Licensure Terms

Assisted Living Services, which are provided in Assisted Living Residences, Comprehensive Personal Care Homes, and Assisted Living Programs

General Approach

The Department of Health and Senior Services licenses three types of assisted living services under one set of rules: assisted living residences (ALRs), which are purpose-built residences; comprehensive personal care homes (CPCHs), which are converted residential boarding homes that may or may not meet new building code requirements; and assisted living programs (ALPs)–service agencies–that provide services to tenants of publicly subsidized housing. The licensing rules refer to all three types as facilities, with specific provisions for ALPs. Assisted living services require a certificate of need to be licensed. The rules do not specify a minimum or maximum number of residents that can be served in any of the three types of assisted living services.

All purpose-built ALRs have apartment-style units with a kitchenette. Only facilities licensed prior to December 1993, the effective date of the assisted living regulations, can convert to CPCHs and offer bedrooms rather than apartment-style units.

The licensing rules were reviewed in 2014 by New Jersey’s Assisted Living Licensing Workgroup and were re-adopted with technical changes only.

Adult Foster Care. Adult family care is a 24-hour living arrangement for no more than three persons who, because of age or physical disability, need assistance with activities of daily living, and for whom services designed to meet their individual needs are provided by licensed caregivers in approved adult family care homes. Providers must own or rent and live in the home. The adult family care program is operated by sponsor agencies who recruit, assess, and match residents and caregivers; train caregivers; develop a care plan for each resident; perform regular and ongoing assessments of each resident’s health status and care plan implementation; and provide care management. In 2009, about 30 providers served 34 residents. Regulatory provisions for adult family care are not included in this profile.

This profile includes summaries of selected regulatory provisions for all three types of assisted living services, unless otherwise specified. The complete regulations are online at the links provided at the end

Definitions

Assisted living means a coordinated array of supportive personal and health services, available 24 hours per day and provided in home-like surroundings to residents who have been assessed to need these services, including those who need formal long-term care. Assisted living promotes resident self-direction and participation in decisions that emphasize independence, individuality, privacy, and dignity.

Assisted living residence means a facility licensed to provide apartment-style housing and congregate dining that ensures the availability of assisted living services when needed, for four or more adult persons unrelated to the proprietor. Apartment units offer, at a minimum, one unfurnished room, a private bathroom, a kitchenette, and a lockable door on the unit entrance.

Comprehensive personal care home means a facility licensed to provide room and board to four or more adults unrelated to the proprietor that ensures the availability of assisted living services when needed. Residential units may house no more than two residents and must have a lockable door on the unit entrance.

Assisted living program means providing or arranging for the provision of meals and assisted living services, when needed, to the tenants of publicly subsidized housing, which because of federal, state, or local housing laws, regulations, or requirements cannot become licensed as an ALR. An ALP may also provide staff resources and other services to licensed ALRs and CPCHs; in these instances, ALPs must comply with the licensing standards applicable to the setting.

Resident Agreements

Prior to, or at the time of admission, the facility administrator must conduct an interview with the prospective resident and, if the individual agrees, the resident’s family, guardian, or interested agency. The interview must cover at least an orientation to the facility’s or program’s policies, business hours, fee schedule, services provided, resident rights, and admission and discharge criteria.

Admission agreements must provide information about the services the facility will provide, the public programs or benefits that it accepts or delivers, the policies that affect a resident’s ability to remain in the residence, and any waivers that have been granted of the regulations regarding physical plant requirements for ALRs and CPCHs.

Disclosure Provisions

In addition to the disclosure requirements for admission agreements above, facilities that advertise or hold themselves out as having an Alzheimer’s unit must make available to all staff, residents, and members of the public: (1) its program policies and procedures, including admission and discharge criteria to identify individuals whose needs the facility cannot meet, based upon a registered nurse (RN) assessment of their cognitive and functional status; (2) the number of licensed and unlicensed staff providing direct care to residents; (3) the specialized activities available for residents with dementia; and (4) safety policies and procedures and any security monitoring system specific to residents with dementia.

Admission and Retention Policy

Facilities offer a suitable living arrangement for persons with a range of capabilities, disabilities, frailties, and strengths but not generally for individuals who are incapable of responding to their environment, expressing volition, interacting, or demonstrating any independent activity (e.g., individuals in a persistent vegetative state must not be placed or cared for any of the three types of assisted living). ALRs and CPCHs may serve terminally ill persons who lack adequate caregiving support to meet their needs while residing at home.

