Licensure Terms

Assisted Care Living Facilities and Residential Homes for the Aged

General Approach

The Tennessee Department of Health, Board for Licensing Health Care Facilities, licenses assisted care living facilities and residential homes for the aged to provide services to older persons who need assistance with personal care. Assisted care living facilities may provide a higher level of care than residential homes for the aged, including the provision of medical services. Licensing rules specify requirements for dementia care in both settings.

Adult Foster Care. The state licenses and administers a family home for adults program for up to five adults who are frail, disabled, or victims of abuse, through the Department of Health Adult Protective Services Program. In addition, the Department of Health licenses adult care homes (ACHs)-Level 2 for five or fewer adults. Regulatory provisions for family homes for adults and ACHs 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 assisted care living facilities and residential homes for the aged. The complete regulations are online at the links provided at the end.

Definitions

Assisted care living facilities provide room and board and services, including medical services, to enable residents to age in place. No provisions regarding the minimum number of residents required for licensure were identified.

Residential homes for the aged provide room and board, and personal care services to four or more non-related persons.

Resident Agreements

Both facility types must provide at admission a written agreement that includes a procedure for handling resident transfers or discharges, which does not violate the residents’ rights under the law or licensing rules.

Disclosure Provisions

Assisted care living facilities must, prior to the admission or execution of a contract for resident care, disclose in writing to the resident or the resident’s legal representative, whether the facility has liability insurance and, if so, the insurance carrier’s name. Facilities with secured units must report to the Department the following information during each annual survey: resident assessments by multidisciplinary teams and reviews; number of deaths, hospitalizations, and incidents; staffing patterns and ratios; staff training; and daily group activities.

Residential Homes for the Aged. No provisions identified.

Admission and Retention Policy

Assisted care living facilities may not admit or retain individuals whose needs the facility cannot safely and effectively meet, including residents who require treatment of Stage III or IV decubitus ulcers; continuous nursing care; or physical or chemical restraints (this does not include psychotropic medications prescribed for a manageable mental disorder). Facilities may also not admit or retain individuals with active, infectious, and reportable diseases that require contact isolation; or verbal or physical aggressive behavior which poses an imminent physical threat to self or others.

A facility must not admit, but may retain residents who require nasopharyngeal or tracheotomy suctioning; nasogastric feedings; gastrostomy feedings; or intravenous (IV) therapy or IV feedings. However, residents cannot require these treatments on more than an intermittent basis (up to three 21-day periods per year), and the resident’s physician must certify that the facility can safely and effectively provide the treatment.

The Board for Licensing Health Care Facilities may permit the treatments listed in the paragraph above to be provided on an ongoing basis to residents who receive hospice services. Residents who require any of the above treatments and who are able to independently manage them may be admitted and retained.

If the resident or legal representative, treating physician, or the facility administrator determine that the facility cannot meet the resident’s needs, including the need for medical services, the resident must be transferred to an appropriate setting.

Facilities may admit residents in all but the later stages of Alzheimer’s disease only after an interdisciplinary team assesses that care can be safely and appropriately provided. This assessment must be reviewed quarterly.

Residential homes for the aged may not admit or retain individuals who cannot self-administer medications; who require professional medical or nursing observation and/or care on a continual or daily basis; who pose a clearly documented danger to themselves or other residents; who cannot safely evacuate the facility in 13 minutes; or who require chemical or physical restraints.

Homes may admit residents who are in the early stages of Alzheimer’s disease or other dementias if an interdisciplinary team determines that care can appropriately and safely be provided in the facility. Residents must be assessed quarterly to ensure that the facility can continue to meet their needs.

Services

Assisted care living facilities must provide personal services such as protective care; responsibility for the safety of the resident when in the facility; the ability and readiness to intervene if crises arise; assistance with activities of daily living (ADLs); laundry services; and dietary services. Facilities may provide and oversee medical services, such as medication administration; part-time intermittent nursing care; various therapies; podiatry; medical social services; and hospice services.

Residential homes for the aged must provide the same personal services listed above.

Service Planning

Assisted care living facilities must assess residents within 72 hours of admission. The written assessment may by conducted by a direct care staff member. A plan of care must be written within 5 days of admission and must be reviewed at least semi-annually or when residents’ needs change. The plan of care describes:

  • The need for personal care assistance and medical services for which the resident requires assistance; how much assistance; who provides the assistance; how often, and when.
  • Requirements and arrangements for visits by or to health care providers. 
  • Provisions of an advance care directive and the name of any individual named as a health carepower-of-attorney.
  • Recreational and social activities.
  • Dietary needs. 

Residential Homes for the Aged. No provisions identified.

Third-Party Providers

Assisted care living facility residents must be able to receive hospice services in the facility as long as the resident’s treating physician certifies that hospice care can be appropriately provided in the facility. In addition to appropriately licensed and qualified facility staff, medical services may be provided by licensed or qualified contractors, a licensed home care organization, licensed staff of a nursing home, or another appropriately licensed entity.

Residential Homes for the Aged. No provisions identified.

Medication Provisions

Both facility types allow staff to assist residents with self-administration, including assistance in reading labels, opening dosage packaging, reminding residents to take their medications, and observing the resident while taking medication. Licensed health care professionals operating within their scope of practice, such as nurses, may administer medications.

