The Department of Health, Office of Residences Regulation, licenses assisted living residences (ALRs) for individuals who do not require the level of medical or nursing care provided in a health care facility but who require room and board and personal assistance, and may require medication administration.
Residences are licensed based on levels according to fire code and medication classifications and also for dementia care. Fire code Level 1 licensure is for residents who are not capable of self-preservation and Level 2 is for residents who are capable of self-preservation in an emergency.
Medication Level 1 licensure is used when one or more residents require central storage and/or medication administration, and Level 2 is used when residents require only assistance with self-administration of medications.
Dementia care licensure is required when one or more resident’s dementia symptoms affects their ability to function based on several specified criteria. Dementia care licensure must be at Level 1 for both fire and medication-related requirements. A residence may have distinct areas with separate licenses.
The state does not have separate licensing requirements for adult foster care. ALR rules1 apply to all facilities that serve two or more adults.
This profile includes summaries of selected regulatory provisions for ALRs and additional provisions for Alzheimer’s dementia special care units (SCUs) where relevant. The complete regulations are online at the links provided at the end. The state is revising the regulations in 2015.
Services are provided to meet each resident’s changing needs and preferences.
Alzheimer’s dementia special care unit means a distinct living environment within a residence that has been physically adapted to accommodate the particular needs and behaviors of persons with dementia. The unit provides a higher level of staffing, additional staff training, and therapeutic activities designed for persons with dementia. Residences must be licensed at the highest fire and medication services level (“F1-M1”).
The residency agreement must include information about residents’ rights; admission and discharge policies and procedures; the unit to be rented; shared space and residences; services to be provided or arranged; financial terms (i.e., basic rates, extra charges at admission or in the future, deposits and advanced fees, and the rate increase policy); special care provisions; resident responsibilities and house rules; initial and ongoing assessment and service plans; and the grievance procedure.
ALRs must disclose the following information to each potential resident and interested family member or representative early in the decision-making process and at least prior to the admission decision being made:
- The residence owner and operator.
- Explanation of licensure level.
- Admission and discharge criteria.
- Available services.
- Financial terms to include all fees and deposits and the residence’s policy regarding increases in fees and rates.
- Terms of the residency agreement.
- Contact information for the Department of Health, the Medicaid Fraud and Patient Abuse Unit of the Department of the Attorney General, the state ombudsperson, and local police offices.
In addition, an Alzheimer’s dementia SCU must include information about the unit’s philosophy and mission; occupancy criteria; the assessment and plan of service process, including provisions related to changes in condition; staff training and continuing education requirements; the physical environment and design features appropriate to support the functioning of cognitively impaired adult residents; the frequency and types of resident activities; the involvement of families and family support programs; and the cost of care and any additional fees.
Admission and Retention Policy
Admission and residency are limited to persons with the physical mobility and decision-making ability to take appropriate action in emergency situations, except in dementia care units. Residences may not admit or retain persons needing medical or skilled nursing care, including daily professional observation and evaluation, and/or persons who are bedbound or in need of the assistance of more than one person for ambulation. However, an established resident may receive daily skilled nursing care or therapy from a licensed health care provider for a condition that results from a temporary illness or injury for up to 21 days, subject to an extension of additional days as approved by the Department, or if the resident is under the care of a licensed hospice agency.
Residents may be discharged only if they:
- Do not meet the residency criteria stated in the residency agreement or the requirements of state or local laws or
- Are a danger to self or others, and the residence has without success made reasonable accommodations to address resident behavior in ways that would make the termination of the residency agreement or change
The residents of an Alzheimer’s dementia SCU must have had a standard medical diagnostic evaluation and have been determined to have a diagnosis of Alzheimer’s dementia or another type of dementia.
ALRs provide assistance with activities of daily living, medication management, arrange for support services, and monitor residents’ recreational, social, and personal activities.
Prior to admission, a comprehensive assessment of each applicant’s health, physical, social, functional, activity, and cognitive needs and preferences must be conducted and signed by a registered nurse (RN). The assessment determines if the residence can meet the individual’s needs and preferences and is the basis for service planning. The Department-approved assessment form, or another approved tool, must be used. The assessment must be updated at least annually and following any significant change in the resident’s condition. In addition, an RN must visit the residence at least once every 30 days to complete the following activities:
- Monitor residents’ medication regimens and complete a quarterly evaluation of the residence’s unlicensed staff members’ administration of medication in accordance with a state-approved protocol.
- Review any new physician orders and evaluate the health status of all residents by identifying symptoms of illness and/or changes in mental/physical health status.
- Evaluate the appropriateness of placement.
- Make any necessary recommendations to the administrator and follow up on any previous recommendations.
Residences that employ one or more RNs may complete this review every 90 days.
A resident may contract with an outside agency to receive skilled nursing care or therapy from a licensed health care provider or care from a licensed hospice agency. The residence must ensure that third-party services are received.
