Licensure Terms

Assisted Living Services Agency, Residential Care Homes

General Approach

The Department of Public Health, Facility Licensing and Investigations Section, licenses assisted living services agencies that provide assistance to residents of managed residential communities, state-funded congregate housing facilities, and apartments subsidized by the U.S. Department of Housing and Urban Development. Assisted living services agencies are required to be licensed, but managed residential communities are not; instead, they must register with the Department of Public Health. The operator of a managed residential community may also be licensed as an assisted living services agency.

Residential care homes (RCHs), also licensed by the Department of Public Health, are another type of community-based care for adults. Renovated private homes can be used as small RCHs. These homes used to be called boarding homes, homes for the aged, and rest homes–terms that are used in the regulations and policy documents.

 Alzheimer’s special care units (SCUs)/programs provide specialized care or services for people with Alzheimer’s disease or dementia and have separate licensure requirements.

 Adult Foster Care. Adult family living, regulated by the Department of Social Services, is a program that matches one or two adults who require room, board, and personal care services with approved host families or individuals. In exchange for a monthly allowance, the host family provides 24-hour supervision and assistance with activities of daily living (ADLs), housekeeping, shopping, and meals. Regulatory provisions for adult family living 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 services agencies that provide services in managed residential communities, and RCHs. The complete regulations can be viewed online using the links provided at the end.

Definitions

Assisted living services agency means an agency that provides, among other things, nursing services and assistance with ADLs to the residents in managed residential communities whose conditions are chronic and stable. A managed residential community means a facility consisting of private residential units primarily for persons age 55 or older who might need assisted living services.

 Residential care home means a facility that is staffed to furnish food, shelter, and laundry for two or more persons unrelated to the proprietor, and to provide services that do not require the training or skills of a licensed nurse, including personal care, special diets, and medication services.

 Alzheimer’s special care unit/program means a nursing facility, RCH, assisted living facility, adult congregate living facility, adult day care center, hospice, or adult foster home that: (1) locks, secures, segregates, or provides special programs or units for residents diagnosed with probable Alzheimer’s disease, dementia, or a similar disorder; and (2) prevents or limits a resident’s access outside the designated or separated area.

Resident Agreements

Assisted Living Services Agencies. The agreement, which must be signed by the resident at move-in, must include information about services available; charges and billing policies and processes; admission and discharge criteria; resident rights and responsibilities; the complaint process; and Medicare-covered services.

 Residential Care Homes. No provisions identified.

Disclosure Provisions

An Alzheimer’s SCU or program that advertises or markets itself as providing specialized care or services for people with Alzheimer’s disease or dementia must provide a written disclosure, updated annually, which includes at a minimum, information about: (1) the program’s philosophy; (2) pre-admission, admission and discharge policies and procedures; (3) assessment; (4) service planning and implementation; (5) staffing patterns and training requirements; (6) physical environment; (7) resident’s activities; (8) the family’s role in care; and (9) program costs.

Admission and Retention Policy

Assisted Living Services Agencies. The rules do not specify specific admission or discharge criteria; however, each agency must develop written policies for the discharge of residents. The policies must include change in a resident’s condition and definitions of routine, emergency, financial, and premature discharge. 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. An attending physician must annually provide written certification that a resident’s condition is chronic and stable.

 Residential Care Homes. Individuals are admitted if they are able to evacuate independently in an emergency.

 

Services

Assisted living services agencies may provide nursing services, assistance with ADLs, and assistance with self-administered medications to residents with chronic and stable conditions as determined by a physician or health care practitioner. Nursing services may include resident teaching; wellness counseling; health promotion and disease prevention; medication administration and delegation of supervision of self- administered medications; and the provision of care and services to residents whose conditions are chronic and stable.

Managed residential communities provide core services, including three meals a day; laundry; scheduled transportation; housekeeping; maintenance services, including chore services for routine domestic tasks that the resident is unable to perform; and social and recreational services.

