Nebraska Assisted Living Facility Training
Licensure Terms :Residential Facilities for Groups
The Division of Health, Bureau of Health Care Quality and Compliance, licenses residential facilities for groups, which generally care for elderly persons or persons with physical disabilities. Some facilities may wish to care for special populations, such as persons with Alzheimer’s disease or other dementia, mental illness, or intellectual disability; or persons with chronic illnesses, such as Hepatitis C and HIV; or to provide assisted living services. To do so, they need to apply for special endorsements to their license and meet additional requirements, including submitting evidence that they have received relevant training in caring for the population they wish to serve.
A facility may have more than one endorsement if it provides satisfactory evidence that it complies with the requirements for each type of endorsement and can demonstrate that the residents will be protected and receive necessary care and services.
Adult Foster Care. Homes for individual residential care are licensed to provide food, shelter, assistance, and supervision for no more than two persons who are aged, infirm, physically disabled, or intellectually disabled. No public funding is available for services in these homes. Regulatory provisions for these 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 residential facilities for groups. The complete regulations can be viewed online using the links provided at the end.
Residential facilities for groups means an establishment that furnishes food, shelter, assistance, and limited supervision to persons who are aged or infirm, have physical or other disabilities, or have chronic illnesses. The term includes, without limitation, an assisted living facility. Residential facilities for groups that provide assisted living services must be operated in a manner that minimizes the need for its residents to move out of the facility as their respective physical and mental conditions change over time; and supports, to the maximum extent possible, each resident’s need for autonomy and the right to make decisions regarding his or her own life.
Facilities must provide in writing, information about basic rates and included services, charges for optional services, and refund policies.
Facilities must make a full written disclosure to prospective residents regarding the type of personal care services available and their cost.
Facilities that want to serve persons with dementia must obtain an endorsement on their licenses to do so. The facility’s policies and procedures must include a description of basic services and activities, the manner in which behavioral problems will be addressed, medication management, steps to encourage family involvement, admission and discharge criteria, and actions that will be taken to prevent and respond to wandering.
Facilities endorsed to provide assisted living services must maintain a list of resources for financial assistance and other social services that may decrease the need for a resident of the residential facility whose physical or mental condition is declining over time to move out of the residential facility.
Admission and Retention Policy
Residents are assessed as either Care Category 1 (ambulatory) or Care Category 2 (non-ambulatory). Ambulatory status is defined based on the residents’ ability to move from an unsafe area to an area of safety without assistance from another person within four minutes. To admit or retain non-ambulatory individuals, a facility must meet specific fire and life safety building standards.
Facilities may not admit individuals who are bedfast or require 24-hour skilled nursing or medical supervision unless they are in a hospice program and have an approved exemption request from the Bureau. Facilities may not admit individuals who require restraints.
The rules do not allow facilities to admit or retain residents with specified health conditions, such as contractures, pressure ulcers, diabetes, and unmanageable incontinence. In addition, persons who require certain treatments, such as catheters, colostomies/ileostomies, enemas/suppositories, oxygen, or wound care may not be admitted or retained unless the resident is physically and mentally capable of performing the required care or if the care is provided or supervised by a medical professional.
The facility may retain a resident who is suffering from an illness or injury from which the resident is expected to recover within 14 days after its onset or occurrence.
Residents may not be retained if the Bureau determines that the facility is unable to provide necessary care.
Services provided include personal care; at least 10 hours of social/recreational activities a week; protective supervision; laundry; and assistance with access to dental, optical, social, and related services needed by residents.
Facilities endorsed to provide assisted living services must include, without limitation, services that will enable the facility to retain residents who are otherwise prohibited from being admitted to the facility because they have specified health conditions or require certain treatments as described above under Admission and Retention criteria. Facilities that are endorsed to provide dementia care must offer activities related to gross motor skills, social activities, sensory enhancement activities, and outdoor activities.
