Licensure Terms

Assisted Living Residence, Personal Care Home

General Approach

Assisted living residences (ALRs) are licensed by the Department of Aging, Office of Long Term Living, Division of Licensing, and personal care homes are licensed by the Department of Public Welfare, Adult Residential Licensing. The two licensure types differ in concept, the type of units provided, and the level of care provided. Personal care homes may not serve individuals who need a nursing home level of care but ALRs can serve such individuals.

ALRs must support aging in place, are constructed with private living units that include kitchen capacity, and provide a level of care higher than personal care homes. A personal care home and ALR may be co-located within a building under a dual license. This profile includes the regulations for both types, as well as the provisions for special care units (SCUs) for residents with Alzheimer’s disease or other dementias for the two types.

Adult Foster Care. The state licenses domiciliary care for up to three residents, which provides a supervised living arrangement in a home-like setting to adult clients placed there by Area Agencies on Aging (AAAs). The AAAs screen providers to ensure that both they and their homes pass safety and background checks. The majority of providers serve only one resident. Regulatory provisions for domiciliary care 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 ALRs and personal care homes. The complete regulations can be viewed online using the links provided at the end of the profile.

Definitions

Assisted living residences provide food, shelter, assisted living services, and supplemental health care services to four or more adults who are not relatives of the operator, who require assistance or supervision with activities of daily living (ADLs), instrumental activities of daily living (IADLs), or medication administration. 

Personal care homes provide food, shelter, and personal assistance or supervision to four or more adults who are not relatives of the operator and who do not require a nursing home level of care. Personal care home residents typically require assistance or supervision with ADLs and/or IADLs.

Resident Agreements

The assisted living residence agreement must provide information about a range of topics, including: a fee schedule; optional services and amenities; assessment and service planning policies; payment and refund policies; arrangements for financial management; the residence’s rules; contract terms and policies; a list of assisted living services, supplemental health care services, or both, to be provided based on the resident’s support plan; residents’ rights; and complaint procedures.

If a resident chooses to opt-out of an assisted living service defined by the licensing rules, the agreement must state that the service is not being provided and that the corresponding charges reflect the reduction in services to be provided.

Personal care home agreements must provide information similar to that provided by ALRs.

For both facility types, the admission agreement must include the services provided in a dementia care unit, admission and discharge criteria, change in condition policies, special programming, and costs and fees.

Disclosure Provisions

Assisted living residences must, in addition to the information provided in the resident agreement, provide each potential resident or designated representative with a written disclosure that includes the:

  • Services and the core packages that the residence offers and their
  • Circumstances under which a potential resident may require the services offered in a different core
  • Most recent inspection reports and instructions for access to the Department’s public website. 
  • Number of living units in the residence that comply with the public accommodation provisions of the Americans with Disabilities Act. 

When a residence holds itself out to the public as providing services or housing for individuals with Alzheimer’s disease or dementia, the residence must disclose to individuals and provide materials that include the following:

  • The residence’s written statement of its philosophy and mission which reflects the needs of individuals with Alzheimer’s disease or dementia. 
  • A description of the residence’s physical environment and design features to support the functioning of individuals with Alzheimer’s disease or dementia. 
  • A description of the frequency and types of individual and group activities designed specifically to meet the needs of individuals with Alzheimer’s disease or dementia.
  • A description of the security measures the residence provides. 
  • A description of the training provided to staff regarding provision of care to individuals with Alzheimer’s disease or dementia. 
  • A description of availability of family support programs and family involvement. 
  • The process used for assessment and establishment of a plan of services for the individual, including methods by which the plan of services will remain responsive to changes in the individual’s condition. 

Personal care homes must, in addition to the information provided in the resident agreement, disclose information about admission and discharge criteria, special programming costs and fees, and a written description of its program that includes the services to be provided and the long-term care needs that can be safely met in the home.

Admission and Retention Policy

Assisted living residences may not admit or retain an individual with any of the following conditions or health care needs unless the residence seeks approval from the licensing agency: ventilator dependency; Stage III and IV decubiti and vascular ulcers that are not in a healing stage; continuous intravenous fluids; reportable infectious diseases in a communicable state that requires isolation of the individual or requires infectious disease precautions, unless the Department directs that isolation be established within the residence; nasogastric tubes; physical restraints; or continuous skilled nursing care 24 hours a day. However, the licensing agency may approve an exception related to any of the conditions or health care needs listed above under specified conditions and procedures.

