Assisted Living Establishment, Shared Housing Establishment, Sheltered Care Facility, and Supportive Living Facility
The Illinois Department of Public Health regulates assisted living establishments and shared housing establishments through one set of rules; assisted living requires single-occupancy private apartment units and shared housing does not. Sheltered care facilities are licensed under the Nursing Home Care Act to provide personal care services and are typically co-located with a nursing facility.
Supportive living facilities are certified by the Department of Healthcare and Family Services to provide residential care and supportive services to either low-income older adults or younger adults with disabilities who are eligible for Medicaid. Facilities must designate which of these two populations it will serve.
There is no separate licensure category for adult foster care.
This profile includes summaries of selected regulatory provisions for assisted living establishments, shared housing establishments, sheltered care facilities, and supportive living programs. The complete regulations are online at the links provided at the end.
Assisted living establishment means a residence for three or more unrelated adults (at least 80 percent of whom are 55 years of age or older) that provides single- occupancy living units with a private bathroom and space for small kitchen appliances. Residents should be able to age in place within the parameters set by the licensing rules.
Shared housing establishment means a publicly or privately operated freestanding residence for 3-16 adults (at least 80 percent of whom are 55 years of age or older) who are unrelated to the facility owners and/or managers. Shared housing provides the same services as assisted living.
Sheltered care facilities provide maintenance and personal care but do not provide routine nursing care.
Supportive living facilities are residential settings that provide or coordinate personal care services, 24-hour supervision and assistance (scheduled and unscheduled), activities, and health-related services. Facilities must be designed and operated to minimize the need for residents to move within or from the setting.
Assisted Living and Shared Housing Establishments. Resident agreements must provide information about the contract duration; the base rate and services included; additional services available and their cost; the complaint resolution process; residents’ rights and obligations; billing and payment procedures; admission, risk management, and termination policies and procedures; the Department’s annual on-site review process; terms of occupancy; payment and refund policies; notice requirements for fee changes; and policies for notifying relatives about changes in the resident’s condition.
Sheltered Care Facilities. Resident agreements must include information about services and charges; residents’ rights and obligations; whether the facility accepts Medicaid; and termination policies.
Supportive Living Facilities. Resident agreements must describe the services provided under Medicaid; payment arrangements; grievance procedures; termination provisions; and residents’ rights. The agreement includes services available for an additional fee and arrangements for sharing units.
The following rule applies to all settings.
A facility that offers to provide care for persons with Alzheimer’s disease and other dementias through an Alzheimer’s special care unit or center must disclose to the state agency responsible for licensing or certification–and to a potential or actual resident of the facility or such a resident’s representative–the following information in writing:
- Form of care or treatment that distinguishes the facility as suitable for persons with Alzheimer’s disease and other dementias.
- Philosophy of the facility concerning the care or treatment of personswith Alzheimer’s disease and other dementias.
- Facility’s pre-admission, admission, and discharge procedures.
- Facility’s assessment, care planning, and implementation guidelines in the care and treatment of persons with Alzheimer’s disease and other dementias.
- Facility’s minimum and maximum staffing ratios, specifying the general licensed health care provider-to-resident ratio and the trainee health care provider-to- resident ratio.
- Facility’s physical environment.
- Activities available to residents at the facility.
- Role of family members in the care of residents at the facility.
- Costs of care and treatment under the program or at the center.
Admission and Retention Policy
Assisted Living and Shared Housing Establishments. Facilities may not admit or retain residents who are a danger to themselves or others; are not able to communicate their needs and do not have a representative residing in the facility; require total assistance with two or more activities of daily living (ADLs); require assistance of more than one paid caregiver with any ADL; or require more than minimal assistance in moving to a safe area in an emergency. Persons with severe mental illness may not be admitted.
Facilities may not admit or retain residents who need the following health services unless self-administered or administered by a qualified licensed health care professional who is not employed by the facility owner or operator: intravenous (IV) therapy or feedings; gastrostomy feedings; catheters, except for routine maintenance of urinary catheters; sterile wound care; sliding scale insulin; routine insulin injections; and Stage III or IV decubitus ulcers.
Residents may not be accepted who need five or more skilled nursing visits a week for 3 or more weeks unless the course of treatment is rehabilitative and the need is temporary. An exception to these admission and discharge provisions is made for terminally ill individuals who are receiving or would qualify for hospice care provided by a licensed hospice provider.
Facilities may not serve people with dementia whose mental or physical condition is detrimental to the health, welfare, or safety of the resident or other residents, as determined by the resident’s physician prior to admission and annually thereafter.
Sheltered Care Facilities. Persons needing nursing care; or who have a communicable disease; or who are mentally ill, need treatment for mental illness, are likely to harm self or others; or who are destructive of property may not be admitted or retained.