The administrator must assess whether residents’ needs are changing and arrange for assessment and monitoring by a health professional when a resident’s health declines. Services must be arranged based on the health professional’s assessment.
Residents may directly contract with licensed home health and hospice agencies to provide services.
Residents who are capable may self-administer medications. Unlicensed staff may administer medications after completing a 16-hour medication course from an approved medication training provider. Four of these hours must be hands-on training with a Bureau-approved provider. These staff must complete 8 hours of continuing education annually and pass an approved examination. Because they manage unlicensed staff, administrators are also required to take the same 16-hour medication course and the annual 8 hours of continuing education.
Facilities must not admit or retain an individual who requires regular intramuscular, subcutaneous, or intradermal injections unless the injections are administered by:
(1) the individual; or
(2) a medical professional, or licensed practical nurse (LPN), acting within his or her authorized scope of practice and in accordance with all applicable statutes and regulations, who has been trained to administer those injections. Owners who are nurses and nurses employed by a facility are prohibited from administering medications by injections according to the rules for residential facilities for groups.
Caregivers may bring equipment to a resident who self-administers insulin injections. If the resident is unable to draw their own insulin, insulin syringes may be pre-filled, labeled, and dated by a nurse or pre-filled insulin pens may be used.
Facilities that do not assist residents with medication administration or that store resident’s medications but allow the resident to independently self-administer medications without direction are not bound by the requirements related to medication administration.
Food Service and Dietary Provisions
Facilities must provide three meals a day that meet the recommended dietary allowance of the Food and Nutrition Board of the National Academy of Sciences. Meals must be nutritious, served in an appropriate manner, suitable for the residents and prepared with regard for individual preferences and religious requirements. Snacks must be made available between meals for residents who are not prohibited by their physicians from eating between meals. Special diets may be provided if ordered by a physician or dietician.
The facility may serve meals to residents in their rooms upon request for no more than 14 consecutive days if the resident is unable to eat in the dining room because of an injury or illness. Facilities with more than ten residents must consult at least quarterly with a registered dietician concerning development and review of weekly menus, training for kitchen employees, and compliance with the facility’s nutritional program.
Type of Staff. The administrator provides oversight and direction for facility staff to ensure that residents receive needed services and protective supervision and that the facility is in compliance with the rules. Administrators must be licensed by the Nevada State Board of Examiners for Administrators of Facilities for Long Term Care and must designate one or more employees to be in charge of the facility during those times when the administrator is absent. Caregivers provide personal care services and may assist with medication services after completing required training.
Facilities licensed for 20-49 residents must have one staff member designated to organize, conduct, and evaluate activities. Facilities with 50 or more residents must have a full-time person to assist with activities. Volunteers may be used to supplement the services and programs of a residential facility, but may not be used to replace staff members.
Staff Ratios. No minimum ratios. Facilities must maintain staffing patterns that are sufficient to meet residents’ care needs and enable them to achieve and maintain their functioning, self-care, and independence. There must be at least one caregiver on the premises of the facility if one or more residents are present at the facility. Facilities with more than 20 residents must ensure that at least one employee is awake and on duty at all times. An additional employee must be available to provide care within 10 minutes after being informed that his or her services are needed.
Within 60 days of employment, caregivers must receive at least 4 hours of training related to the care that is specific to the facility’s resident population, for example, the elderly, persons with mental illness, or persons with chronic illness and debilitating diseases; and must receive 8 hours of annual continuing education and training related to the care of such residents.
Within 30 days after an administrator or caregiver is employed at the facility, they must be trained in first-aid and cardiopulmonary resuscitation (CPR) and maintain a current certification based on the requirements of the certification agency. The advanced certificate in first-aid and adult CPR issued by the American Red Cross or an equivalent certification will be accepted as proof of that training.
A registered nurse (RN) is exempt from first-aid training due to his or her body of knowledge, but must maintain current CPR certification. LPNs are exempt from first-aid training only if they are under direct supervision of an RN.