Residences are licensed in part based on the type of medication services permitted. For ALRs licensed at the Level M1, licensed employees (RNs, licensed practical nurses) or unlicensed persons who have completed a state-approved course in drug administration and have demonstrated competency, in accordance with the state- approved protocol in drug administration, may administer oral or topical drugs and monitor health indicators if indirect supervision is provided for unlicensed staff by a nurse or physician. However, Schedule II medications may only be administered by licensed personnel, and injectable medications, including but not limited to insulin, which cannot be self-administered by the resident, must be administered by a licensed nurse.
In Level M2 residences, unlicensed staff may assist residents with self- administration by reminding them to take medication and observing them. A resident who self-administers may request the residence to provide a 1-week medi-set (pre- poured packaging distribution system). A licensed nurse, pharmacist, or an unlicensed person who has completed a state-approved course in drug administration and who has demonstrated competency, in accordance with the state-approved protocol in drug administration, may organize a medi-set.
Food Service and Dietary Provisions
Residences must provide three balanced and varied meals each day and provide a diet that is appropriate to the resident’s medical regimen.
Type of Staff. A Department-certified administrator must be responsible for the safe and proper operation of the residence at all times by competent and appropriate employees, who provide direct care services to residents. At least one employee who has completed the required training and who is trained in cardiopulmonary resuscitation must be designated in charge of the operation of the residence, must be awake and on the premises at all times, and must be capable of communicating with emergency personnel.
Staff Ratios. No minimum ratios. Staffing levels must be sufficient to provide the necessary care and services to attain or maintain residents’ highest practicable physical, mental, and psychosocial well-being.
New employees must receive at least 2 hours of orientation and training in specified topics within 10 days of hire and prior to beginning work alone in the ALR, in addition to any job-specific training that may be required. Employees who have regular contact with residents and provide them with personal care must receive at least 10 hours of orientation and training within 30 days of hire in additional topics, to include universal precautions; medical emergency procedures; basic knowledge of aging- related behaviors; personal assistance; assistance with medications; safety; record- keeping; service plans; reporting; and where appropriate, basic knowledge of cultural differences.
Employees must have ongoing in-service training as appropriate for their job classifications. Administrators must complete at least 32 hours of continuing education every 2 years.
Provisions for Apartments and Private Units
Apartment-style private units are not required. Resident rooms or apartments may be single-occupancy or double-occupancy. Residents must have access to a locked area for keeping personal possessions. Residents have the right to share a room or unit with a spouse or other consenting resident in accordance with terms of the resident contract.
Residences must have at least one bath for each ten beds and one toilet for each eight beds on each floor where residents’ rooms are located and when bathing facilities within the resident’s room are not provided.
Provisions for Serving Persons with Dementia
A license for an Alzheimer’s dementia SCU is required when the residence has one or more residents whose dementia symptoms affect their ability to function as demonstrated by any of the following: safety concerns due to elopement risk or other behaviors; inappropriate social behaviors that adversely impact the rights of others; inability to self-preserve; a physician’s recommendation that the resident needs dementia support; or if the residence advertises or represents dementia services or segregates residents with dementia. Each ALR licensed for providing dementia care must specifically design recreational and social activities in order to engage each resident at his/her individual level of functioning.
Dementia Care Staff. An RN with approved training in dementia-related health and behavioral issues must be on staff and available for consultation at all times.
Dementia Staff Training. In addition to the training required of assisted living staff, new employees must receive 12 hours of training about the various types of dementia; communicating effectively with individuals who have dementia; and managing behaviors.
Dementia Facility Requirements. Residences must provide a secure environment appropriate for the resident population that may include, but not be limited to, a locked unit, secured perimeter, or other mechanisms to ensure resident safety and quality of life
Within 1 week of employment, all employees are subject to a statewide criminal records check through the state or local police departments. Fingerprinting is not required. If disqualifying information is found, the administrator makes a judgment regarding the employee’s continued employment.
Inspection and Monitoring
The licensing agency determines the frequency of inspections based on a consideration of the residence’s past compliance with regulations, complaint investigations, any quality of care issues, and license type.
The Department of Human Services administers a Medicaid 1115 demonstration waiver program called the Rhode Island Comprehensive Demonstration that covers assisted living services. This program consolidated all prior 1915(c) waiver programs.
Room and Board Policy
The state provides an optional state supplement (OSS) to Supplemental Security Income recipients who reside in ALRs. In 2015, the maximum amount of the OSS is $332. The personal needs allowance is $100. Family supplementation is not allowed.
Location of Licensing, Certification, or Other Requirements
Rules and Regulations for Licensing Assisted Living Residences. State of Rhode Island and Providence Plantations, Department of Health. [September 2012] http://sos.ri.gov/documents/archives/regdocs/released/pdf/DOH/6999.pdf
Rules and Regulations for the Certification of Administrators of Assisted Living Residences. State of Rhode Island and Providence Plantations, Department of Health. [September 2012] http://sos.ri.gov/documents/archives/regdocs/released/pdf/DOH/7048.pdf
Rhode Island Health Care Association