In facilities licensed as ALRs, a SCU may be the complete residence or a portion of a residence that provides specialized care and services for residents with Alzheimer’s disease or other dementias.1 Admission to a SCU must occur only in consultation with the resident’s family or designated representative and documentation must include the resident’s diagnosis of Alzheimer’s disease or dementia and the need for the resident to be served in a SCU.

Personal care homes may not admit or retain residents who meet the state’s eligibility criteria for nursing home care.

Services

Assisted living residences provide an “independent core package” for residents who do not require ADL assistance, which includes 24-hour supervision, laundry, social activities, and cognitive supports. The “enhanced core package” includes the services in the independent core package plus assistance with ADLs/IADLs for an undefined period of time, transportation, and assistance with self-administration of medication or medication administration.

Facilities must also provide financial management, monitoring, and emergency response, and must make reasonable accommodations for aging in place that may include the provision of supplemental services provided by the resident’s family.

Dementia-specific assisted living services are described as intermittent cuing, redirecting, environmental cues, measures to address wandering, dementia-specific activity programming, and specialized communication techniques.

Personal care homes provide many of the same services as ALRs, including medication administration.

Both facility types require that the following be offered in dementia care units at least weekly: gross motor activities and exercise; self-care activities, such as personal hygiene; group and individual activities; sensory and memory enhancement activities; and outdoor activities. Resident participation in offered activities must be voluntary.

Service Planning

Within 60 days prior to admission to an ALR, a medical evaluation, using a Department-required form and conducted by a physician, physician’s assistant, or nurse practitioner must be completed. The medical evaluation may be completed within 15 days after admission under specified conditions, such as admission from an acute care hospital or to escape an abusive situation.

The medical evaluation must include information needed to determine if the applicant can be safely served and to inform the development of the service plan, including: (1) health status; (2) medical information pertinent to diagnosis and treatment in case of an emergency; (3) special health or dietary needs; (4) allergies; (5) immunization history; (6) medication regimen, contraindicated medications, medication side effects, and the ability to self-administer medications; (7) the need for body positioning and movement stimulation; (8) mobility assessment; (9) tuberculin skin test results within the past 2 years; and (10) information about day-to-day assisted living service needs.

Within 30 days after admission to an assisted living facility (ALF)–or 15 days with certain exceptions–the administrator, administrator-designee, a registered nurse (RN), or a licensed practical nurse (LPN) under the supervision of RN must complete an initial assessment, using a Department-provided form or an approved facility-developed form. The assessment is used to develop a preliminary support plan, which must be reviewed and approved by an LPN or RN. The following items, at a minimum, must be assessed: ADLs and IADLs; mobility; ability to self-administer medication; medical history and medical conditions that affect the individual’s service needs; supplemental health care service needs; dietary needs; the individual’s ability to safely operate key-locking devices; and the individual’s ability to evacuate from the residence. The final support plan must be signed by the resident or his/her designated representative and implemented within 30 days of admission.

Reassessments must be conducted annually and support plans updated following a significant change in condition or at the Department’s request. Medical evaluations may be updated as needed.

Personal care homes must complete a pre-admission screening to assess whether the home can meet an applicant’s needs. A medical evaluation must be completed 60 days prior to or 30 days after moving into the home. Within 15 days of admission, the facility must conduct an assessment of mobility needs, medication administration needs, cognitive functioning communication abilities, ADLs, IADLs, referral sources, and personal interests and preferences. A support plan must be developed to meet the needs identified in the assessment and be implemented within 30 days after admission. The facility must use Department-specified forms.

Both Facility Types. Within 72 hours prior to an individual’s admission to a secured dementia care unit, both ALRs and personal care homes must conduct a written cognitive pre-admission screening in collaboration with a physician or a geriatric assessment team. The resident must be assessed annually to determine the need for continuing residency.

Third-Party Providers

Assisted living residences must provide or arrange for the provision of supplemental health care services, including hospice services, occupational therapy, skilled nursing services, physical therapy, behavioral health services, home health services, escort service to and from medical appointments if indicated in the resident’s support plan or requested by the resident, and specialized cognitive support services.

Personal care homes may permit residents to use hospice services and must encourage residents to use services available in the community, as relevant, including mental health services, drug and alcohol counseling, senior centers, home health agencies, or services provide by an AAA.

