-muscular diseases if the resident is able to communicate their needs and does not require assistance with complex medical problems) may not be retained.
Residents with a diagnosis of Alzheimer's disease or advanced dementia may be retained if they have no significant health problems requiring nursing services. Terminally ill residents may continue in any assisted living facility if a licensed hospice agency coordinates services, an interdisciplinary care plan is developed and all parties agree to the continued residency.
To receive services under the Medicaid waiver, tenants must be 60 years of age or older and meet one of the following criteria:
Three levels of licensure are available: standard, limited nursing service and extended congregate care. The first level allows facilities to provide personal care and administration of medications. Facilities with an ECC license may provide a higher level of service including total care with up to three ADLs and any nursing service allowed under the scope of the nurse's license except those that are prohibited in the rule. ECC facilities must describe the personal, supportive and nursing services to be made available. Facilities may provide limited nursing services (eg., medication administration and supervision of self-administration, applying heat, passive range of motion exercises, ice packs, urine tests, routine dressings that do not require packing or irrigation and others), intermittent nursing services (eg., routine change of colostomy bag and related care, catheter care, administration of oxygen, routine care of an amputation or fracture, prophylactic and palliative skin care).
Other supportive services that may be provided include counseling, emotional support, networking, assistance securing social and leisure services, shopping, escort, companionship, family support, information and referral, transportation assistance developing and implementing self-directed activities. In addition, facilities provide ongoing medical and social evaluation, dietary management, and medication administration.
ECC facilities must make available nursing diagnosis or observation and evaluation of physical conditions, ongoing medical and social evaluation to determine when the person's conditions cannot be met within the facility, control of occurrence of infections, promotion of normal elimination patterns through diet and exercise, routine measurement and recording of vital functions, dietary management, administration of medications and treatment, preventive regimens for residents liable to develop pressure sores, provide or arrange for rehabilitation services, transportation or escort services for health related services.
ECC facilities may not provide oral or nasopharyngeal suctioning, assistance with tube feeding, monitoring of blood gasses, intermittent positive pressure breathing therapy, intensive rehabilitation services for a stroke or fracture or treatment of surgical incisions which are not clean and free from infection and any treatment requiring 24-hour nursing supervision.
The Medicaid waiver includes the following services for recipients in ECC settings: personal care, homemaker, attendant and companion, medication administration and oversight, therapeutic social and recreational programming, physical, occupational and speech therapy, intermittent nursing services, specialized medical supplies, specialized approaches for behavior management for people with dementia, emergency call systems and case management.
Services are reimbursed through SSI, SSDI, an optional state supplement to the federal SSI payment and a Medicaid home and community based services waiver. The waiver reimburses providers $750 a month for services for a total payment of $1415 less the $43 personal needs allowance. The SSI benefit is $665 a month. State officials are exploring a system to base payment on the level of care required by residents.
To be eligible for the waiver program, recipients receive SSI, have income under 300% of the federal SSI benefit or, for aged and disabled applicants, have income under 90% of the federal poverty level. Only facilities with an ECC or limited nursing services license may participate in the waiver program.
Medications may be administered by staff within the scope of their license.
Facilities must employ sufficient staff in accordance with required ratios and based on the physical and mental condition of residents, size and layout of the facility, capabilities of trained staff and compliance with all minimum standards. Staff must be employed that are able to assure the safety and proper care of residents and implement the evacuation and emergency management plan.
Administrators employed on or after October 1995 must be over 18, have a high school diploma or GED, or have been an administrator for one of the last three years. Effective July 1997, administrators must complete the core training requirements, including a competency exam and a background check. Administrators must also receive 12 hours of continuing education every two years. ECC administrators must complete six hours of initial training on the physical, psychological or social needs of frail elders or persons with Alzheimer's disease and adults with disabilities and six hours of continuing training each year.
Staff New staff must complete one hour training each on the following topics: infection control, including universal precautions; reporting major incidents and emergency procedures; resident rights and recognizing/reporting abuse, neglect or exploitation. HIV/AIDS training is required on hiring (two hours) and every two years (one hour). Staff who supervise self-administration of medications must receive two hours of training prior to assuming these responsibilities.
For direct care staff, the department shall establish a core educational requirement to be used in these programs. Staff must successfully complete a competency test. The 26 hour core educational requirement must cover at least the following topics:
Effective April 20, 1998, the department will review and approve curricula for HIV/AIDS training, First Aid, and CPR.
