Licensure Terms

Assisted Living Facilities, Specialty Care Assisted Living Facilities

General Approach

The Department of Public Health, Bureau of Health Provider Standards, licenses three categories of assisted living facilities based on the number of residents. Specialty care assisted living facilities must be separately certified by the Board of Health.

Adult Foster Care. The Department of Human Resources, Adult Protective Services Unit, sets policy and standards and oversees adult foster homes that serve one resident. Regulatory provisions for adult foster homes are not included in this profile but a link to the provisions can found at the end.

This profile includes summaries of selected regulatory provisions for assisted living facilities and specialty care assisted living facilities. The complete regulations are online at the links provided at the end.

Definitions

Assisted living facilities are individuals or entities that provide or offer to provide residence and personal care to two or more individuals who need assistance with activities of daily living (ADLs). Individuals who provide residential and personal care services solely to persons to whom they are personally related are not defined as assisted living.

Specialty care assisted living facility means an assisted living facility that is specially licensed and staffed to care for residents with a degree of cognitive impairment that would ordinarily make them ineligible for admission or continued stay in an assisted living facility.

Both assisted living and specialty care assisted living are sub-classified according to the number of residents they serve:

  • Family assisted living facilities are authorized to care for 2-3
  • Group assisted living facilities are authorized to care for 4-16
  • Congregate assisted living facilities are authorized to care for 17 or more

Resident Agreements

Assisted Living Facilities. Agreements must be signed prior to or at the time of admission and must include: (1) basic charges for room, board, laundry, personal care, and basic and optional services; refund and discharge policies; (2) bed hold policy; (3) documentation that the resident and sponsor understand that the facility is not authorized or staffed to perform skilled nursing services nor to care for residents with severe cognitive impairment, and that the resident and sponsor agree that if the resident needs skilled nursing services or care for a severe cognitive impairment as a result of a condition expected to last for more than 90 days, the resident will be discharged by the facility after prior written notice; and (4) information about the local ombudsman.

Specialty care assisted living facilities require the same agreement except that these facilities may care for residents with severe cognitive impairment.

Disclosure Provisions

No provisions identified for either type of facility.

Admission and Retention Policy

Assisted Living Facilities. To be admitted and retained, residents may not (1) require restraints or confinement or limitations on egress from the facility; (2) be unable, because of dementia, to understand the facility’s unit dose medication system; (3) have chronic health conditions requiring extensive nursing care, or daily professional observation or judgment; and (4) require medical care, skilled nursing care, or care beyond assistance with ADLs. Persons with severe cognitive impairment may not be admitted or retained.

An exception may be made for a resident who requires medical care, administration of oral medications, or skilled nursing care for a period no longer than 90 days, or if a resident has been admitted to a certified and licensed hospice program because of a condition other than dementia. In these cases, care must be delivered by a properly licensed individual and the facility is responsible for the delivery of the appropriate care.

Specialty Care Assisted Living Facilities. A facility may not admit nor retain a resident who requires medical or skilled nursing care for an acute condition or exacerbation of a chronic condition that is expected to exceed 90 days unless: (1) the individual is capable of performing and does perform all tasks related to his or her own care; or (2) the individual is incapable of performing self-care tasks but has sufficient cognitive ability to direct his/her own care and is able to direct others to provide needed assistance. The resident may not have symptoms that infringe on the rights or safety of other residents.

 Residents diagnosed with a terminal illness may be admitted to a licensed hospice program and may remain in the facility beyond 90 days. Residents who are combative, violent, suicidal, or homicidal may not be admitted or retained. Residents who are abusive to other residents must be monitored. Whenever a resident requires hospitalization, medical, nursing, or other care beyond the facility’s capabilities, the facility must arrange discharge and transfer to an appropriate setting.

Services

Assisted Living Facilities. Facilities must provide general observation and health supervision of each resident to identify changes in health condition and functioning, and the need for medical attention or nursing services; ADL assistance; medication services; laundry; housekeeping; coordination of medical transportation; and social activities.

Specialty Care Assisted Living Facilities. Assistance with ADLs, health monitoring and services, and medication services must be provided. Facilities must also have a daily activity program designed to meet residents’ individual needs.

Service Planning

Assisted Living Facilities. Each resident must have a medical examination by a physician prior to admission. A plan of care must be developed by the facility in cooperation with the resident and, if appropriate, their representative.

Specialty Care Assisted Living Facilities. Residents must be screened and approved for admission. The screening includes a clinical history, a mental status examination to include aphasia screening, a geriatric depression screen, a physical functioning screen, and a behavior screen. 

Third-Party Providers

Residents in both types of facilities may contract with a hospice or home health agency.

Medication Provisions

Assisted Living Facilities. Residents who are aware of their medications may self-administer medications or receive assistance with self-administration of medication by any staff member, including those who are unlicensed. Aware means that the resident can maintain possession and control of his/her medications and self-administer medications without creating an unreasonable risk to health and safety, or that the resident has a reasonable layperson’s understanding of the unit dose packaging system the facility uses and is unlikely to make medication errors.

 Medications managed and kept under the custody and control of the facility must be unit dose packaged. Assistance with self-administration means reminding the resident to take a medication, bringing the container to the resident and opening it, and offering liquids. Assistance with self-administration does not include administering injections, drops, inhalers or suppositories, reminders to take PRN medications, or special preparation (e.g., crushing, mixing with liquids, or inserting in feeding tube). If the resident would be capable of administering medications through these routes except for limitations of mobility or dexterity, then unlicensed staff may assist so long as the assistance provided is under the resident’s total control and direction.