No notice is required to discharge a resident who poses a threat to the life and safety of the resident or others.

Services

At a minimum, assisted living residences and comprehensive personal care homes must provide or arrange for assistance with personal care; health care, nursing, pharmacy, and social work services; activities; recreation; and transportation to meet residents’ individual needs. Supervision of and assistance with self-administration of medications, and administration of medications by trained and supervised personnel are also required services.

Assisted living programs must have contracts between service providers and the housing entity. The programs must be able to provide or arrange for assistance with personal care; nursing, pharmaceutical, dietary, and social work services; recreational activities; and transportation.

Service Planning

Within 30 days prior to admission, facilities must obtain assessments from individuals’ health care practitioner stating that they are appropriate for the level of care the facility provides. Facilities must also obtain information about individuals’ nursing needs, and routines and preferences from their regular caregivers, if any. Upon admission, an RN conducts an initial assessment and, if services are needed, develops a general service plan within 14 days of admission.

If the assessment indicates that the individual requires health care services, a health care assessment must be completed within 14 days of admission by an RN using a Department-provided or approved assessment instrument. The assessment must be updated as required in accordance with professional standards of practice. A service plan must be developed based on the assessment.

The general and health service plan must be reviewed, and if necessary, revised quarterly and as needed based on changes in the residents’ physical or cognitive status.

When the resident assessment process indicates a high probability that a choice or action of the resident has resulted or will result in placing the resident or others at risk, lead to adverse outcome and/or violate the norms of the facility or program or the majority of the residents, the facility must seek to negotiate a managed risk agreement with the resident (or legal guardian), that will minimize the possible risk and adverse consequences while still respecting the resident’s preferences.

Third-Party Providers

Facilities and residents who are not Medicaid-eligible may contract with outside health care professionals.

Medication Provisions

Facilities are allowed to provide supervision of and assistance with self- administration of medications, and administration of medications by trained and supervised personnel. Employees who have been designated to provide supervision of residents’ self-administration of medications must be trained by the facility’s RN or the licensed pharmacist.

The state has extensive rules regarding medication administration. Certified nurse aides, certified home health aides, or staff members with other equivalent training approved by the Department of Health (DOH) and who have completed a medication aide course and passed a certifying exam are permitted to administer medications to residents under the delegation of an RN.

The facility must use a unit-of-use/unit dose drug distribution system whenever the administration of medication is delegated by an RN to a certified medication aide

Food Service and Dietary Provisions

Assisted living residences and comprehensive personal care homes must provide three meals a day, snacks, and beverages based on the current recommended dietary allowances of the Food and Nutrition Board. Menus must reflect nutritional and therapeutic needs, cultural backgrounds, food habits, and personal preferences. Facilities must designate a food service coordinator who is either a dietician or who consults with a dietician. If indicated by resident needs, a dietician must assess and reassess nutritional needs, provide dietary services, and revise the dietary portion of the health plan as needed.

Assisted living programs must make available dining services and/or meal preparation assistance to meet residents’ daily nutritional needs; have a mechanism to assist residents with shopping and/or preparation of meals in accordance with their needs and plans of care; and ensure that meals are planned, prepared and served in accordance with, but not limited to, residents’ nutritional needs.

Staffing Requirements

Type of Staff. All three licensed settings must have a full-time administrator or designated alternate on-site at all times in facilities with 60 or more beds, and half-time in facilities with fewer than 60 beds. A registered nurse must be available on staff or on call 24 hours a day. ALPs must have policies that ensure that at least one staff member of the ALP or the housing program is on-site 24 hours a day.

Facilities must designate a food service coordinator who, if not a dietitian, receives scheduled consultation from a dietitian. They must also designate a pharmacist to direct pharmaceutical services and provide consultation to the physician, facility, or program staff, and residents, as needed.

Facilities must employ personal care assistants who are certified nurse aides, certified homemaker-home health aides, or have passed a personal care assistant training course.

Staff Ratios. No minimum ratios. At least one awake personal care assistant and one additional staff person must be on site 24 hours a day. Facilities must employ both professional and unlicensed staff in sufficient numbers and with sufficient abilities and training to provide the basic resident care, assistance, and supervision required, based on an assessment of the acuity of residents’ needs.

