Licensure Terms

Assisted Living Facilities, Adult Residential Care Homes

General Approach

The Department of Health, Office of Health Care Assurance, licenses two residential care settings: assisted living facilities (ALFs) and adult residential care homes (ARCHs). Type I ARCHs are licensed for five or fewer residents and Type II for six or more residents. In addition, the state has provisions for licensure of expanded adult residential care homes (E-ARCHs) that provide professional health services similar to those provided by nursing facilities.

Adult Foster Care. The Department certifies private homes as community care foster family homes (CCFFHs) to serve one to three adults who have been certified by a physician to need care in a nursing facility. Both Medicaid-eligible and private pay clients entering a CCFFH must have a case management agency licensed by the Department of Human Services to coordinate health care requirements. If a CCFFH is certified for 2-3 persons, the home is allowed to have one private pay resident in addition to Medicaid waiver participants. This profile does not include the regulatory provisions for Type I ARCHs or for CCFFHs, but a link to the provisions can found at the end.

This profile includes summaries of selected regulatory provisions for ALFs and for Type II ARCHs. The complete regulations are online at the links provided at the end.

Definitions

Assisted living facility means a community setting that provides 24-hour access to services based on the individual needs of each resident. The facility must be designed to maximize the independence and self-esteem of limited-mobility persons who may no longer be capable of independent living.

Adult residential care home means a facility providing 24-hour living accommodations to adults, unrelated to the provider, who require at least minimal assistance in activities of daily living (ADLs). E-ARCH are licensed to serve a limited number of residents who need an intermediate level of nursing facility care.

Resident Agreements

Assisted Living Facilities. A residents’ agreement is required prior to and upon move-in. It must describe the services to be provided and their cost, and the conditions under which additional services may be provided and fees charged. The facility must describe services that it does not provide but will assist with arranging or coordinating.

Adult residential care homes must have a written agreement that explains the resident’s rights, the provider’s responsibilities, and services to be provided based on the resident’s care plan.

Disclosure Provisions

No provision identified.

Admission and Retention Policy

Assisted living facilities must develop discharge policies and procedures that include a written 14-day notice when: (1) a resident’s behavior poses an imminent danger to self or others; (2) a resident’s needs exceed what the facility is able to meet with available support services; or (3) a resident has an established pattern of not abiding by agreements necessary for assisted living. Each facility may use its professional judgment and take into account the capacity and expertise of its staff in determining who may be served.

Adult residential care homes are for individuals who need assistance with personal care below an intermediate level of nursing facility care. Homes must develop admission and discharge policies and procedures. E-ARCHs may admit individuals who meet nursing facility level of care criteria as determined and certified by a physician or an advanced practice registered nurse (RN). No more than 20 percent of residents in Type II E-ARCHs may need a nursing facility level of care, though exceptions are possible.

Services

Assisted living facilities must provide laundry and housekeeping services; opportunities for individual and group socialization; assistance with ADLs; nursing assessment, health monitoring, and routine nursing tasks; medication administration; 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, therapy, pharmacist, and podiatry), and hospice care.

Adult residential care homes provide personal care services, medication services, assistance with self-administration of medications, laundry and housekeeping, transportation to health care appointments, supervision, and social activities. E-ARCHs provide additional health-related services needed by residents who meet nursing facility level of care criteria; the facility must make arrangements for such residents to visit a medical doctor every 4 months for a medical evaluation.

Service Planning

Assisted living facilities must conduct a comprehensive assessment of each resident’s needs, plan and implement responsive services, and periodically update the service plan. The service plan should be developed with the resident’s involvement and should support dignity, privacy, choice, individuality, and independence. Managed risk is described as the process of negotiating and developing a plan to address residents’ needs, decisions, or preferences to reduce the probability of a poor outcome for the resident or others at risk for adverse consequences based on the residents’ actions. 

Adult residential care homes must conduct a comprehensive assessment of each resident’s needs and develop a schedule of activities that describes the services to be provided. For E-ARCHs, a care plan is developed by the resident’s case management agency and–at a minimum–monthly visits are required to assess and evaluate residents’ care and services. 

Third-Party Providers

Assisted living facilities may arrange access to ancillary services for medically- related care (e.g., physician, podiatrist) and social work services.

Adult Residential Care Homes. Residents who require therapeutic services prescribed by a physician may receive these services provided by an outside agency at the facility.