Medication Provisions

Both facility types must provide assistance, as needed, with resident self- administration of prescribed medications. Assistance includes helping the resident to remember the schedule for taking the medication, storing the medication in a secure place, and offering the resident the medication at prescribed times. The facility must provide medication administration services for residents assessed to need them and for residents who choose not to self-administer. Prescription medication that is not self- administered by a resident must be administered by a licensed professional or a staff person who has completed Department-approved medication administration training and has passed the performance-based competency test.

Food Service and Dietary Provisions

Assisted living residents must be permitted to prepare food in their apartment unless stated otherwise in their support plan.

Both facility types must offer three daily meals that meet recommended dietary allowances established by the U.S. Department of Agriculture. Between meal snacks and beverages must be available at all times, unless medically contraindicated.

Prescribed dietary needs must be met.

Residents must receive adequate physical assistance with eating or be provided with appropriate adaptive devices, or both, as indicated in their support plan. The facility must have a dietician on staff or under contract to provide for residents’ special dietary needs as indicated in their support plan.

Staffing Requirements

Assisted Living Residence

Type of Staff. Administrators are responsible for daily operations and must be able to provide assisted living services and supervise direct care workers. An administrator-designee is responsible when the administrator is absent. Direct care staff provide personal care assistance. A registered nurse must be available in the building or on call at all times.

Staff Ratios.  No minimum ratios.  Administrators must be present in the residence an average of 36 hours or more per week. Direct care staff persons on duty must be awake at all times and must provide at least 1 hour per day of assisted living services to each mobile resident and at least 2 hours per day to each resident with mobility needs. At least 75 percent of the assisted living service hours must be available during waking hours.

Staffing must be sufficient to meet residents’ needs as specified in their individual support plans. For every 35 residents, at least one staff person trained in first-aid and certified in obstructed airway techniques and cardiopulmonary resuscitation (CPR) must be present in the residence at all times.

Personal Care Homes

Type of Staff. An administrator oversees facility operations. At least one direct care staff person must be awake whenever residents are present.

Staff Ratios. No minimum ratios. The administrator must be present in the home an average of 20 hours or more per week. The direct care staffing requirements are the same as for ALFs except that at least one staff person who is trained in first-aid, and certified in obstructed airway techniques and CPR must be present in the home at all times for every 50 residents.

Training Requirements

Assisted Living Residences. Prior to or during the first work day, direct care and other staff, including ancillary staff, substitute personnel, and volunteers must have an orientation in fire safety and emergency preparedness. These staff and all administrative staff must also receive at least 4 hours of dementia-specific training within 30 days of hire and at least 2 hours annually thereafter.

Within 40 scheduled working hours, direct care staff, ancillary staff, substitute personnel, and volunteers must have an orientation training that includes numerous topics related to their job responsibilities, including residents’ rights; mandatory reporting of abuse and neglect; behavior management techniques; person-centered care; communication, problem solving, and relationship skills; assisting with ADLs/IADLs; care of residents with mental illness, neurological impairments, mental retardation, and other mental disabilities; and nutrition, food handling, and sanitation.

All ALR administrators must successfully complete an orientation program approved and administered by the licensing agency, a 100-hour standardized administrator training course, and a competency-based training test with a passing score. Administrators must have at least 24 hours of annual training relating to their job duties.

Assisted living direct care staff may not provide unsupervised services until they have completed 18 hours of training, including a demonstration of their job duties, followed by supervised practice; and successfully completed and passed the licensing agency-approved direct care training course, which includes a competency test.

Assisted living direct care staff must have 16 hours of annual training on a range of topics related to their job responsibilities, including medication self-administration; care for residents with dementia, cognitive, and neurological impairments; infection control and general principles of cleanliness and hygiene; preventing complications of immobility, such as decubitus ulcers, incontinence, malnutrition, and dehydration; and care for residents with mental illness or intellectual disabilities, or both, if served in the residence.

Personal Care Homes. Administrators must have at least 24 hours of annual training relating to their job duties and direct care staff must have 12 hours of annual training in the same topics required for staff in ALRs.

Provisions for Apartments and Private Units

Assisted living residences must provide each resident with his or her own living unit, unless two residents voluntarily agree in writing to share one living unit, and such agreement is included in their resident contracts. The maximum number of residents in any living unit is two. Bathrooms in living units must include a toilet, a sink, and a bathtub or shower. Shared units must be larger than single-occupancy units and the bathroom door in a double-occupancy living unit must be lockable by the resident, unless contraindicated by the support plan.