Training Requirements

Administrators must complete a minimum of 30 hours of continuing education every 3 years covering assisted living concepts and related topics, as specified and approved by the Department of Health and Senior Services.

Each personal care aide (PCA) must receive orientation prior to or upon employment on the following topics: assisted living concepts, emergency plans and procedures, infection control and prevention, the care of residents with physical.

impairment, resident rights, abuse and neglect, pain management, and the care of residents with Alzheimer’s and other dementia conditions.

PCAs must complete 20 hours of continuing education every 2 years in assisted living concepts and related topics, including cognitive and physical impairment and dementia. Medication aides must complete an additional 10 hours of continuing education related to medication administration and elderly drug use every 2 years.

Provisions for Apartments and Private Units

Assisted living residences must offer apartment-style units with a private bathroom, a kitchenette, and a lockable door on the unit entrance. No more than two people may occupy a unit. Additional toilet facilities must be provided in areas other than the residential units to meet the needs of residents, staff, and visitors to the facility.

Comprehensive personal care homes provide single-occupancy and double- occupancy units with a lockable door. Private baths and kitchenettes are not required.

Assisted living programs are licensed as a service. Requirements for the apartments in subsidized housing projects are specified by the source of financing and the building code.

Provisions for Serving Persons with Dementia

Facilities may establish programs to meet the needs of residents with Alzheimer’s disease or other dementias. Such programs must provide individualized care based upon assessment of the cognitive and functional abilities of its residents with dementia. All licensed and unlicensed staff who provide direct care to residents must have training in specialized care of residents with dementia. No other provisions identified.

Background Checks

The state revised its rules regarding criminal background checks in 2014. The new rules are extensive. The assisted living licensing regulations require that staff be certified or licensed, as applicable, and the certification processes for nurse aides and personal care assistants, and the licensing and certification processes for assisted living administrators require fingerprint criminal background checks.

Assisted living facilities and programs may not employ individuals as certified nurse aides or personal care assistants without making inquiries to the New Jersey Certified Personal Care Assistant Registry, the New Jersey Certified Nurse Aide Registry, or to any other state agency registry in which the facility has a good faith belief the individual is registered.

Inspection and Monitoring

ALRs and CPCHs are inspected prior to licensure, every 2 years thereafter, and at any time deemed necessary by the licensing agency. The DOH has a voluntary quality– focused program titled Advanced Standing, which is open to all licensed ALRs and CPCHs. Facilities that participate in the program do not receive a routine survey. However, any time a facility falls below DOH standards, such as poor performance on a complaint investigation, that facility can be removed for cause from the program. In addition, DOH provides follow-up surveys based on a random sample of facilities that participate in the program.

Public Financing

New Jersey consolidated its home and community-based waiver programs into one 1115 Demonstration Waiver program–Managed Long-Term Services and Supports–which covers assisted living services.

Assisted living service settings licensed after September 2001 must set aside 10 percent of their units to serve Medicaid residents within 3 years of licensing. The requirement is waived if there is a waiting list for Medicaid waiver services.

Room and Board Policy

Assisted Living Residences and Comprehensive Personal Care Homes. In 2014, the state provided an optional state supplement (OSS) of $150.05 per month to Supplemental Security Income (SSI) recipients and capped room and board for Medicaid-eligible residents at $764.05 per month (federal SSI benefit of $721 plus the OSS benefit of $150.05, minus a personal needs allowance of $107 retained by the resident).

Family supplementation is permitted for an upgraded living unit (i.e., a private room).

Assisted living program participants who live in subsidized housing are charged a percentage of their income for rent. Those eligible for SSI benefits are eligible for an OSS payment–$31.25 in 2014–as are SSI recipients who live in adult family homes.

Location of Licensing, Certification, or Other Requirements

New Jersey Administrative Code, Title 8, Chapter 36: Standards for Licensure of Assisted Living Residences, Comprehensive Personal Care Homes, and Assisted Living Programs; and Title 8,

Chapter 43-I: Criminal Background Investigations of Nurse Aides, Personal Care Assistants, and Assisted Living Administrators.

The New Jersey Administrative Code is accessible at Lexus Nexus. http://www.lexisnexis.com/hottopics/njcode/

Information Sources

Kathy Fiery
Health Care Association of New Jersey