Staff who have not taken the core training program shall receive a minimum of two hours of training within the first 30 days of employment in the following subjects:
The following training is required for staff performing specific functions:
Nutrition and food service. Person responsible for total food services and day to day supervision of food services shall participate in continuing education with a minimum of two hours on an annual basis.
Six hours of initial training that addresses ECC care, concepts and requirements and delivery of personal care and supportive services is required for ECC staff.
New rules for staff in facilities serving people with Alzheimer's disease require 4 hours of initial training in areas of the disease in relation to the normal aging process, diagnosing Alzheimer's disease, characteristics of the disease process; psychological issues including resident abuse, stress management and burn out for staff, families and residents; and ethical issues. An additional four hours is required on medical information, behavior management and therapeutic approaches. Direct care staff must participate in four hours of continuing education each year.
Core training and Alzheimer's disease training may be obtained from persons approved by the Department of Elder Affairs or the Department staff. The draft rules contain a sliding fee for training that varies with the percentage of residents supported by public funds.
A criminal history record check, AHCA form 3110-0002 September 1996, shall be obtained from the Florida Department of Law Enforcement on each applicant, administrator, offices of the corporation and general partners. Applicants must submit a Florida Abuse Hotline Information Systems background check (Form AHCA 3110-0003). Administrators may request a background check pursuant to Chapter 435 on employees.
Registered nurses must visit ECC facilities twice a year to monitor residents and to determine if the facility is in compliance with relevant rules.
The base biennial fee is $253 per license plus $33 per resident. Facilities providing ECC services pay an additional fee of $410.
Personal Care Homes. Georgia Code Annotated §s 31-2-4 et seq.; 31-7-2.1 et seq.; Georgia Comp R and Regulations § 290-5-35.07 et seq.
A Medicaid waiver provides reimbursement for group homes. The maximum size of group homes was increased from 15 to 24 or fewer clients in February 1998.
"Any dwelling, whether operated for profit or not, which undertakes through its ownership or management to provide or arrange for the provision of housing, food services, and one or more personal services for two or more adults who are not related to the owner or administrator by blood or marriage."
Bedrooms must have at least 80 square feet of usable floor space per resident. There may be no more than four residents per bedroom. Spouses may be permitted, but not required to share a bedroom. Both the occupant and the administrator or on-site manager must be provided with keys for rooms with lockable doors.
Personal Care Homes serve people 18 and older who meet the personal care definition of "ambulatory" - "a resident who has the ability to move from place to place by walking, either unaided or aided by prosthesis, brace, cane, crutches, walker or hand rails, or by propelling a wheelchair; who can respond to an emergency condition ... and escape with minimal human assistance ..." Personal Care Homes cannot admit or retain persons who need physical or chemical restraints, isolation, or confinement for behavioral control. Residents may not be bedbound or require continuous medical or nursing care and treatment.
If short term medical, nursing, health or supportive services are necessary, the resident (or representative) is responsible for purchasing them from licensed providers that are managed independently of the home. The home may assist in the arrangement for such services, but not the provision of those services. Applicants requiring continuous medical or nursing services shall not be admitted or retained.
Room, meals, and personal services which include but are not limited to individual assistance with, or supervision of, self-administered medication, assistance with ambulation and transfer, and essential activities of daily living. Homes are responsible 24-hours a day for the well-being of residents.
A Medicaid HCBS waiver reimburses two models of personal care homes, group homes serving 7-24 people and the family homes serving 2-6 people. Group homes are reimbursed at $24.66 per day. The SSI payment for room and board is $494 less a personal needs allowance of $86 a month. Family homes are reimbursed by a provider agency that contracts with the Medicaid agency. Medicaid pays $23.49 to the provider agency which must then pay at least $11.52 to the family home subcontractor. In 1997, there were 117 group homes and 1,154 beneficiaries participating in the waiver and 30 family homes serving 788 beneficiaries.
At least one administrator, on-site manager, or a responsible staff person must be on the premises 24-hours per day. The minimum on-site staff to resident ratio is one staff person per fifteen residents during waking hours and one staff person per 25 residents during non-waking hours.
All employees must receive work-related training acceptable to the Department within the first 60 days of employment. This training must include: current certification in emergency first aid, except where the staff person is a currently licensed health care professional; current certification in CPR; emergency evacuation procedures; medical and social needs and characteristics of the resident population; residents' rights; and a copy of the Long Term Care Abuse Reporting Act.