Each living unit must: (1) have storage space, a telephone jack, and individually controlled thermostats for heating and cooling; (2) have a door with a lock, except where a lock would pose a risk or be unsafe; and (3) be equipped with an emergency notification system. The doors, including entrance doors, must be accessible or adaptable for wheelchair use.

The residence must provide space in the unit with electrical outlets suitable for small appliances, such as a microwave oven and small refrigerator, and provide such equipment at the request of the resident. Residents may choose to provide their own cooking appliances or refrigerator, or both, which must meet the residence’s safety standards. An appliance must be designed so it can be disconnected and removed for resident safety or if the resident chooses not to have the appliance within the living unit.

The residence must provide access to a sink for dishes, a stovetop for hot food preparation, and a food preparation area in a common area, which must not include the kitchen used by staff for the preparation of resident or employee meals, or the storage of goods.

For new construction of residences after January 18, 2011, the kitchen capacity in each unit, at a minimum, must contain a cabinet for food storage, a small bar-type sink with hot and cold running water, and space with electrical outlets suitable for small appliances such as a microwave oven and a small refrigerator.

Personal care homes may have single-occupancy and multiple-occupancy bedrooms with bathrooms shared by up to six users (toilet and sink) and bathtub or shower rooms for up to ten users.

Provisions for Serving Persons with Dementia

Dementia Care Staff. Each resident in a secured dementia care unit is considered to be a resident with mobility needs, therefore direct care staff persons on duty must be awake at all times and must provide at least 2 hours per day of personal care services to each resident.

Dementia Staff Training. In addition to the training requirements required in a standard ALR, each direct care staff person working in a SCU must have 8 hours of initial training within the first 30 days of the date of hire and a minimum of 8 hours of annual training related to dementia care and services, which at a minimum must include the following topics: (1) an overview of Alzheimer’s disease and other dementias; (2) managing challenging behaviors; (3) effective communications; (4) assistance with ADLs; and (5) creating a safe environment.

Personal care home direct care staff must have 6 hours of annual training related to dementia care and services, in addition to the 12 hours of annual training required of all personal care home staff.

Dementia Facility Requirements. SCUs in both ALRs and personal care homes must provide indoor and outdoor exercise space. No more than two residents may occupy a living unit regardless of its size. Facilities must provide a full description of the measures that will be implemented to enhance environmental awareness, minimize environmental stimulation, and maximize residents’ independence in public and private spaces.

Doors equipped with key-locking devices, electronic card-operated systems, or other devices that prevent immediate egress are permitted if the facility receives written approval from the state’s Department of Labor and Industry, Department of Health, or appropriate local building authority permitting the use of the specific locking system.

Background Checks

Both facility types require criminal history and background checks under Pennsylvania adult protective services statutes and regulations.

Inspection and Monitoring

Both facility types must be inspected at least annually, and more often if violations are found during the annual inspection. The Department may conduct abbreviated visits to facilities that have a history of compliance.

Public Financing

The state does not cover services in ALRs or personal care homes through either the Medicaid State Plan or a waiver program.

Room and Board Policy

If an ALR or a personal care home agrees to admit a resident eligible for Supplemental Security Income (SSI) benefits, the residence’s charges for rent and other services may not exceed the SSI resident’s actual current monthly income reduced by the current personal needs allowance (PNA).

The state adds money to the federal SSI payment. A single payment that includes both the federal SSI payment and the state supplement is issued to residents of domiciliary care homes and personal care homes. In 2015, the maximum state supplement is $434.30 for domiciliary care residents and $439.30 for personal care home residents.

Family supplementation for items not included in the room and board rate is permitted if paid directly to the home or residence.

Location of Licensing, Certification, or Other Requirements

The Pennsylvania Code, Title 55, Chapter 2800: Assisted Living Residences. [January 18, 2011]

http://www.pacode.com/secure/data/055/chapter2800/chap2800toc.html

The Pennsylvania Code; Title 55, Chapter 2600: Personal Care Homes. [April 24, 2007] http://www.pacode.com/secure/data/055/chapter2600/chap2600toc.html

The Pennsylvania Code, Title 6, Chapter 21: Domiciliary Care Services for Adults. [January 6, 1990]

http://www.pacode.com/secure/data/006/chapter21/chap21toc.html

Information Sources

Brandon Smeltzer
Pennsylvania Healthcare Association