Supportive living facilities may serve residents age 22 or older who have been screened and determined to meet Department-defined eligibility criteria. Applicants must have their name checked against the sex offender registry data base. Residents may be discharged if they are a danger to self or others or have needs that the facility cannot meet. Residents, with the exception of a spouse or significant other, must have a dementia diagnosis from a physician.
Assisted Living and Shared Housing Establishments. Mandatory services include housekeeping, laundry, security, emergency response systems, and assistance with ADLs. Optional services include medication reminders, supervision of self- administered medications, medication administration, and non-medical services.
Facilities must ensure that residents have the right to direct the scope of services they receive and to make individual choices based on their needs and preferences.
Establishments must be operated in a manner that provides the least restrictive and most home-like environment and that promotes independence, autonomy, individuality, privacy, dignity, and the right to negotiate risk-taking in residential surroundings.
Sheltered Care Facilities. Facilities may provide personal care; group and individual activities, including restorative and therapeutic activities; medical services; and assistance with self-administration of medications or administration by a physician or licensed nurse.
Supportive living facilities must provide personal and health-related services, including nursing services; personal care; medication oversight and assistance in self- administration; social and recreational programs; 24-hour response/security staff; emergency call systems; health promotion and referral; exercise; transportation; daily checks; and maintenance services. Nursing services include resident assessment and service planning; a quarterly health status evaluation; administration of medication when residents are temporarily unable to self-administer; medication setup; health counseling; episodic and intermittent health promotion or disease prevention counseling; and teaching self-care to meet routine and special health care needs.
Assisted Living and Shared Housing Establishments. A comprehensive assessment that includes an evaluation of a prospective resident’s physical, cognitive, and psychosocial condition must be completed by a physician. This assessment must be updated by a physician annually or upon a significant change in condition.
“Negotiated risk” is described as a process by which a resident, or his or her representative, may formally negotiate with providers what risks each are willing and unwilling to assume in service provision and the resident’s living environment. The provider must ensure that the resident and the resident’s representative, if any, are informed of the potential consequences of activities that the provider considers to pose risks to health and/or safety. A risk agreement describes the problem, issue, or service that is covered; the choices available to the resident and their risks/consequences; the resulting agreement; mutual responsibilities; and a specific time for reviewing the agreement. The agreement must be limited to the resident’s care and personal environment and cannot waive regulatory requirements.
Before admission, persons with dementia must be assessed with any one or a combination of assessment tools based upon the resident’s condition and stage in the disease process. Specified tools include the Functional Activities Questionnaire, Clock Drawing Test, and Functional Assessment Staging, among others.
Sheltered Care Facilities. The role of family in the care of persons with dementia must be described in the service plan. No other provisions identified.
Supportive Living Facilities. Residents must receive an initial assessment within 24 hours of admission and a comprehensive assessment within 14 days. Assessments must be completed by a licensed practical or registered nurse and be updated at least annually. Facilities are expected to involve family members in service planning.
Assisted Living and Shared Housing Establishments. Home health agencies unrelated to the facility may provide services under contract with residents.
Sheltered Care and Supportive Living Facilities. No provisions identified.
Assisted Living and Shared Housing Establishments. Facilities may provide medication reminders, supervision of self-administered medications, and medication administration. Medication reminders include reminding residents to take pre-dispensed, self-administered medication; observing the resident; and documenting whether or not the resident took the medication. Only a licensed health care professional employed by the facility may administer medications, including injections, oral medications, topical treatments, eye and ear drops, or nitroglycerin patches.
Supervision of self-administered medication includes assisting the resident with any combination of the following activities: reminding residents to take medication; reading the medication label to residents; checking the self-administered medication dosage against the label of the medication; confirming that residents have obtained and are taking the dosage as prescribed; and documenting in writing that the resident has taken (or refused to take) the medication. If residents are physically unable to open a container, the container may be opened for them. Supervision of self-administered medication must be under the direction of a licensed health care professional.
Sheltered Care Facilities. Residents must be capable of self-administering medications or receive medications administered by licensed personnel. At admission, all residents must be capable of self-administration. Facility staff may assist a resident in medication self-administration by taking the medication from the locked area where it is stored and handing it to the resident, and they may open containers for residents who are physically incapable of doing so.
Supportive Living Facilities. Residents must be capable of self-administering medications or receive medications administered by a licensed nurse. Unlicensed facility staff may remind the resident to take medications; take medication from where it is stored and hand it to the resident when requested to do so by the resident; and open medication containers. Only a licensed nurse may remove medication from a container and assist the resident in consuming or applying the medication.
