Licensure Terms

Community Residential Care Facilities

General Approach

Community residential care facilities (CRCFs), also called assisted living facilities, are licensed by the state Board of Health and Environmental Control, Division of Health Licensing to provide room, board, and a degree of personal care to two or more adults unrelated to the owner. They are designed to accommodate residents’ changing needs and preferences, maximize residents’ dignity, autonomy, privacy, independence, and safety, and encourage family and community involvement. Personal care services are covered under the Medicaid State Plan.

Facilities owned by the same entity but which are not located on the same adjoining or contiguous property must be separately licensed. There is no category of licensure for adult foster care. Providers that care for two or more persons are licensed as CRCFs.

This profile includes summaries of selected regulatory provisions for CRCFs. The complete regulations are online at the links provided at the end.

Definitions

Community Residential Care Facility. A CRCF offers room and board and a degree of personal assistance for a period of time in excess of 24 consecutive hours for two or more adults. Any facility that offers a beneficial or protected environment specifically for individuals who have mental illness or disabilities are included in this definition, as well as facilities that are referred to as assisted living, provided they meet the definition of CRCF.

Alzheimer’s special care unit (SCU) or program means a facility, or area within a facility, providing a secure, segregated special program or unit for residents with a diagnosis of probable Alzheimer’s disease or other dementia to prevent or limit access by a resident outside the designated or separated areas; and that advertises, markets, or otherwise promotes the facility as providing specialized care and services for persons with Alzheimer’s disease or other dementias, or both.

Resident Agreements

The written agreement between the resident (or his/her responsible party) and the facility must include at least the following: (1) an explanation of the specific care, services, and equipment provided by the facility, such as administration of medications, special diets, and assistance with activities of daily living (ADLs), including their costs (2) advance notice requirements to change fee amounts; (3) discharge/transfer provisions and refund policies; (4) the date a resident is to receive his/her personal needs allowance (PNA); (5) transportation policies; and (6) an explanation of the resident’s bill of rights and the grievance procedure. 

Disclosure Provisions

Facilities advertised as offering SCUs or programs for residents with Alzheimer’s disease are required to disclose the form of care and treatment provided that distinguishes it as being suitable for people with Alzheimer’s disease. Disclosure must include the admission/transfer and discharge criteria, care planning process, staffing and training, physical environment, activities, the role of family members, and the cost of care.

Admission and Retention Policy

A facility must not admit or retain any person whose needs it cannot meet; who displays serious aggressive, violent, or socially inappropriate behavioral symptoms; who is dangerous to themselves or others; who is in need of daily attention of a licensed nurse; or who requires hospital or nursing care, including the following:

  • Daily skilled monitoring/observation due to an unstable/complex medical condition.
  • Medications that require frequent dosage adjustment, or regular intramuscular and subcutaneous injections.
  • Intravenous medications or fluids.
  • Care of urinary catheter that cannot be cared for by the resident.
  • Treatment of Stage II, III, or IV decubitus, or multiple pressure sores.
  • Nasogastric tube feeding. 
  • Suctioning.
  • Tracheostomy or sterile care that cannot be managed by the resident.
  • Receiving oxygen for the first time, which requires adjustment and evaluationof oxygen concentration.
  • Dependency in all ADLs for more than 14 days.
  • Sterile dressing changes.

Short-term (no more than 14 consecutive days), intermittent nursing needs may be furnished by a licensed nurse facility staff member or a home health agency nurse.

Services

Facilities must provide appropriate assistance with ADLs, medication assistance, at least one structured recreation activity each day, and transportation.

Service Planning

A facility direct care staff member must assess residents’ needs no later than 72 hours after admission. The assessment must include a procedure for determining the nature and extent of residents’ problems and needs to ascertain if the facility can adequately address those problems, meet those needs, and to secure information for use in the development of the individualized care plan (ICP).