Direct care staff are required to complete 16 hours of continuing education a year in courses approved by the department covering but not limited to: Working with the elderly; working with residents with Alzheimer's disease; working with the mentally retarded, mentally ill and developmentally disabled; social and recreational activities; legal issues; physical maintenance and fire safety; housekeeping; or topics as needed or determined by the department.
All employees must obtain a satisfactory criminal records check determination from the Department. The Administrator and on-site manager must obtain a satisfactory fingerprint records check determination from the Department.
The Office of Regulatory Services (ORS) investigates complaints and the Division of Public Health conducts an annual inspection. Inspections may be conducted on an announced and unannounced basis. ORS is planning to hire 14 new staff in order to conduct annual reviews.
Assisted living facilities. (Draft) Hawaii Administrative Rules §11-90-1 et seq.
Adult residential care homes (Draft) Hawaii Administrative Rules §11-101-1 et seq.
The Department of Health has developed proposed rules for a new assisted living category and revised rules for adult residential care homes. In 1994, a multi-member task force was created by House Concurrent Resolution 377 to make recommendations concerning assisted living and to explore the use of Medicaid waivers to support low income residents in assisted living. The report was issued in December 1994 and recommended that the Department of Health be authorized to develop regulations to establish an assisted living program. Members of the task force made site visits to facilities in Oregon and Washington. Legislation authorizing the development of assisted living regulations was passed in April, 1995. The draft regulations are expected to be finalized in 1998.
Assisted living facility means a facility as defined in §321-15.1, HRS. The facility is a building complex offering dwelling units to individuals and services to allow residents to maintain an independent assisted living lifestyle. The environment of assisted living is one in which meals are provided, staff are available on a 24-hour basis and services are based on the individual needs of each resident. Each resident, family member, and others work together with the facility staff to assess what is needed to support the resident in his or her greatest capacity for living independently. The facility is designed to maximize the independence and self-esteem of limitedmobility persons who feel that they are no longer able to live on their own.
Assisted living means encouraging and supporting individuals to live independently and receive services and assistance to maintain independence. All individuals have the right to live independently with respect for their privacy and dignity, fee from restraints.
Adult residential care facility means any facility providing 24-hourliving accommodations, for a fee, to adults unrelated to the family, who require at least minimal assistance in ADLs, but who do not need the services of an intermediate care facility. There are two types of homes. Type I homes serve five or fewer residents and Type II serve six or more residents. Adult residential care homes may obtain an extended care license to serve a limited number of residents who meet the nursing home level of care.
Assisted living The draft rules require apartment units with a bathroom, refrigerator and cooking capacity, including a sink and a minimum of 220 square feet, not including the bathroom (sink, shower and toilet). The cooking capacity may be removed or disconnected depending on the needs of the resident. Other requirements include wiring for phone and television, a private accessible mail box and a call system monitored 24 hours by staff.
Adult residential care homes The current rules require that single rooms have 90 square feet and multiple occupancy rooms 70 square feet per occupant. One toilet is required for every eight residents, one shower for every 14 residents and one lavatory for every 10 residents.
Assisted living facility Each facility must develop admission policies and procedures which support the principles of dignity and choice. The policies include a listing of services available, the base rates, services included in the base rates, services not provided but which may be coordinated and a service plan and contract. Facilities must also develop discharge policies and procedures which allow 14 days notice for behavior, other needs that exceed the facility's ability to meet or the resident's established pattern of non-compliance. The rules do not specify who may be admitted and retained. Rather, each facility may use its professional judgement and the capacity and expertise of the staff in determining who may be served.
Adult residential care homes Homes without an extended care license may not serve residents needing nursing home care. Type I extended care homes may serve no more than two residents qualifying for nursing home care and Type II homes may serve no more than 10% of its residents needing this level of care.
Assisted living facilities shall provide awake, 24-hour on-site staff, three dietician approved meals a day, laundry services, opportunities for individual and group socialization, services to assist with ADLs, nursing assessment and health monitoring, housekeeping, medication administration and services for residents with behavior problems (staff support, intervention and supervision), and recreational and social activities. Facilities must also arrange or provide transportation, ancillary services for medically related care (physician, pharmacist, therapy, podiatry), barber/beauty care, hospice, home health and other services.
Service agreements are developed using negotiated risk principles.