Food Service and Dietary Provisions
Assisted Living and Shared Housing Establishments. Facilities must provide three daily meals.
Sheltered care facilities must provide three meals a day or two meals and a breakfast bar. Meals must meet the adult general diet requirements recommended by the National Academy of Science’s Food and Nutrition Board. Facilities must provide therapeutic diets ordered by a physician.
Supportive living facilities must offer three meals per day, or two meals per day (noon and evening meals) and a breakfast bar. The menu must provide food choices and therapeutic diets as ordered by a resident’s physician. The menu must comply with the National Academy of Science’s Food and Nutrition Board recommendations.
Assisted Living and Shared Housing Establishments
Type of Staff. Facilities must employ a full-time manager responsible for daily operations and direct care staff to provide services to residents. If the facility offers medication administration or specified treatments (e.g., injections, IV therapy), a licensed health care professional must be available. At least one staff member certified in cardiopulmonary resuscitation must be awake and on-duty at all times.
Staff Ratios. No minimum ratios. Staff must be sufficient in number and qualifications, awake, and on-duty all hours of each day to provide services that meet residents’ scheduled and unscheduled needs.
Sheltered Care Facility
Type of Staff. An administrator is required and an assistant administrator is optional. Personnel to assist with personal care are required.
Staff Ratios. No minimum ratios. Facilities must have staffing patterns that are sufficient to meet residents’ needs. At least one awake staff member is required at all times.
Supportive Living Facility
Type of Staff. A manager is required to manage daily operations. Personal care services and assistance with self-administration of medications must be provided by certified nursing assistants (CNAs). Licensed nurses are required to administer medications and provide other nursing tasks. Response/security staff who are certified in emergency resuscitation are required to respond to scheduled or unpredictable needs and to emergency calls from residents. A trained staff person must be responsible for planning and directing social and recreation activities.
Staff Ratios. One CNA must be on-duty during all shifts. At least one response/security staff person is required for facilities with 1-75 residents, a second staff person for facilities with 76-150 residents, and a third staff person for facilities with 151 or more residents. Facilities must provide a sufficient number of licensed and certified staff to meet residents’ needs in accordance with their contractual agreements.
Assisted Living and Shared Housing Establishments. All staff must complete an orientation that addresses service philosophy and goals; promotion of dignity, independence, self-determination, privacy, choice, and resident rights; confidentiality; hygiene and infection control; abuse and neglect prevention and reporting; and disaster procedures. An additional orientation is required to cover residents’ need and service plans; internal policies; job responsibilities and limitations; and ADL assistance. Eight hours of annual training is required on the topics listed above. Managers must complete 20 hours of training every 2 years.
Sheltered Care Facilities. Supervisory personnel must annually attend appropriate education programs on supervision, nutrition, and other pertinent subjects. Staff must attend an orientation to the facility and its policies, and receive skill training and continuing education on topics relevant to their duties.
Supportive Living Facilities. Staff must receive documented training by qualified individuals in their area(s) of responsibility and on infection control; crisis intervention; prevention and notification of abuse and neglect; behavior intervention; negotiated risk; encouraging independence; and techniques for working with persons with disabilities and elderly populations. In facilities serving persons with disabilities, disability-specific sensitivity training must be provided at least annually. Nursing assistants must be certified or enrolled in a course that will result in certification.
Provisions for Apartments and Private Units
Assisted living establishments require single-occupancy units that may be shared by choice. Units must accommodate small kitchen appliances and have a sink, toilet, and private bathing or washing facilities.
Shared housing establishments may have shared bathrooms (one for every four residents) and shared tubs/shower facilities (one for every six residents).
Sheltered Care Facilities. No more than four persons may share a room. One sink and toilet is required for every ten residents and one shower/bath is required for every 15 residents. A sink and toilet and shower/bath is required on each floor.
Supportive Living Facilities. Units in facilities licensed on or after October 18, 2004 must have a full bathroom, lockable doors, an emergency call system, a sink, microwave oven or stove, a refrigerator, and a separate bedroom for each unrelated occupant.
Provisions for Serving Persons with Dementia
Dementia Care Staff
Assisted Living and Shared Housing Establishments. A manager and sufficient numbers of staff, with qualifications, adequate skills, education, and experience must be available to meet residents’ 24-hour scheduled and unscheduled needs. Facilities must provide at least 1.4 hours of services per resident per day.
Sheltered Care Facilities. Facilities must have staff with the skills required to meet residents’ needs.
Supportive Living Facilities. There must be one licensed nurse available at all times on site or on call to meet medication administration needs, and at least one CNA on each shift for every ten residents.
