Licensure Terms

Assisted Living Facility

General Approach

The Delaware Department of Health and Social Services (DHSS), Division of Long Term Care Residents Protection, licenses assisted living facilities (ALFs) that offer living arrangements to medically stable persons who do not require skilled nursing services and supervision.

Adult Foster Care. The state licenses two types of adult foster care (called rest homes)–family care homes and residential care homes (RCHs)–which provide room and board and personal care services for 2-3 residents who can no longer live independently and/or who need supervision and a family living situation. Family care homes can provide a higher level of care than can RCHs, but when admitted, individuals must be able to perform all activities of daily living (ADLs) and self- administer medications. Regulatory provisions for adult foster care settings 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 ALFs. The complete regulations can be viewed online using the links provided at the end.

Definitions

Assisted living is a special combination of housing, supportive services, supervision, personalized assistance, and health care designed to respond to the individual needs of those who need help with ADLs and/or instrumental activities of daily living.

Resident Agreements

Prior to executing a contract, which includes financial and non-financial components, residents must receive a statement of all charges. Financial components include: service rates and ancillary charges; billing and payment policies; criteria for additional charges as needs change; the process for changing the rates; and the party responsible for handling finances, obtaining equipment/supplies, arranging services not covered by the contract, and disposing of belongings.

Non-financial components include: basic and optional services; optional services provided by third parties; residents’ rights and obligations; grievance procedures; occupancy provisions, such as policies concerning modifications to the resident’s living area; procedures for changing the resident’s accommodations (relocation, roommate, number of occupants in the room); transfer procedures; security; temporary absence policy; interim service arrangement during an emergency; staff members’ right to enter a resident’s room; discharge policies and procedures; and facility obligations.

 

Disclosure Provisions

Facilities must make a financial disclosure statement available to the public.

Facilities offering special care for persons with dementia must disclose the philosophy of care; the population served; the admission and discharge process and criteria; the assessment, care planning, and care implementation process; the staffing plan and training policies; physical environment and design features; resident activities; family roles; psychosocial services; nutrition and hydration services; policies on wandering; and costs.

 

Admission and Retention Policy

Facilities may not admit people with a range of medical conditions, including those who: (1) require more than intermittent or short-term nursing care; (2) require skilled monitoring, testing, and adjustment of medications and treatments; (3) require monitoring of a chronic unstable medical condition; (4) are bedridden more than 14 days; (5) have Stage III or IV pressure sores; (6) require a ventilator; (7) require treatment for a disease or condition that requires more than contact isolation; (8) have an unstable tracheotomy or a stable tracheotomy of less than 6 months’ duration; (9) require an intravenous or central line; (10) wander to the extent that facilities cannot provide adequate supervision or security arrangements; or (11) pose a threat to themselves or others.

Resident-specific waivers may be granted to allow facilities to temporarily care for people with excluded conditions for up to 90 days, as long as services are provided by appropriate health professionals. These restrictions do not apply to residents under the care of a licensed hospice program.

Services

Facilities must provide assistance with ADLs; laundry and housekeeping; access to appropriate health care and social services, as described in resident service agreements; opportunities for social interaction and leisure activities that promote the physical and mental well-being of each resident; and arrangements for emergency transportation.

Service Planning

A registered nurse (RN) must complete the state’s Uniform Assessment Instrument (UAI) prior to admitting an individual and it must be updated within 30 days of admission, annually, and following a change in condition. The UAI collects information about the applicant’s/resident’s physical condition, medical status, and psychosocial needs. This information determines whether applicants meet criteria for admission/ retention, level of care criteria (for Medicaid-eligible applicants), and whether the facility can meet their service needs.

Facilities must develop a service agreement with each resident to describe what services will be provided, who will provide the services, when the services will be provided, how the services will be provided, and, if applicable, the expected outcome. The service agreement includes a risk agreement.

A managed or negotiated risk agreement is a signed document between a resident and the facility–and any other involved party–that describes mutually agreeable actions for balancing the resident’s choices and independence with the facility’s requirement to oversee residents’ health and safety. Only residents who are capable of making choices and decisions and understanding consequences may enter into a managed/negotiated risk agreement.

Third-Party Providers

Third-party providers are defined as any party, other than the facility, that furnishes services/supplies to a resident. Third-party providers, including family members, must be specified in the resident’s service agreement.

Medication Provisions

Facilities must establish and adhere to written medication policies and procedures that specify processes for obtaining, documenting, storing, and administering medications. Residents may self-administer or receive assistance with self- administration of medications, or have medications administered to them.

An RN must review medications within 30 days of admission for residents who self-administer medications to: (1) assess their cognitive and physical ability and need for assistance; (2) ensure that medications have been received and properly labeled and stored; and (3) determine the presence of adverse side effects.