Specialty Care Assisted Living Facilities. Facilities may allow residents to self- administer or receive assistance with self-administration of medications, or may provide medication administration. Residents who are aware of their own medications may self- administer medications. Aware means that the resident can maintain possession and control of their own medications and self-administer medications without creating an unreasonable risk to health and safety. Medication administration must be provided by a physician, osteopath, physician assistant, registered nurse (RN), or licensed practical nurse (LPN).

Food Service and Dietary Provisions

The following provisions are for both types of facilities.

Facilities must serve daily at least three meals that meet the Dietary Reference Intakes of the Food and Nutrition Board of the National Research Council, National Academy of Sciences. Snacks and beverages must be available throughout the day and after the evening meal. Alternate food selections must be available for residents on medically prescribed diets, including those for hypertension, diabetes, and hyper- lipidemia, as well as modified consistency diets.

If residents need therapeutic or other special diets, a dietician must be available to make certain that food is of the quality and quantity required to meet their needs.

Facilities with 17 or more residents (congregate, the third category of licensure) must hire a full-time or part-time professionally qualified dietitian, or contract with a consulting dietitian.

Staffing Requirements

Assisted Living Facilities

Type of Staff. Facilities must employ an administrator to operate the facility and personal care staff to meet residents’ care needs. If residents require medication administration, a licensed health professional such as a registered nurse or licensed practical nurse must be hired.

Facilities must be staffed at all times by at least one individual who has current cardiopulmonary resuscitation (CPR) certification. Facilities equipped with an automated external defibrillator (AED) must be staffed at all times by at least one individual who has a current certification from the American Heart Association or the American Red Cross in AED utilization.

Staff Ratios. No minimum ratios. The number of staff must be adequate to meet residents’ needs.

Specialty Care Assisted Living Facilities

See Provisions for Serving Persons with Dementia below.

Training Requirements

Assisted Living Facilities. All staff must receive initial and ongoing training on required topics, such as: (1) applicable rules and statutes; (2) identifying and reporting abuse, neglect and exploitation; (3) needs of the elderly, mentally ill, and intellectually disabled; (4) basic first-aid; (5) advance directives; (6) confidentiality; (7) nutritional needs of the elderly; (8) fire and environmental safety; and (9) signs and symptoms of dementia. Administrators must complete 6 hours of continuing education each year; licensed nursing home administrators are exempt.

Specialty Care Assisted Living Facilities. See Provisions for Serving Persons with Dementia below.

Provisions for Apartments and Private Units

Assisted Living Facilities. Apartment-style units are not required; units may be single-occupancy or double-occupancy. Bathrooms and bathing facilities may be shared, with at least one bathtub or shower for every eight residents, and one sink and toilet for every six residents.

Specialty Care Assisted Living Facilities. See the following section.

Provisions for Serving Persons with Dementia

This section describes the requirements for Specialty Care Assisted Living Facilities only.

Dementia Care Staff. Facilities are required to have an administrator, a medical director, at least one registered nurse, and a unit coordinator in addition to personal care staff. Facilities must be staffed at all times by at least one individual who has CPR certification. Facilities equipped with an AED must be staffed at all times by at least one individual who has a current certification from the American Heart Association or the American Red Cross in AED utilization.

Minimum staffing levels are required based on facility size and time of day (based on three shifts). At least two staff must be on-duty 24 hours a day, 7 days a week. If necessary, facilities must exceed minimum ratios to meet residents’ needs.

Dementia Staff Training. The administrator and all staff must complete 6 hours of continuing education each year. Licensed nurses must complete a specified dementia training curriculum before working in the unit.

Dementia Facility Requirements. Apartment-style units are not required; units may be single-occupancy or double-occupancy. Bathrooms and bathing facilities may be shared, with at least one bathtub or shower for every eight residents; and one sink and toilet for every six residents.

Facilities must have a secure boundary or perimeter to safely accommodate residents who wander. Locks on exit doors, if installed, must be electrically locked or electrically delayed-egress locking devices. Delayed-egress locks must comply with detailed requirements. In group and congregate facilities (second and third categories of licensure), panic hardware must be installed on all exit doors, except where electrically controlled door hardware is used.

Background Checks

Both types of facilities may not hire an individual whose name appears on the Alabama Department of Public Health Nurse Aide Abuse Registry.

Inspection and Monitoring

Both types of facilities are monitored through periodic inspections by the Board of Health. The initial inspection may occur during building construction. Facilities must renew their license annually.

Public Financing

The state does not provide public funding for services in either type of facility, through either Medicaid or non-Medicaid programs.

Room and Board Policy

The state provides an optional supplement to Supplemental Security Income (SSI) recipients and some non-SSI recipients who reside in specified living arrangements, but not assisted living facilities.

Location of Licensing, Certification, or Other Requirements

Rules of Alabama State Board of Health, Chapter 420-5-4: Assisted Living Facilities. Alabama Department of Public Health. [October 27, 2008] http://www.adph.org/HEALTHCAREFACILITIES/assets/ALFRules.pdf

Rules of Alabama State Board of Health, Chapter 420-5-20: Specialty Care Assisted Living Facilities. Alabama Department of Public Health. [October 27, 2008] http://www.adph.org/HEALTHCAREFACILITIES/assets/SCALFRules.pdf

Alabama Department of Human Resources website: An Introduction to Adult Foster Care and Adult Foster Care Home Requirements http://dhr.alabama.gov/services/Adult_Protective_Services/Adult_Foster_Care.aspx

Information Sources

Kelley Mitchell, RNC, MSN
Division of Health Care Facilities
Alabama Department of Public Health