The report suggested that land policies should be reviewed and modification of zoning requirements made to allow existing housing stock to be used. State loans and bonds would be made available to at favorable interest rates to stimulate development. The report recommended consideration of providing a higher level of service in residential care facilities as a means of maximizing existing buildings to meet new needs. A resolution passed the legislature directing the Medicaid Agency to study the feasibility of using a Medicaid Home and Community Based Services Waiver to finance services.
Assisted living facilities The draft rules allow assistance with self-administration and administration of medication as allowed under the nurse practice act.
Assisted living facilities must have licensed nursing staff available seven days a week to meet care management and monitoring needs of residents.
Adult residential care homes Licensees must submit a plan showing how they will obtain a registered nurse and case manager. Sufficient staff must be on duty 24-hours a day to meet resident needs.
Assisted living facilities
Administrators The administrator/director must have two years experience in the health and social services field and show evidence of having completed an assisted living facility administrator's course acceptable to the Department.
All staff shall be trained in CPR and first aid. The facility shall have written policies and procedures which incorporate the assisted living principles of individuality, independence, dignity, privacy, choice and home-like environment. In-service education consists of an orientation for all new employees to acquaint them with the philosophy, organization, practice and goals of assisted living; and ongoing in-service training on a regularly scheduled basis (minimum of six hours annually).
Adult residential care homes A registered nurse must train and monitor primary caregivers.
Assisted living facilities Licensure may be denied for convictions in a court of law or substantiated findings of abuse, neglect or misappropriation of resident funds or property.
Adult residential care homes All staff, including the licensee must have no history of confirmed abuse, neglect or misappropriation of funds.
Assisted living facilities The rules require biannual inspection and license renewal.
Fees will be established by the Department of Health.
Residential Care Facilities. Idaho code § 39-3301 et seq., Idaho Administrative Rules Title 3, Chapter 22., § 70 et seq.
The Governor's long term care policy statement includes the following:
"amending the current federal waiver and make changes to state law and rules necessary to create a system of long-term care for elderly or disabled adults. Such a system will allow for the provision of client- or family-directed services whenever possible and for the provision of services in the least restrictive, most cost-effective setting (including assisted living, personal care, and other community-based services).
In 1996, the legislature passed HB 742 which made changes in the state's residential care facility rules. Regulations implementing the law are being developed. Medicaid is considering adding assisted living as a covered service under the HCBS waiver, however legislation has not passed to authorize coverage.
A task force has been to make further recommendations and a report is expected to be issued in 1999.
The supply of RCFS has increased from 175 facilities and 3,500 beds in 1996 to 227 and 4,902 in 1998.
Residential care facility means one or more buildings constituting a facility or residence, however named, operated on either a profit or nonprofit basis, for the purpose of providing 24hour non-medical care for three or more persons, not related to the owner, eighteen years of age or older, who need personal care or assistance and supervision essential for sustaining activities of daily living or for the protection of the individual.
Specialized care units/facilities for Alzheimer's/dementia residents "are specifically designed, dedicated, and operated to provide the elderly individual with chronic confusion, or dementing illness, or both, with the maximum potential to reside in an unrestrictive environment through the provision of a supervised life-style which is safe, secure, structured but flexible, stress free and encourages physical activity through a well developed activity and recreational program. The program constantly strives to enable residents to maintain the highest practicable physical, mental or psychosocial well-being."
Facilities operating without a license may be subject to six months in jail and fines up to $5,000.
Facilities licensed before July 1, 1991 must not have more than four residents per bedroom, and new facilities or conversions licensed after July 1, 1992 must not have more than two residents in each bedroom. Facilities that have been continuously licensed since before May 9, 1977 must have 75 square feet of floor space per single bed rooms and 60 square feet per resident in multibed rooms. Facilities licensed after May 9, 1977 must have 100 square feet of floor space per single bed rooms and 80 square feet per resident in multi-bed rooms. There must be at least one toilet for every six persons, residents or employees, and at least one tub or shower for every eight persons, residents or employees.