Staff who complete a Board of Nursing-approved medication training program, called Assistance with Self-Administration of Medication, in accordance with the state’s

Nurse Practice Act, may provide assistance with self-administration of medications. Assistance includes holding the container, opening the container, and assisting the resident in taking the medication (other than by injection), following the directions of the original container, and documenting in the medication log that each medication has been taken.

An adult family member/support person, as identified in the resident’s contract and service agreement, may provide help with prescription or non-prescription medication. The family role in the care of a resident receiving specialized care for memory impairment must be disclosed in the service agreement.

A required quarterly pharmacy review includes a review of residents’ medication regimens and writing a report describing any irregularities.

 

Food Service and Dietary Provisions

Facilities must ensure that three meals, snacks, and prescribed food supplements are available during each 24-hour period, 7 days per week. A dietician or nutritionist must ensure that menus are nutritionally adequate.

Staffing Requirements

Type of Staff. Every ALF must have a director, who has overall responsibility for managing the facility to ensure that all statutory and regulatory requirements are met, and resident assistants who provide direct care services. Facilities licensed for 25 or more beds must have a full-time nursing home administrator. Facilities licensed for 5-24 beds must have a part-time nursing home administrator on-site and on-duty at least 20 hours a week. Each facility with four beds or fewer must have a full-time, on-site house manager who is responsible for daily operations; the director of the facility must be on site at least 8 hours a week.

Every ALF must have a director of nursing who is an RN. The director of nursing must be full-time in facilities licensed for 25 or more beds, and on-site and on-duty at least 20 hours a week in facilities licensed for 5-24 beds, and on site at least 8 hours a week in a facility with four beds or fewer.

The ALF must have a staffing plan that specifies supervisory responsibilities, including the person responsible in the director’s absence. All direct care staff must be familiar with the service agreement for each resident for whom they provide care. At least one staff person must be on site 24 hours per day who is qualified to administer medication and/or assist with self-administration of medication, and has knowledge of emergency procedures, basic first-aid, cardiopulmonary resuscitation, and the Heimlich maneuver.

Staff Ratios. No minimum ratios. Facilities must provide a sufficient number of staff who are adequately trained, certified, or licensed to meet residents’ needs and to comply with applicable state laws and regulations. At least one awake qualified staff person must be on site 24 hours per day.

 

Training Requirements

Orientation is required for regular and temporary resident assistants. It must cover several topics, including fire and life safety and emergency disaster plans; infection control; basic food service; first-aid and the Heimlich maneuver; job responsibilities; residents’ health and psychosocial needs; the assessment process; use of service agreements; resident rights and reporting of abuse, neglect, and mistreatment; and hospice services. A minimum of 12 hours of annual training must be provided.

Provisions for Apartments and Private Units

Living units may be single-occupancy or double-occupancy; no more than two residents may share a room. Bathrooms must be available to residents either in their individual living units or in an area accessible to each resident. There must be at least one bathroom for every four residents. Residents must have access to a microwave or stove/conventional oven, refrigerator, and sink in their own living unit and/or a readily accessible central kitchen. Bedrooms and all bathrooms used by residents, except in specialized care units for memory impairment, must be equipped with an intercom or other mechanical means of communication for emergencies.

 

Provisions for Serving Persons with Dementia

Dementia Care Staff and Facility Requirements. No provisions identified.

Dementia Staff Training. Facilities that provide direct health care services to persons diagnosed with dementia must provide dementia-specific training each year to health care providers, who must also participate in continuing education programs. The training must cover topics relevant to dementia care, including communicating with persons diagnosed with various forms of dementia; their psychological, social, and physical needs; and required safety measures.

Background Checks

Facilities must obtain a report of each employee’s entire criminal history record from the Delaware Bureau of Identification and a report from DHSS regarding its review of any report of any person’s entire federal criminal history record. Facilities must also comply with the state’s mandatory drug testing law for all employees. The licensing agency may impose civil money penalties for violations of the criminal background check and drug testing laws.

Inspection and Monitoring

Facilities are surveyed annually. When investigating abuse, neglect, mistreatment, or financial exploitation reports, the Division may make unannounced visit(s) to the facility.

Public Financing

The Delaware Diamond State Health Plan Plus is a Medicaid managed long-term care program, which is currently being implemented throughout the state through an 1115 demonstration waiver. The program covers services provided in assisted living.

Room and Board Policy

In 2015, the state pays a maximum optional state supplement of $140 to Supplemental Security Income recipients who reside in ALFs; Medicaid-eligible residents are allowed to keep a $131 personal needs allowance. Family supplementation is allowed.

 

Location of Licensing, Certification, or Other Requirements

Delaware Department of Health and Social Services, Division of Long Term Care Residents Protection website: Regulations. This site has links to the regulations for ALFs and both types of rest homes–family care and residential care.
http://www.dhss.delaware.gov/dltcrp/regs.html

Information Sources

Yrene Waldron
Delaware Health Care Facilities Association

Robert H. Smith
Licensing and Certification Administrator
Delaware Division of Long Term Care Resident Protection