Managed residential communities may not provide health services unless they have also been licensed as an assisted living services agency. They may contract with one or more assisted living service agencies, home health care agencies, or other appropriately licensed health care providers, to provide health services for residents.

Residential Care Homes. Services provided include personal care, medication services, recreational activities, laundry, and housekeeping.

Service Planning

Assisted Living Services Agencies. Within 7 days of admission, a registered nurse (RN) must develop a resident service program in consultation with the resident, family, and others involved in the resident’s care. The service program must include information about the resident’s problems and needs; types and frequency of services and equipment required; and medications, treatments, and other required nursing services. The program must be reviewed as the resident’s condition requires.

 Residential Care Homes. No provisions identified.

Third-Party Providers

Assisted living services agencies may contract with a home health agency or other licensed health care agency.

 Residential Care Homes. No provisions identified.

 

Medication Provisions

Assisted Living Services Agencies. A licensed nurse may administer medications and/or pre-pour medications for residents who are able to self-administer medications. Family members may also assist a relative with self-administration of medications by preparing or pre-pouring medications.

With the approval of the resident or his or her representative, an assisted living services agency aide may supervise a resident’s self-administration of medications, including reminding, verifying, and opening medication packages. All medications must be stored in the resident’s unit.

Residential Care Homes. Residents may self-administer medications, and may request assistance from staff with opening containers or packages and replacing lids. Unlicensed staff may administer medications if they have been trained by a registered pharmacist, physician, physician assistant, RN, or advanced practice RN, in the methods of medication administration and must have successfully completed a written examination and practicum administered by the Connecticut League For Nursing or other Department-approved certifying organization.

If the RCH permits the administration of medication by certified program staff, a program staff member trained and certified to administer medication by the route ordered by the authorized prescriber must be present at all times whenever a resident has to take physician-prescribed medication.

 

Food Service and Dietary Provisions

Assisted Living Services Agencies. Managed residential communities must offer three meals a day.

Residential Care Homes. Menus and the time scheduling of regular meals and snacks must meet Connecticut Department of Health requirements for basic nutritional needs.

 

Staffing Requirements

Assisted Living Services Agencies

Type of Staff. Agencies must employ a supervisor who is a RN and who is responsible for: (1) coordinating and managing all nursing and assisted living aide services provided to residents by direct service staff; and (2) communicating with the service coordinator. Direct care staff are either certified nurse aides or home health aides who assist with ADLs, self-administration of medications, and routine household tasks. A licensed nurse, in addition to the supervisor, is required to perform nursing services and quarterly assessments, as well as coordination, training, and supervision of aides.

Managed residential communities must have a service coordinator who assists residents and acts as a liaison with the assisted living services agency. Service coordinators must: (1) ensure that all core services are provided to or are made available to residents and assist residents to make arrangements to meet their personal needs; (2) establish collaborative relations with provider agencies, support services, and community resources; (3) establish a resident council; and (4) coordinate a resident information system. In an assisted living services agency serving no more than 30 residents, one individual may serve as both the supervisor of assisted living services and the service coordinator if the services agency and the managed RCH are owned by the same company.

Staff Ratios. No minimum ratios.  A supervisor must be available 20 hours a week for every ten or fewer licensed nurses or assisted living aides and a full-time supervisor must be available for every 20 licensed nurses or aides. A sufficient number of aides must be available to meet residents’ needs. Twenty-four hour awake staff are not required since needs vary among residents, but 24-hour staffing could be required if indicated by residents’ service plans. An RN must be available on call 24 hours a day.

Residential Care Homes

Type of Staff. The licensee is responsible for daily operations. Certified unlicensed staff are those who have completed Department-approved training to assist with medication services. Program staff are employees who assist with personal care services.

Staff Ratios. At least one program staff person must be on-duty at all times for every 25 residents. Facilities that provide medication administration must have at least one certified unlicensed staff person on duty at all times.