Dementia Staff Training
Assisted Living and Shared Housing Establishments. All staff members must receive 4 hours of dementia-specific orientation prior to assuming job responsibilities without direct supervision. Following orientation, direct care staff must receive 16 hours of on-the-job supervision and training within the first 16 hours of employment following orientation. Training must cover the following topics: encouraging independence in ADLs and providing ADL assistance; emergency and evacuation procedures specific to the dementia population; techniques for minimizing challenging behaviors; rights and choice for persons with dementia, working with families, and caregiver stress; and communication skills.
Direct care staff must annually complete 12 hours of in-service education regarding Alzheimer’s disease and other types of dementia. Topics may include: (1) assessing resident capabilities and developing and implementing service plans; (2) promoting resident dignity, independence, individuality, privacy and choice; (3) planning and facilitating activities appropriate for persons with dementia; (4) communicating with families and other persons interested in the resident; (5) residents’ rights and principles of self-determination; (6) care of elderly persons with physical, cognitive, behavioral and social disabilities; (7) residents’ medical and social needs; (8) common psychotropic medications and side effects; and (9) local community resources.
The manager or supervisor must complete–in addition to other training requirements–6 hours of annual continuing education regarding dementia care.
Sheltered Care Facilities. No provisions identified.
Supportive Living Facilities. Staff must receive a 4-hour orientation that includes information about dementia; communication techniques; planning activities; behavior management techniques; reducing safety risks; personal care; and how to partner with families and the community. Staff must receive 12 hours of annual in-service training on these and other relevant topics, including pharmacological and non-pharmacological interventions, and medical and social aspects of dementia.
Dementia Facility Requirements
No provisions identified for assisted living, shared housing, or sheltered care facilities.
Supportive Living Facilities. A dementia care unit may not have more than 20 apartments and all exterior doors must be alarmed. Apartments must include a sink, microwave, and refrigerator, although each resident’s ability to use these appliances must be assessed.
All licensed programs must follow the rules established by the state’s Health Care Worker Background Check law.
Inspection and Monitoring
Assisted Living and Shared Housing Establishments. Facilities are inspected annually.
Sheltered Care Facilities. Facilities are inspected annually.
Supportive Living Facilities. Facilities participating in the Medicaid program must be certified and monitored, at least annually, by the Department of Healthcare and Family Services.
Medicaid does not pay for services in assisted living establishments, shared housing establishments, and sheltered care facilities.
A Medicaid 1915(c) waiver called the Supported Living Program and a 1915(b) waiver called the Managed Long-Term Services and Supports program pay for assisted living services for eligible residents in supportive living facilities.
Room and Board Policy
In 2015, Medicaid limits room and board rates for eligible residents to the federal Supplemental Security Income (SSI) benefit–$733–minus a $90 personal needs allowance. Family supplementation is permitted.
The state provides an optional state supplement (OSS) to SSI recipients and other low-income residents in sheltered care facilities. The OSS amount is based on a state- approved allowance provided for individual needs.
Location of Licensing, Certification, or Other Requirements
Administrative Code, Title 77, Chapter I, Subchapter c, Part 295: Assisted Living and Shared Housing Establishment Code. [August 16, 2012] http://www.ilga.gov/commission/jcar/admincode/077/07700295sections.html
Administrative Code, Title 77, Chapter I, Subchapter c, Part 330: Sheltered Care Facilities Code. [March 29, 2013] http://www.ilga.gov/commission/jcar/admincode/077/07700330sections.html
Administrative Code, Title 89, Chapter I, Subchapter d, Part 146, subpart B: Supportive Living Facilities. [December 2, 2014] http://www.ilga.gov/commission/jcar/admincode/089/08900146sections.html
Illinois Supportive Living Program website. http://www.slfillinois.com/
Illinois Compiled Statutes 4, Chapter 210: Alzheimer’s Disease and Related Dementias Special Care Disclosure Act. [July 2, 2010] http://www.ilga.gov/legislation/ilcs/ilcs3.asp?ActID=1215&ChapAct=210%C2%A0ILCS%C2%A0 4/&ChapterID=21&ChapterName=HEALTH+FACILITIES&ActName=Alzheimer%92s+Special+ Care+Disclosure+Act%2E
Illinois Compiled Statutes 7, Chapter 225: Board and Care Home Act. [August 13, 2009] http://www.ilga.gov/legislation/ilcs/ilcs3.asp?ActID=1292&ChapAct=225%C2%A0ILCS%C2%A0 7/&ChapterID=24&ChapterName=PROFESSIONS%20AND%20OCCUPATIONS&ActName=Bo ard%20and%20Care%20Home%20Act
Illinois Department of Public Health website: Health Care Worker Registry. http://www.idph.state.il.us/nar/
Illinois Health Care Association