Licensure Terms

Assisted Living Residence-Supported Residential Health Care, Assisted Living Residence-Residential Care Facilities

General Approach

The New Hampshire Department of Health and Human Services, Bureau of Health Facilities Administration, licenses two categories of assisted living residences (ALRs): (1) supported residential health care facilities that may retain nursing home-eligible residents if appropriate care and services are provided; and (2) residential care facilities (RCFs) that provide a lower level of care. Some licensing provisions differ based on facility size–17 or more residents or 4-16 residents. In smaller settings, the licensee might be the home owner.

Adult Foster Care. Adult family care residences are certified to provide social or health services to one or two residents in a home-like environment. Such services may include, but are not limited to, supervision, medical monitoring, supervision of medications, and assistance with daily living activities. Regulatory provisions for adult family care residences 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 ALR- supported residential health care and ALR-RCFs. The complete regulations are online at the links provided at the end.

Definitions

Assisted Living Residences-Supported Residential Health Care. Facilities provide social or health services by appropriately trained or licensed individuals to three or more residents. Facilities may not serve those who require nursing services complex enough to require 24-hour nursing supervision. Facilities may provide short-term medical care for residents who may be convalescing from an illness and these residents must be capable of self-evacuation.

Assisted Living Residences-Residential Care. Facilities offer assistance with personal and social activities that require a minimum of supervision, or health care that can be provided in a home or home-like setting.

Resident Agreements

Assisted Living Residences-Supported Residential Health Care. Agreements must list the fees and core services; house rules; responsibility for discharge planning; information about nursing and other health care services and supplies that are not core services–their availability, the facility’s responsibility for arranging them, and their cost (if known); policies and procedures regarding arranging/providing transportation and arranging for third-party services; and medication management services.

Assisted Living Residences-Residential Care. In addition to the topics listed above, agreements must state the resident acuity level that the facility can accommodate.

Disclosure Provisions

Both licensure categories must use a Department-required disclosure summary form to provide information to applicants prior to admission, including the facility’s base rate and the services included in that rate; staff coverage; transportation; and other services offered.

Admission and Retention Policy

Assisted Living Residences-Supported Residential Health Care. Facilities may only admit and retain individuals whose needs they can meet and who can evacuate in accordance with the state fire code. Facilities with appropriate staff may admit or retain individuals who require mechanical assistance to transfer or who have a Stage III or higher pressure ulcer. Facilities may admit and retain those who require 24- hour licensed nursing care or monitoring for less than 21 days and those receiving hospice care.

Assisted Living Residences-Residential Care. Facilities may only admit and retain individuals whose needs they can meet. Residents must be capable of self- evacuation without assistance. Residents who require rehabilitative or nursing care longer than 21 days must be discharged, with the exception of those receiving hospice services.

Services

Assisted Living Residences-Supported Residential Health Care. Core services include supervision of residents with cognitive deficits; health and safety services; personal care; emergency response and crisis intervention; medication services; social and recreational activities; and assistance with arranging medical and dental appointments. Facilities must also provide access to nursing services, including supervision and instruction of direct care, rehabilitation, and behavioral health care as needed by residents.

Assisted Living Residences-Residential Care. Services include supervision of residents with cognitive deficits; arrangement of appointments; crisis intervention; supervision of activities of daily living; medication services; provision of or arrangement for transient medical care with licensed home health care providers; and assistance accessing community services.

Service Planning

Both licensure categories require that residents be assessed by a trained assessor using a Department-approved resident assessment tool. The assessment must be repeated twice yearly and following a change in condition. If indicated by the resident assessment, a nursing assessment must be completed that addresses medication use, clinical services, pain, vital signs, and physical, cognitive, mental, and behavioral status. Assessments are used to develop the resident’s care plan.

Third-Party Providers

Both licensure categories permit residents to contract with home health and hospice services.

Medication Provisions

Assisted Living Residences-Supported Residential Health Care. Residents may self-direct administration of medications if their physical condition prevents them from self-administration and they can verbally direct personnel to assist in the process. Facility staff may supervise self-administration in the following ways: remind residents to take medications; place containers within reach; and observe, record and document observed or reported side effects. Staff may not physically handle the medication.

Unlicensed staff may administer oral medications if they have been delegated to do so by a licensed nurse. A licensed nursing assistant working under the direction of a licensed nurse may administer medicinal shampoos and baths; glycerin suppositories and enemas; and topical products to intact skin.

Unlicensed staff who supervise and/or administer medications must first receive a 4-hour training on the following topics: infection control and proper hand-washing techniques; the five rights (right resident; right medication; right dose; right time; and right route); general categories of medications such as antihypertensives or antibiotics; documentation; desired effects and potential side effects of medications; and medication precautions and interactions. The rules include extensive provisions regarding assisting with self-administration and administering medications.

Assisted Living Residences-Residential Care. Residents may self-administer medications with or without staff supervision or may self-direct medication administration as described above. Medications must be administered by a licensed nurse, a medication nursing assistant, or any other individuals authorized by law. [Nurse delegation is not described.]

Food Service and Dietary Provisions

Assisted Living Residences-Supported Residential Health Care. Facilities must provide three or more meals a day–and snacks between meals and before retiring–that meet the recommended dietary allowances of the National Academy of Science’s Food and Nutrition Board. Staff responsible for food service must have knowledge of nutritional requirements and planning and preparation of prescribed diets.