Within 7 days of a resident’s admission, the facility must develop an ICP with participation by the resident, facility administrator, and the resident’s responsible party when appropriate. The plan must be reviewed and/or revised as changes in a resident’s needs occur, but not less than semi-annually. The ICP describes the resident’s needs, including the ADLs for which the resident requires assistance; requirements and arrangements for visits by or to physicians or other authorized health providers; advanced care directives/health care power-of-attorney, as applicable; recreational and social activities that are suitable, desirable, and important to the resident’s well-being; and dietary needs.

Third-Party Providers

Individuals requiring short-term, intermittent nursing care while convalescing from illness or injury may utilize the services of home health agency nurses.

The resident or the resident’s responsible party may contract with a private provider not associated with or employed by the facility to provide sitter or companion services.

Medication Provisions

Medications that residents are taking at admission may be administered to residents provided the medication is in the original labeled container and the order is subsequently obtained as a part of the admission physical examination.

Facility staff members may administer routine medications, acting in a “surrogate family role,” provided these staff members have been trained to perform these tasks in the proper manner by individuals licensed to administer medications. Facility staff members may administer injections of medications only in instances where medications are required for diabetes and conditions associated with anaphylactic reactions under established medical protocols. A staff licensed nurse may administer influenza and vitamin B-12 injections and perform tuberculin skin tests. Although facility staff members may monitor blood sugar levels, if they meet specified requirements, the provision of sliding scale insulin injections by facility staff members is prohibited.

Self-administering of medications by a resident is permitted only upon the specific written orders of the physician or other authorized health care provider, obtained on a semi-annual basis; or the facility must ascertain by resident demonstration to the staff, at least quarterly, that she or he remains capable of self-administering medications.
Facilities may elect not to permit self-administration.

Food Service and Dietary Provisions

Three meals and snacks that meet dietary needs must be provided daily. Not more than 14 hours may elapse between the serving of the evening meal and breakfast the following day. Tray service is not permitted unless the resident is medically unable to go to the dining room or occasionally, if the resident prefers. If special diets are provided, the menus must be prepared by a professionally qualified dietician or reviewed by a physician or other qualified medical provider. 

Staffing Requirements

Type of Staff. The licensee must designate an administrator, appropriately licensed as a CRCF administrator by the state Board of Long Term Health Care Administrators, to be in charge of all the facility’s functions and activities. A staff member must be designated in writing to act in the absence of the administrator.

The facility must designate a recreational program staff member responsible for the development of the program and for obtaining and maintaining recreational supplies. At least one staff person must be responsible for providing/coordinating recreational activities for the residents.

Facilities that serve Medicaid-eligible residents must contract with a licensed nurse at least 1 day a week who is responsible for providing personal care training to staff, and developing and monitoring care plans of individuals served by the Medicaid State Plan.

Each facility must have a responsible staff member actively on duty and accessible at all times that residents are present to ensure that appropriate action is taken promptly in the event of injuries, symptoms of illness, or emergencies. This responsible staff member must be an adult, who through training or work experience, is capable of recognizing and reporting significant changes in each resident’s physical and mental condition.

Unless the written agreement between a resident and the facility prohibits the use of private sitters, the facility must establish a formalized private sitter program directed by a facility staff member, so that residents or their responsible party may contract for sitter services if they want to.

Staff Ratios. The number and qualifications of staff members/volunteers is determined by the number and condition of the residents. In each building, there must be at least one staff member/volunteer on duty for each eight residents or fraction thereof during all periods of peak hours (i.e., during the day), and at least one staff member/volunteer on duty for each 30 residents or fraction thereof during nighttime (non-peak) hours. Facilities with more than eight residents must have one staff member awake and dressed at night. Awake staff are required in facilities with fewer than eight beds if there are residents with dementia. In multi-floor facilities that are licensed for more than ten beds, staff must be available on each floor at all times that residents are present. Privately hired sitters may not be included in the minimum staffing requirements.

Training Requirements

All new staff members/volunteers must be oriented to acquaint them with the facility’s organization and environment, specific duties and responsibilities of staff members and volunteers, and residents’ needs. In addition, they must receive emergency procedures, disaster preparedness, and fire response training within 24 hours of their first day on-the-job in the facility.