There are three levels of care to which a resident may be assigned: minimal assistance, moderate assistance, and maximum assistance. See table.
| LEVELS OF CARE | ||
| Level I Minimum Assistance | Level II Moderate Assistance | Level III Maximum Assistance |
| Resident requires room, board, and supervision, and requires only verbal prompting to function independently in ADLs, is independently mobile, is capable of self preservation, and does not require medication management or supervision. | Resident requires room, board, and supervision, and requires both verbal prompting and some physical assistance with ADLs, mobility (such as transferring, climbing stairs and walking), self preservation, medication management, and behavior management. | Resident requires room, board, and supervision, and requires staff up and awake on a 24-hour basis and may require extensive hands on assistance with ADLs, non-medical personal assistance needs, mobility such that the person may be immobile without assistance, self preservation, medications such that the person needs extensive assistance with the self-administration of medications, or extensive behavior management for antisocial and aggressive behavior. |
Residents may not be admitted or retained if they require ongoing skilled nursing, intermediate care or care not within the legally licensed authority of the facility for the elderly. Residents may not be admitted or retained who are unable to feed themselves; are bedfast; need nursing judgment for an ongoing unstable health condition; have decubitus ulcers or open wounds; need the ongoing technical or professional personnel to appropriately evaluate, plan and deliver resident care; are beyond the level of fire safety provided by the facility; have physical, emotional, or social needs that are not homogenous with other residents in the home; or who are violent or a danger to themselves or others. Residents who need ongoing 24-hour nursing care must be discharged. Residents who need 24-hour care for a short time for an acute condition may be retained.
Residents of specialized care units for Alzheimer's disease must be evaluated by their primary care physician for the appropriateness of placement into the unlocked specialized care unit/facility prior to admission. No resident shall be admitted to these units without a diagnosis of Alzheimer's disease or related disorder. Residents must be at a stage in their disease such that only periodic professional observation and evaluation is required. Residents in these units must be re-evaluated quarterly. No resident shall be admitted who requires physical or chemical restraints.
Services include assistance with activities of daily living, arrangements for medical and dental services, provisions for trips to social functions, recreational activities, maintenance of self-help skills, special diets, arrangement for payments and medication management. A licensed nurse must visit the facility at least once a month to conduct a nursing assessment of each resident's response to medications and to assure that the medication orders are current. The nurse also assesses the health status of each resident and makes recommendations to the administrator regarding any needs.
Services in specialized care units for Alzheimer's disease include habilitation services, activity program and behavior management according to the individualized plan of care.
A uniform assessment and a negotiated service agreement must be used with residents. New rules will address qualifications of assessors, state responsibilities for public clients, time frames for completing assessments and the information to be included. The negotiated service agreement is based on the assessment and provides for coordination of services and guidance of staff. Residents shall be given the choice and control of how and what services the facility, or external vendor, will provide to the extent the resident can make choices.
Currently, residential care homes are reimbursed privately and through a state fund. The highest reimbursement rate from the state fund is $800, and the private pay rate is generally $900 to $1200. The SSI rate in Idaho in about $500.
Facilities must have sufficient staff to serve residents in keeping with negotiated service plans. At least one staff member must be immediately available to residents at all times. Facilities admitting level III residents must have a minimum of one awake staff during sleeping hours. Waivers may be sought by small facilities.
Administrators must have a valid residential care administrator's license. Personnel must be given an orientation to the facility and participate in a continuing training program developed by the facility.
Staff Orientation training. Each facility shall develop an orientation program including, but not be limited to: job responsibilities; resident rights; operational procedures; disaster preparedness; fire safety, fire extinguisher and smoke alarms; assisting residents with medications; first aid and CPR; policies and procedures; complaint investigations and survey procedures; emergency procedures; employee dress code; house keeping and proper sanitation procedures; infection control; grievance procedures; work schedules, holidays and paydays; recognizing indications of illness, change in condition, and the need for professional help including facility documentation procedures; living skills training; death, dying and the grieving process; risk management; behavior management techniques and documentation; the aging process for facilities admitting elderly residents; mental illness, facilities admitting residents with mental illness; developmental disabilities, for facilities admitting residents with a developmental disability; and other topics as outlined by the administrator.
A minimum of eight hours of job-related pre-service orientation training shall be provided to all new employees, upon being hired, who are to provide personal assistance to the resident upon being hired
Continuing training. An ongoing, planned, and written continuing training program which maintains and upgrades the knowledge, skills and abilities of the staff in relation to services provided and employee responsibilities shall be provided to employees at least every six month, to include, but not be limited to, the orientation training program as required above.
Each employee, providing personal assistance to residents, shall receive a minimum of 16 hours of job related continuing training per year.