Medication Provisions

Assisted living facilities may provide assistance with self-administration of medications and unlicensed assistive personnel may provide this assistance as delegated by an RN under state administrative rules and the state’s Nursing Model Act. Residents who self-administer may keep medications in their unit. Medications in units shared by two residents must be kept in a locked container in the unit. An RN or physician must review all residents’ medications at least every 90 days.

Adult residential care homes may make medications available unless the resident is capable of and prefers to self-administer. E-ARCHs require licensed nurses to administer medications by injection unless the resident is capable of self- administration. In addition, this task may be delegated to unlicensed assistive personnel according to state administrative rules and the state’s Nursing Model Act.

Food Service and Dietary Provisions

Assisted living facilities provide three meals a day, modified diets, and snacks, which are evaluated and approved by a dietitian on a semi-annual basis and are appropriate to the residents’ needs and choices.

Adult residential care homes provide three meals a day, snacks, and may offer meals recommended or prescribed by a physician.

Staffing Requirements

Assisted Living Facility

Type of Staff. Facilities must employ direct care staff and an administrator who is accountable for providing training for all facility staff in the provision of services and principles of assisted living. All staff must be qualified in cardiopulmonary resuscitation and first-aid.

Facilities must make arrangements for a registered nurse to conduct resident assessments and to train and supervise staff. 

Staff Ratios. No minimum ratios. Licensed nursing staff must be available 7 days a week to meet residents’ care management and monitoring needs, and sufficient direct care staff must be available 24 hours daily to meet residents’ needs. 

Residential Care 

Type of Staff. An administrator of a Type II ARCH manages and oversees all staff and residents. Facilities must make arrangements for an registered nurse to conduct resident assessments. E-ARCHs must have an RN or case manager available to train and supervise caregivers. A case manager is a person who is licensed by the state as an RN or social worker. Other staff include nurse aides and direct care staff who assist residents with personal care needs and some nursing tasks.

Staff Ratios. No minimum ratios. Sufficient staff must be on-duty 24 hours a day to meet residents’ needs. At least one nurse aide must be on each shift.

Training Requirements

Assisted Living Facilities. All facility staff must complete an orientation to acquaint them with the philosophy, organization, practice, and goals of assisted living; and a minimum of 6 hours annually of regularly scheduled in-service training.

Adult Residential Care Homes. For E-ARCHs, an RN must train and monitor primary caregivers. All Type II ARCH staff must have 6 hours of annual training on specified topics, including personal care; infection control; pharmacology; medical and behavioral management of residents; diseases and chronic illnesses; and community services and resources.

Provisions for Apartments and Private Units

Assisted living facilities must provide apartment units with a bathroom (sink, shower, and toilet), refrigerator, and cooking capacity; and a call system monitored 24 hours per day by staff. The cooking appliances may be removed or disconnected depending on residents’ needs.

Adult residential care homes may have up to four residents sharing a room. One toilet is required for every eight residents, one sink for every ten residents, and one shower for every 14 residents.

Provisions for Serving Persons with Dementia

No provisions identified.

Background Checks

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.

Inspection and Monitoring

Assisted Living Facilities. Facilities are inspected by the Department of Health no less than every 2 years for re-licensing. The Department representative, without prior notice, may enter the premises at any reasonable time to ensure compliance with regulations.

Adult residential care homes are inspected annually or based on requests or complaints. Inspections are unannounced except for the annual re-licensing inspection.

Public Financing

The state has a Medicaid 1115 demonstration waiver program called QUEST Expanded Access, which is a managed care program that covers services in ALFs, E- ARCHs, and continuing care foster family homes.

Room and Board Policy

The state provides an optional state supplement (OSS) to Supplemental Security Income (SSI) recipients, who reside in CCFFHs and ARCHs, and limits room and board charges for Medicaid-eligible residents to the combined SSI and OSS payment minus a personal needs allowance (PNA). In 2015, the federal SSI benefit is $733 and the maximum OSS is $759.90. In 2009, family supplementation was not allowed.

Location of Licensing, Certification, or Other Requirements

Hawaii Administrative Rules, Title 11, Chapter 90: Assisted Living Facility and Chapter 101.1: Adult Residential Care Homes.

http://health.hawaii.gov/ohca/type-of-hawaii-state-licensed-andor-federal-certified-facilities-or- agencies/

Hawaii Administrative Rules, Chapter 1454: Regulation of Home and Community-Based Care Case Management Agencies and Community Care Foster Family Homes. http://health.hawaii.gov/ohca/files/2014/07/17-1454-Case-Mgmt-and-CCFFH-Current-Admin- Rules.pdf

Information Sources

Rachael Wong
Hawaii Health Care Association