Training in the following topics must be provided to all staff members/direct care volunteers and private sitters in the context of their job duties and responsibilities:

  • Basic first-aid to include emergency procedures, as well as procedures to manage/care for minor accidents or injuries. 
  • Procedures for checking and recording vital signs (for designated staff members only).
  • Management/care of persons with contagious and/or communicable disease (e.g., hepatitis, tuberculosis, HIV infection).
  • Medication management including storage, administration, receiving orders, securing medications, interactions, and adverse reactions. 
  • Care of persons specific to the physical/mental condition being cared for in the facility (e.g., Alzheimer’s disease and other dementias, cognitive disability)to include communication techniques (cueing and mirroring), understanding and coping with behaviors, safety, and activities.
  • Use of restraints (for designated staff members only).
  • Occupational Safety and Health Administration standards regarding blood-borne pathogens.
  • Cardiopulmonary resuscitation (CPR) for designated staff members/volunteers to ensure that there is a certified staff member/volunteer present whenever residents are in the facility. 
  • Confidentiality of resident information and records and review of the Bill of Rights for Long-Term Care Facilities. 

This training must be provided prior to resident contact and at a frequency determined by the facility, but at least annually unless otherwise specified by certification requirements, such as for CPR.

The staff member responsible for recreational programming must receive appropriate training prior to contact with residents and at least annually thereafter.

Provisions for Apartments and Private Units

Apartment-style units are not required. No more than three residents may share a room. One toilet is required for every six residents and one tub/shower for every eight residents.

Provisions for Serving Persons with Dementia

Dementia Care Staff. Facilities must have sufficient staff members/volunteers to provide supervision, direct care, and basic services for residents with Alzheimer’s disease and/or other dementias.

Dementia Staff Training. Training must be provided to all staff members/direct care volunteers prior to resident contact and as often as the facility determines is necessary, but at least annually. Training should be specific to the needs of residents in the facility, including communication techniques, understanding and coping with behaviors, resident safety, and appropriate activities.

Dementia Facility Requirements. No provisions identified.

Background Checks

Staff members, direct care volunteers, and private sitters of the facility must have a criminal record check and not have a prior conviction or have pled no contest to abuse, neglect, or exploitation of a child or a vulnerable adult as defined in South Carolina code.

Inspection and Monitoring

The Department conducts inspections prior to initial licensing of a facility and subsequently as it deems appropriate. All facilities are subject to inspection/ investigation at any time by individuals authorized by state law and without prior notice.

Public Financing

The state covers personal care in residential settings under the Medicaid State Plan. To be eligible for coverage, individuals must meet all Medicaid program criteria and be receiving the optional state supplement (OSS) to the federal Supplemental Security Income (SSI) program, which is available to persons residing in CRCFs.

Facilities participating in the Medicaid program must be able to provide medical monitoring, medication administration, personal care, and must be Americans with Disabilities Act compliant.

Room and Board Policy

The state pays an OSS to SSI recipients and other eligible residents, and limits room and board charges for Medicaid-eligible residents in CRCFs to the combined SSI and OSS payments minus a PNA retained by the resident. In 2014, the federal SSI payment was $721, the average OSS payment was $682, and the PNA was $65, providing an average room and board payment of $1,338 per month. Family supplementation was not allowed.

Location of Licensing, Certification, or Other Requirements

State Register, Regulation Number 61-84: Standards for Licensing Community Residential Care Facilities. Promulgated by the Board of Health and Environmental Control, administered by the Division of Health Licensing. [June 25, 2010]

https://www.scdhec.gov/Agency/docs/health-regs/61-84.pdf

Assisted Living and Community Residential Care Facilities, A Practical Guide for Consumers. Developed by the South Carolina Community Residential Care Facilities Committee. [January 4, 2013]

http://www.state.sc.us/dmh/crcf/crcf_guide.pdf

Information Sources

Alexis Martin
Program Manager I
South Carolina Medicaid
Department of Health and Human Services