Licensure Terms

Assisted Living Facilities

General Approach

The Division of Public Health Licensing Services, Bureau of Residential Facilities Licensing, licenses assisted living facilities (ALFs). This licensure category consolidates six previous licensure categories for residential care institutions into one universal license that is sub-classified based on size and the level of services provided. Physical plant requirements vary depending upon facility size and staff training requirements vary depending upon the level of care provided.

Assisted living facilities include adult foster care (AFC) homes where care is provided for up to four people in the home in which the caregiver lives; assisted living homes, which provide care for up to ten people; and assisted living centers, which provide care for 11 or more people. This profile does not include provisions for AFC homes.

Facilities may complete a supplemental application that authorizes the facility to provide adult day health care services and/or behavioral health services.

This profile includes summaries of selected regulatory provisions for assisted living homes and assisted living centers. The complete regulations can be viewed online using the links provided at the end.

Definitions

Assisted living facility means a residential care institution that provides, or contracts with another entity to provide, on a continuing basis, one of three types of services: supervisory care services, personal care services, or directed care services.

Supervisory care services means general supervision and daily monitoring of residents’ abilities and needs, the ability to intervene in a crisis, and assistance with resident self-administration of medications.

Personal care services means assistance with activities of daily living, and includes the coordination or provision of intermittent nursing services, and the administration of medications and treatments. 

Directed care services means programs and services provided to persons who are incapable of recognizing danger, summoning assistance, expressing needs, or making basic care decisions.

Resident Agreements

At the time of admission, a resident or the resident’s representative must receive a written agreement with information regarding resident and facility responsibilities. The agreement must also include a list of the services to be provided by the facility and services available from the facility for an additional fee or charge. Information about rates and charges for services must be given before services are provided.

For an assisted living home, the agreement must also include information about whether the manager or a caregiver is awake during nighttime hours, the refund policy, residency criteria, and the complaint process.

Disclosure Provisions

No provisions identified.

Admission and Retention Policy

An ALF must not accept or retain a resident who is unable to direct self-care and who requires continuous medical services; nursing services; physical or chemical restraints, including bedrails; behavioral health services; or services that the ALF is not licensed or able to provide. A facility may terminate residency without notice if the resident exhibits behavior that is an immediate threat to his or her health and safety or that of other individuals in the facility.

Facilities licensed to provide personal care services or directed care services may not accept or retain residents who are bedbound, have Stage III or IV pressure sores, or require continuous nursing services, unless the resident is under the care of a licensed hospice service agency, or a private duty nurse is providing the nursing services.

Services

Facilities provide supervisory care services, personal care services, directed care services, behavioral health services, and ancillary services. The facility must establish, in writing, the scope of services it will provide.

Facilities licensed to provide directed care services must have policies and procedures to ensure the safety of residents who may wander, and must provide cognitive stimulation and activities to maximize functioning.

Service Planning

A written service plan is required and must be completed within 14 calendar days after the resident’s date of acceptance and must be developed with assistance and review from the resident or resident’s representative, the facility manager, and any individual requested by the resident or the resident’s representative. The service plan must include the following:

  • A description of the resident’s medical or health conditions, including physical, behavioral, cognitive, or functional conditions or
  • The level of service the resident is expected to
  • The amount, type, and frequency of services that will be provided to the resident, including medication administration or assistance in the self-administration of medication.

For residents who require behavioral care, the service plan must also include planned goals, strategies, and actions for changing the resident’s psychosocial interactions or behavior, and must be reviewed by a medical practitioner or behavioral health professional.

If intermittent nursing services or medication administration are provided, a nurse or medical practitioner must review the service plan. Service plans must be updated no later than 14 calendar days after a significant change in the resident’s physical, cognitive, or functional condition, and as follows: (1) at least once every 12 months for a resident receiving supervisory care services; (2) at least once every 6 months for a resident receiving personal care services; and (3) at least once every 3 months for a resident receiving directed care services.

Third-Party Providers

Nursing and health-related services may be delivered by a licensed home health agency, licensed hospice service agency, or a private duty nurse.

Medication Provisions

Facilities may provide medication administration, assistance with self- administration, monitoring of self-administration, and medication procurement. Medication administration means restricting a patient’s access to the patient’s medication and providing the medication to the patient or applying the medication to the patient’s body, as ordered by a medical practitioner. Licensed nurses may administer medications.