Assisted Living Residences-Residential Care. Facilities must provide three meals and snacks daily that meet the U.S. Department of Agriculture recommended dietary allowance specified in the 2005 Dietary Guidelines for Americans. Therapeutic diets must be provided to residents as directed by a licensed practitioner or other professional with prescriptive authority.

Staffing Requirements

Assisted Living Residences-Supported Residential Health Care

Type of Staff. Facilities must employ a full-time administrator who is responsible for day-to-day operations; direct care personnel to provide personal care assistance; and a licensed nurse to provide or delegate medication administration, assist with resident assessment, and oversee health services. A certified medication nursing assistant may be employed to administer medications.

Staff Ratios. No minimum ratios. Personnel levels are determined by the administrator based on the facility’s size and residents’ service needs. At least one awake staff must be on-duty at all times except for facilities with eight or fewer beds that have an electronic communication system, an installed wandering prevention system for facilities serving residents with dementia, and the ability to meet residents’ needs at all times.

Assisted Living Residences-Residential Care

Type of Staff. Facilities must employ an administrator who is responsible for day- to-day operations, direct care personnel to provide personal care assistance, and a licensed nurse (or other licensed practitioner) to administer medications. The administrator must be employed at least 35 hours per week.

Staff Ratios. No minimum ratios. Personnel levels must be sufficient to meet residents’ needs. In facilities with 16 or fewer beds, an awake personnel member is not required during the night if: (1) there is a communication system that allows a resident to contact and awaken the sleeping personnel member via an intercom or other communication system; (2) the licensee has, for residents with dementia, installed a wandering prevention system that will awaken the sleeping personnel member; (3) residents require nothing more than occasional reminding, cueing, or verbal prompting for mobility and evacuation; (4) residents have no acute medical needs or ongoing nursing needs and no history of being verbally or physically abusive; and (5) the facility meets the needs of the residents at all times as described in resident care plans.

Training Requirements

Both licensure categories require that administrators complete 12 hours of continuing education each year that includes topics such as the resident plan of care; characteristics of residents’ disabilities; nutrition, basic hygiene, and dental care; first- aid; medication management; dementia; resident assessment; aging; and residents’ rights. Personnel must receive orientation and training within a week of hire that includes residents’ rights; complaint procedures; duties and responsibilities; emergency and evacuation procedures; infection control; mandatory reporting requirements; and limitations on and the correct use of restraints. Continuing education must be provided annually on residents’ rights, infection control, and the emergency plan.

Provisions for Apartments and Private Units

Both Licensure Categories. Private apartments are not required. Resident units may be single-occupancy or double-occupancy. There must be at least one toilet and one sink, and one shower/bathtub for every six residents.

Provisions for Serving Persons with Dementia

Dementia Care Staff. No provisions identified for either licensure category.

Dementia Staff Training. No provisions identified for either licensure category. Legislation adopted in 2014 requires the Department to develop dementia care training and education programs for staff of health facilities, which include both types of ALRs.

Dementia Facility Requirements

Assisted Living Residences-Supported Residential Health Care. Facilities may install a wandering prevention system and/or install locked, secured, or alarmed systems that automatically lock when approached by a resident wearing an electronic sensor. 

Assisted Living Residences-Residential Care. Mechanical constraints are prohibited. Facilities with fewer than 16 residents must install a wandering prevention system if awake staff are not available overnight.

Background Checks

Both licensure types must obtain and review a criminal records check from the New Hampshire Department of Safety for all applicants for employment, and for household members 18 years of age or older, and verify their qualifications prior to employment. Unless a waiver is granted, licensees may not offer employment for any position or allow a household member to continue to reside in the residence if the individual has been convicted of sexual assault, another violent crime, assault, fraud, abuse, neglect, or exploitation; has been found guilty by the Department or any administrative agency in any state of assault, fraud, abuse, neglect or exploitation of any person; or otherwise poses a threat to residents’ health, safety, or well-being.

Inspection and Monitoring

Both licensure categories are inspected prior to licensure and before annual license renewals.

Public Financing

The New Hampshire Department of Health and Human Services, Bureau of Elderly and Adult Services, administers the Medicaid Choices for Independence 1915(c) Waiver program that pays for assisted living services. The state has applied for an 1115 waiver, which, if received, will cover assisted living services.

Room and Board Policy

The state provides an optional state supplement (OSS) to Supplemental Security Income recipients who reside in a RCF for adults. In 2011, the OSS was $207.1 In 2009, the personal needs allowance (PNA) was $56, and family supplementation was allowed on a case-by-case basis.

Location of Licensing, Certification, or Other Requirements

New Hampshire Code of Administrative Rules, Chapter He-P 800, PART He-P 804: Assisted Living Residence-Residential Care Licensing. [April 3, 2008] http://www.dhhs.nh.gov/oos/bhfa/documents/he-p804.pdf

New Hampshire Code of Administrative Rules, Chapter He-P 800, PART He-P 805: Assisted Living Residence-Supported Residential Health Care Licensing. [October 25, 2006] http://www.dhhs.nh.gov/oos/bhfa/documents/he-p805.pdf

New Hampshire Code of Administrative Rules, Chapter He-P 800, Part He-P 813: Adult Family Care Residence. [March 29, 2011]

http://www.dhhs.nh.gov/oos/bhfa/documents/he-p813.pdf

Revised Statutes Annotated, Title XI, Chapter 151: Residential Care and Health Facility Licensing.

http://www.gencourt.state.nh.us/rsa/html/xi/151/151-mrg.htm

Information Sources

Jeffrey A. Meyers
Director, Intergovernmental Affairs
Department of Health and Human Services