Provisions for Apartments and Private Units
Apartment-style units are not required. Facilities may provide private or shared rooms. No more than three residents may share a room. One toilet and sink is required for every four residents, and a bathtub or shower is required for every six residents.
Residents of facilities that provide assisted living services reside in their own units, which must contain a sleeping area/bedroom and toilet facilities.3 Units may be shared by two occupants only by mutual consent.
Provisions for Serving Persons with Dementia
Dementia Care Staff. A residential facility that provides care to persons with Alzheimer’s disease must be administered by a person who has not less than 3 years of experience in caring for residents with Alzheimer’s disease or other dementias in a licensed facility; or has a combination of education and training that the Bureau determines is equivalent to the experience required. The administrator is required to be responsible for facility policies and services and must ensure that at least one member of the staff is awake and on duty at the facility at all times.
Dementia Staff Training. Within a week of employment, all staff must receive at least 2 hours of training in providing care, including emergency care, to residents with any form of dementia, including Alzheimer’s disease; and providing support for the members of the resident’s family. Within 3 months of employment and then annually, caregivers must complete 8 hours of training in providing care to a resident with any form of dementia, including Alzheimer’s disease.
If an employee is licensed or certified by an occupational licensing board, at least 3 hours of required continuing education must address the provision of care to residents with dementia. Continuing education must be completed on or before the first anniversary date of employment.
Dementia Facility Requirements. Locked quarters are allowed in Alzheimer’s/dementia units. Exits must have warning devices such as alarms, buzzers, horns, or other audible devices that are activated when a door is opened, or time-delay locks. Facilities must have a secure yard, completely fenced and gated with locking devices.
Within 10 days of hire, all employees must undergo a fingerprint criminal background check. Facilities may not accept the results of background checks conducted in other states or by companies other than the Department of Public Safety and the Federal Bureau of Investigation. Caregivers must have no prior convictions or findings of abuse, neglect, or exploitation or other serious convictions relating to the ability to care for dependent persons. All other staff must not have any convictions or history of abuse, neglect, or exploitation.
Inspection and Monitoring
The Health Division conducts a pre-licensure investigation of the premises, personnel qualifications, and the licensing applicants’ policies. Facilities are subject to on-site inspections and complaint investigations. The licensing agency provides on-site education during the survey process.
The Nevada Aging and Disability Services Division covers augmented personal care for older persons (65+ years) in a licensed residential facility for groups under the Medicaid Frail Elderly 1915(c) Waiver program. Augmented personal care includes homemaker services, chore services, social and recreational programming, personal care services, companion services, medication oversight, and services that will ensure that residents of the facility are safe, secure, and adequately supervised. Assisted living is covered under the Home and Community-Based Services for Persons with Physical Disabilities 1915(c) Waiver program that serves all age groups.
Room and Board Policy
In 2009, the state did not limit what providers could charge Medicaid-eligible residents for room and board but allowed residents to retain $110 from their income as a personal needs allowance (PNA). Family supplementation for room and board charges was allowed.
The state provides an optional state supplement (OSS) to aged and blind recipients who live in residential facilities that provide personal care and services to 16 or fewer persons. In 2011, the maximum amount of the OSS was $391.
Location of Licensing, Certification, or Other Requirements
Nebraska Administrative Code, Chapter 443.15511 to 15529: Homes for Residential Care. http://leg.state.nv.us/nac/NAC-449.html#NAC449Sec15511
Nebraska Administrative Code, Chapter 449.156 to 27706: Residential Group Homes. http://leg.state.nv.us/nac/NAC-449.html#NAC449Sec156
Nebraska Administrative Code, Regulations and Interpretive Guidelines for Residential Facilities for Groups.
Frequently Asked Questions: New Medication Regulations for Residential Facilities for Groups. http://www.health.nv.gov/HCQC/NAC449-FAQ-NewMedRegulations.pdf
Nevada Aging and Disability Services Division website: Home and Community-Based Waiver Program information.