 

Training Requirements

Assisted Living Services Agencies. All staff must complete a 10-hour orientation program that includes the assisted living philosophy; facility policies and procedures; and applicable regulations. Aides must pass a competency exam. Each aide must have at least 6 hours of annual in-service continuing education on service procedures and techniques for the population being served.

Residential Care Homes. New staff must receive an orientation that includes information about safety and emergency procedures for staff and residents, facility policies and procedures, and residents’ rights. The amount of required continuing education is calculated based on a percentage of total annual hours worked (to a maximum of 12 hours) per year. Continuing education topics include residents’ rights; behavioral management; personal care; nutrition and food safety; and general health and safety.

Provisions for Apartments and Private Units

Managed residential communities must provide private units that include a full bathroom and access to facilities and equipment for the preparation and storage of food. Units must be single-occupancy; sharing a unit is permitted upon the request and mutual consent of residents.

Residential Care Homes. Apartment-style units are not required. Residents’ rooms may be single-occupancy or double-occupancy. Bathrooms must have one separate shower or bathtub for every eight residents. One toilet may serve two resident rooms, but no more than four residents.

 

Provisions for Serving Persons with Dementia

Dementia Care Staff. Staffing requirements are based on the licensure category of the facility or program.

Dementia Staff Training. All licensed and registered direct care staff in Alzheimer’s SCUs or programs must receive training annually that includes, but is not limited to: (1) at least 8 hours of dementia-specific training completed within 6 months of hire, and at least 8 hours of training annually; and (2) at least 2 hours annual training in pain recognition and administration of pain management techniques. At least 1 hour of training must be provided to all non-direct care staff within 6 months of hire.

Dementia Facility Requirements. No provisions identified.

 

Background Checks

No provisions identified for either licensure category.

Inspection and Monitoring

Assisted living services agencies are inspected every 2 years.

Residential care homes are inspected by the Department of Public Health. No additional provisions identified.

 

Public Financing

The state pays for assisted living services and RCH services through several Medicaid 1915(c) waiver programs and through the non-Medicaid state-funded Connecticut Home Care Program for Elders.

Room and Board Policy

The Department of Social Services provides an optional state supplement (OSS) to help cover the room and board costs for eligible RCH residents. Only licensed facilities can receive payment through the state supplement program, therefore residents of managed residential communities who receive assisted living services are not eligible.

The OSS amount is calculated individually, based on the per diem rate of the licensed facility and the difference between the resident’s income and the Supplemental Security Income federal benefit–$733 in 2015–less a personal needs allowance of $29.95, which is retained by the resident.

There are no rules prohibiting a family member from supplementing or assisting a resident with paying for their room and board at a facility.

Location of Licensing, Certification, or Other Requirements

Connecticut Department of Social Services, Medical Assistance Program, Provider Bulletin: Adult Family Living. [December 2013]

http://www.swcaa.org/wp-content/uploads/2014/01/pb13_50AdultFamilyLiving.pdf

Connecticut Department of Social Services website: Assisted Living Program. [October 12, 2012]

http://www.ct.gov/dss/cwp/view.asp?a=2353&q=391114

Public Health Code, 19-13-D105: Assisted living services agency. [June 1, 2006] http://www.ct.gov/dph/lib/dph/public_health_code/sections/19-13- d105_assisted_living_agency.pdf

Public Health Code, 19-13-D6: Home for the Aged and Rest Homes. [April 2, 2002] http://www.sots.ct.gov/sots/lib/sots/regulations/title_19/013d.pdf

General Statutes of Connecticut, Title 19A, Chapter 368v, Sec. 19a-562: Alzheimer’s Special Care Units or Programs.

http://www.cga.ct.gov/current/pub/chap_368v.htm#sec_19a-562

 

Information Sources

Matt Barrett
Connecticut Association of Health Facilities

Paul Chase
Public Assistance Consultant
Connecticut Department of Social Services Alternate Care Unit