Food Service and Dietary Provisions

Both facility types must provide three meals a day that meet acceptable and/or prescribed diet standards. No more than 14 hours must elapse between the evening and morning meals. The food must be adapted to residents’ habits, preferences, and physical abilities.

Assisted care living facilities are required to provide additional nourishment and/or snacks to residents with special dietary needs or upon request.

Staffing Requirements

Assisted Care Living Facilities

Type of Staff. Facilities must have a certified administrator or a licensed nursing home administrator; a designated attendant who is awake and responsible for providing personal services to residents; and a licensed nurse available as needed. A qualified dietician must be hired on staff or as a consultant.

Staff Ratios. No minimum ratios. Facilities must have a sufficient number of staff to meet residents’ needs, including the need for medical services.

Residential Homes for the Aged

Type of Staff. Facilities must have a certified administrator or a licensed nursing home administrator; a designated attendant who is awake and responsible for providing personal services to residents; and additional staff as needed.

Staff Ratios. No minimum ratios. Facilities must have a sufficient number of staff to meet residents’ needs.

Training Requirements

Both facility types require administrators to be certified and recertified every 2 years. Administrator certification requires 24 classroom hours of Board-approved continuing education courses during the 2 years that includes instruction in the following topics: applicable state rules and regulations; health care management; nutrition and food service; financial management; and healthy lifestyles. All employees must be trained annually in fire safety, disaster preparedness, and other emergency procedures

Provisions for Apartments and Private Units

Assisted Living Facilities. Apartment-style units are not required; units may be single-occupancy or double-occupancy. Bathrooms and bathing facilities may be shared, with at least one bathtub or shower for every eight residents, and one sink and toilet for every six residents.

Specialty Care Assisted Living Facilities. See the following section.

Provisions for Serving Persons with Dementia

Dementia Care Staff. Both facility types require a minimum of one attendant, awake, on-duty, and physically located on the unit at all times.

Dementia Staff Training. Both facility types require any staff working in a secured unit to have annual in-service training covering as a minimum the following topics:

  • Basic facts about the causes, progression, and management of Alzheimer’s disease and other dementias. 
  • Dealing with residents’ dysfunctional behavior and catastrophic reactions.
  • Identifying and alleviating safety risks. 
  • Providing ADL assistance. 
  • Communicating with families. 

Dementia Facility Requirements. No provisions identified for either facility type.

Background Checks

Both facility types require that administrators must not have been convicted of a criminal offense involving the abuse or intentional neglect of an elderly or vulnerable individual. Facilities may not employ any person listed on the Department’s abuse registry.

Inspection and Monitoring

Assisted Care Living Facility. A pre-licensure inspection is required and the Department makes an unannounced inspection of every facility within 15 months following the date of its last inspection and as needed.

Residential homes for the aged are inspected pre-licensure and periodically as a condition of re-licensing.

Public Financing

The state covers services in assisted care living facilities through its Medicaid 1115 managed care Long-Term Services and Supports CHOICES program (CHOICES).

Room and Board Policy

Medicaid policy limits the amount that assisted care living facilities can charge for room and board to 80 percent of the maximum personal needs allowance (PNA). The CHOICES program sets the PNA at 300 percent of the federal Supplemental Security Income (SSI) rate, which is $2,199 per month in 2015. Thus, the maximum monthly room and board charges in an assisted living care facility for CHOICES members cannot exceed the lesser of $1,759.20 per month or any lesser amount that would be charged to a resident not enrolled in the CHOICES program. This limitation applies only to CHOICES members, and not to other assisted living care facility residents.

The state does not provide an SSI payment. Family supplementation is permitted up to the maximum allowable charges for room and board.

Location of Licensing, Certification, or Other Requirements

Rules of the Tennessee Department of Health, Board for Licensing Healthcare Facilities, Chapter 1200-08-25: Standards for Assisted Living Care Facility Regulations. [December 23, 2009]

http://www.state.tn.us/sos/rules/1200/1200-08/1200-08-25.20091223.pdf

Rules of the Tennessee Department of Health, Board for Licensing Healthcare Facilities, Chapter 1200-08-11: Homes for the Aged. [May 2010] http://www.tennessee.gov/sos/rules/1200/1200-08/1200-08-11.20100523.pdf

Rules of the Tennessee Department of Health, Board for Licensing Healthcare Facilities, Chapter 1200-08-36: Standards for Adult Care Homes-Level 2. [November 2010] http://www.tn.gov/sos/rules_all/2010/1200-08-36.20101102.pdf

Department of Human Services website: Adult Protective Services, Family Homes for Adults. http://tennessee.gov/humanserv/adfam/aps_fh.html

TennCare website: Long Term Services and Supports CHOICES Program, with information and links to participant eligibility, service descriptions, and provider resources. [TennCare is the name of the state’s Medicaid program.]

http://www.tn.gov/tenncare/long_choices.shtml

Information Sources

Brett McReynolds
Tennessee Health Care Association

Ann Rutherford Reed, RN, BSN, MB
Director of Licensure
Division of Health Licensure and Regulation
Office of Health Care Facilities

Will Hines
Policy Specialist
Quality and Administration
Long-Term Services and Supports
Bureau of TennCare