Staff in specialized care units for Alzheimer's/dementia residents must complete an orientation/continuing training program that includes information on Alzheimer's and dementia, symptoms and behaviors of memory impaired people, communication with memory impaired people, resident's adjustment, inappropriate and problem behavior of residents and appropriate staff response, activities of daily living for special care unit residents, and stress reduction for special care unit staff and residents. Staff must have at least six additional hours of orientation training, and four hours of the required twelve hours per year of continuing education must be in the provision of services to persons with Alzheimer's disease.
Applicants for licensure must submit a criminal history clearance as described in IDHW rules title 05, Chapter 06 and a notarized set of fingerprints.
With the exception of the initial surveys for licensure, all inspections and investigations shall be made unannounced and without prior notice. Inspections are conducted at least annually.
Inspections entail reviews of the quality of care and service delivery, resident records, and other items relating to the running of the facility. If deficiencies are found, then plans of correction are made and follow-up surveys are conducted to determine if corrections have been made. Complaints against the facility are investigated by the licensing agency. A complainant's name or identifying characteristics may not be made public unless "the complainant consents in writing to the disclosure; the investigation results in a judicial proceeding and disclosure is ordered by the court; or the disclosure is essential to the investigation. The complainant shall be given the opportunity to withdraw the complaint before disclosure."
Inspections of specialized care units for Alzheimer's disease are conducted by the licensing agency with participation from the Regional Department staff who have program knowledge of and experience with the type of residents to be served and the proposed program offered by the facility. Facilities that are specialized or have specialized care units must submit a synopsis of the program of care to be offered by the unit/facility.
Enforcement options include ban on admissions, civil monetary penalties, appointment of temporary management, suspension or revocation of the license, transfer of residents, and other remedies.
Shelter care facility 77 IAC 330 et seq.
Supported residential living Title 89, Chapter I, Subchapter d, Part 146
Community based residential facilities Public Act 89-530. 89 IAC Chapter II, §280
The legislature has approved two assisted living projects. A "supportive living" facility model has been developed by the Department of Public Aid for Medicaid beneficiaries who are frail elderly or have disabilities and need assistance with activities of daily living. It targets lighter need nursing facility residents who are unable to remain in their homes. A supportive living facility (SLF) may be converted nursing home units or free standing buildings that integrate housing, health, personal care and supportive services in home-like residential settings. The program is consistent with the definition of assisted living used by the federal 1915 c Medicaid Home and Community Based Services Waiver program.
The SLF program was developed with the assistance of advisory groups composed of members of the nursing home industry, advocates, consumers, long term care experts and the aging network. A request for proposals was issued in October 1997. Bids were received for a total of 1486 units. Two bids were received from nursing homes seeking to create 46 units. The approved waiver can serve up to 750 Medicaid residents the first year, 1,750 Medicaid residents in the second year and 2,750 Medicaid residents in the third year.
The Department on Aging is testing a Community Based Residential Facilities service model. Services will be reimbursed as home care services through the Medicaid Home and Community Based Services Waiver or state funds. The pilot may include three facilities and serve no more than 360 people. The authorizing statute allows the programs to serve people with short or long term needs as a means of relieving family caregivers. Projects may offer, directly or through contract, services that preclude admission to a nursing home. Sites that continue to be in compliance with the demonstration project rules will be eligible for annual renewals "until an assisted living or similar licensure model is established by legislation." Two facilities have been selected, including an Alzheimer's care facility. The Department may contract with a third program involving a nursing home seeking to convert its facility. If no applicant is forthcoming, another housing setting can be chosen.
Shelter care facility means a facility licensed under the nursing home care act that provide maintenance and personal care but does not provide routine nursing care.
Supportive living facility (SLF) means a residential setting that provides or coordinates flexible personal care services, 24-hour supervision and assistance (scheduled and unscheduled), activities and health related services with a service program and physical environment designed to minimize the need for residents to move within or from the setting to accommodate changing needs and preferences; has an organized mission, service programs and a physical environment designed to maximize residents' dignity, autonomy, privacy and independence; and encourages family and community involvement.
Community Based Residential Facilities (CBRFs) provide care that combines housing, personal and health-related services in response to the individual needs of those who need help in ADLs and IADLs. Supportive and intermittent health-related services are available 24 hours per day, if needed, to meet scheduled and unscheduled needs, in a way that promotes self-direction and participation in decisions that emphasize independence, individuality, privacy and di