Certified assisted living managers and trained caregivers may provide medication assistance to residents and may provide medication administration with a physician’s order and proper training. Assistance with self-administration of medications includes:

  • Reminding the resident when it is time to take the medication.
  • Opening the medication container or medication organizer for the resident.
  • Observing as the resident removes the medication from a container ororganizer:
    • For a resident using a medication organizer, verifying that the resident is taking the medication according to the schedule specified on the medical practitioner’s order.
    • For a resident not using a medication organizer, confirming that the resident taking the medication is the individual stated on the medication container label, and is taking the dosage of the medication at the time stated on the medication container label or according to an order from a medical practitioner dated later than the date on the medication container label.

The resident service plan must indicate if the resident stores his or her own medication, how the medication will be controlled, and whether the resident uses psychotropic medications. For residents who self-administer medications, a family member may fill their medication organizer with prescribed medications.

Facilities that provide assistance in the self-administration of medication must store residents’ medication. The facility must ensure that a resident’s medication organizer, if used, is only filled by the resident, the resident’s representative or family member, a personnel member of a home health agency or hospice service agency; or the facility manager or a caregiver who has been designated by–and is under the direction of–a medical practitioner.

Food Service and Dietary Provisions

Facilities must provide meals and snacks in accordance with federal dietary guidelines. Residents must receive a diet that meets any nutritional needs or therapeutic diets specified in their service plan. Adaptive eating equipment or utensils must be available to residents who need them to eat.

Staffing Requirements

Type of Staff. ALF staff include managers, caregivers, and assistant caregivers.

All staff must be capable of providing assisted living services, behavioral health services, behavioral care, and ancillary services needed by residents.

Staff Ratios. No minimum ratios. Sufficient staff must be present at all times to provide services consistent with the facility’s licensure category. At least one manager or caregiver must be present and awake at an assisted living center when a resident is on the premises.

Training Requirements

The manager must ensure that orientation and in-service education is provided for employees and volunteers. Before providing assisted living services to a resident, a caregiver or an assistant caregiver, must receive orientation that is specific to their duties. All staff must be trained in first-aid and cardiopulmonary resuscitation for adults.

Provisions for Apartments and Private Units

Apartment-style units are not required. Assisted living centers (11+ residents) may provide either residential units or bedrooms that are single-occupancy or double- occupancy. Residential 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.

In an assisted living home (up to ten residents), a resident’s sleeping area must be on the ground floor of the home unless the resident is able to direct self-care; the resident is ambulatory without assistance; and there are at least two unobstructed, usable exits to the outside from the sleeping area that the resident is able to use. All facilities require at least one toilet, sink, and shower for every eight residents.

Provisions for Serving Persons with Dementia

Dementia Care Staff and Staff Training. No provisions identified.

Dementia Facility Requirements. Facilities must have egress controls and access to secure outside areas for residents who wander.

Background Checks

All staff and volunteers must have a valid fingerprint clearance card issued by the Department of Health Services within 20 days of hire. A person who has been denied a clearance card may not be employed by the facility.

Inspection and Monitoring

The licensing agency conducts a pre-licensure inspection and annual renewal inspections. Facilities that are free of deficiencies may have licenses renewed for 2 years.

Public Financing

Services are covered through the Arizona Long-Term Care System (ALTCS) program, which operates under a Medicaid 1115 demonstration waiver. The ALTCS managed care program is part of the Arizona Health Care Costs Containment System. Private insurance companies bid through an RFP process to provide services to residents in AFC, assisted living homes, and assisted living centers. Each plan then contracts with individual facilities to pay for services; there are no uniform costs as insurers work with providers and local agencies to establish rates based on the needs of, in some cases, individual residents (e.g., an individual who requires psychiatric services) and the basic facility services.

Room and Board Policy

The state did not provide an optional supplementation to the federal Supplemental Security Income (SSI) benefit as of 2009. In the same year, the room and board rate was capped for Medicaid-eligible residents who paid a share of cost that was their spend down amount or the amount of the SSI benefit minus a personal needs allowance (PNA) of $101.10, whichever was greater. Family supplementation was allowed to pay for room upgrades.

Location of Licensing, Certification, or Other Requirements

Arizona Administrative Code, Title 9, Chapter 10, Article 8: Assisted Living Facilities. [July 1, 2014]

http://www.azdhs.gov/als/residential/documents/article-8.pdf

Arizona Department of Health Services website: Bureau of Residential Facilities Licensing, Provider Information, with links to licensing tools and resources. [January 13, 2015] http://www.azdhs.gov/als/residential/providers.htm

Information Sources

Sylvia Balistreri
Arizona Healthcare Association

Diane Eckles
Residential Facilities Licensing
Division of Public Health
Licensing Arizona Department of Health Services