Licensure Terms

Assisted Living Facility

General Approach

The Department of Health, Facility Licensing and Certification, licenses two types of assisted living facilities (ALFs) according to the level of care required by residents. The regulations establish assisted living as a place of residence where elderly and disabled persons can receive 24-hour individualized personal and health-related services to help maintain maximum independence, choice, dignity, privacy, and individuality in a home-like environment. The regulations allow facilities to offer both respite services and adult day care services under the assisted living license without requiring a separate license from the Department of Human Services.

Adult Foster Care (AFC). AFC is licensed by the Department of Human Services and is defined as the provision of care to up to three adults in a private home owned by the provider. The services should be conducive to the physical, social, emotional, and mental health of elderly persons and adults with disabilities who are temporarily unable to remain in their own homes due to abuse, neglect, or exploitation. Regulatory provisions for AFC 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 ALFs.
The complete regulations are online at the links provided at the end.

Definitions

Assisted living facility Type I is a residential facility that provides assistance with activities of daily living (ADLs) and social care to two or more ambulatory residents who are capable of achieving mobility sufficient to exit the facility without the assistance of another person.

Assisted living facility Type II is a residential facility that provides an array of coordinated supportive personal and health care services, available 24 hours a day, to residents who are physically disabled but able to direct their own care or who are cognitively impaired or physically disabled but able to evacuate from the facility or to a zone or area of safety, with the physical assistance of one person.

Type I and Type II facilities may be classified as large (17 or more residents), small (6-16 residents), and limited capacity (2-5 residents). Depending on their classification facilities must comply with different building codes.

Resident Agreements

The signed admission agreement must include room and board charges, and basic and optional services charges; a provision stating that a 30-day notice will be given for changes in base charges; refund policies; admission, retention, transfer, discharge, and eviction policies; conditions for termination of the agreement; the name of a responsible party (if any); and a notice that the state agency has the authority to examine resident records.

Only Type II facilities may operate secure units and admit residents with a diagnosis of Alzheimer’s disease or dementia, and only if the resident is able to exit the facility with limited assistance from one person. The admission agreement must document that a Department-approved wandering risk management agreement has been negotiated with the resident or resident’s responsible person,1 and must identify discharge criteria that would initiate a transfer of the resident to a higher level of care than the facility is able to provide.

Disclosure Provisions

No provisions identified.

Admission and Retention Policy

Type I facilities may serve residents who are ambulatory or mobile and are capable of taking life-saving action in an emergency without assistance; have stable health; do not require assistance–or require only limited assistance with ADLs; and require and receive regular or intermittent care or treatment in the facility from a licensed health professional employed by the facility or through a contract with a third party. These facilities may serve individuals who do not require significant assistance during the night and do not require significant assistance with more than two ADLs.

Type II facilities are intended for residents who are independent or semi- independent but not dependent.2 These facilities may serve individuals who require significant assistance in two or more ADLs providing their health and service needs can be met by staffing levels.

Neither Type I nor Type II facilities may serve anyone who requires inpatient hospital care or long-term nursing care; anyone who is suicidal, assaultive, or a danger to self or others; or anyone with active tuberculosis or another communicable disease that cannot be adequately treated at the facility, or on an outpatient basis, or that may be transmitted to other residents through the normal course of activities.

Persons receiving hospice care may be admitted and retained in both types of facilities that meet specified conditions regarding physician orders, service planning, staffing, and evacuation plans.

Both types of facilities may discharge, transfer, or evict residents if the facility is no longer able to meet their needs or the resident fails to comply with the facility’s policies or rules.

Services

Both facility types must provide personal care, housekeeping, laundry, maintenance, activity programs, medication administration, and assistance with self- administration of medications; and must arrange for necessary medical and dental care. Facilities may provide some nursing services, including assessment, health monitoring, routine nursing tasks, and medication administration.

Type II facilities provide substantial assistance with ADLs, supervision or coordination, nursing services, activities, and medication administration. Residents must have a service plan that includes specified intermittent nursing services, medication administration, and support services that promote residents’ independence and self- sufficiency. These facilities must employ or contract with a registered nurse (RN) to provide or supervise nursing assessment, general health monitoring, and to provide and delegate routine nursing tasks.

Facilities do not provide skilled nursing care but must assist the resident in obtaining it. Whether a service is considered skilled is determined by its complexity or specialized nature, which includes tasks that can be safely or effectively performed only by or under the close supervision of licensed health care professionals, and care that is needed to prevent deterioration of a condition or to sustain residents’ current capacities.

Service Planning

An assessment must be conducted before move-in and at least every 6 months thereafter, and must be reviewed and signed by a licensed health care professional. An individualized service plan based on the initial resident assessment must be developed within 7 days of admission. Service plans must meet residents’ unique cognitive, medical, physical, and social needs and must describe the services provided, how, when, how often, and by whom they will be provided. Service plans must be updated as needed.

Third-Party Providers

Residents have the right to arrange directly with an outside agency for the provision of medical and personal care.

Medication Provisions

Both facility types require that a licensed health care professional assess each resident to determine what type and level of medication administration assistance is needed. The rules specify four types: (1) The resident may self-administer medications; (2) the resident may self-administer medications with staff assistance, including reminders to take medication, help opening containers, and reminders to refill prescription orders; (3) family members may administer medications (described below); and (4) facility-staff may administer medications, including unlicensed staff who have received appropriate delegation from a licensed health care professional. A licensed health care professional or licensed pharmacist must review all resident medications at least every 6 months.

Family members or a designated responsible person may administer medications; they must sign a waiver indicating that they will agree to assume the responsibility of filling prescriptions, administering medications, and documenting the administration.

Food Service and Dietary Provisions

Facilities must be capable of providing three meals a day and snacks. Facilities admitting residents with therapeutic diets must have an approved dietary manual available.

Staffing Requirements

Assisted Living Facility Type I

Type of Staff. Facilities must have an administrator whose duties include responsibility for recruiting, employing, and training the number of licensed and unlicensed staff needed to provide services; direct care staff who provide personal care services; and a licensed nurse who is either employed or contracted with to provide health monitoring and to provide or delegate nursing tasks to staff. The administrator must be on the premises a sufficient number of hours to manage the facility and must designate, in writing, a competent employee, 21 years of age or older, to act as administrator when the administrator is unavailable for immediate contact.

Staff Ratios. No minimum ratios. A sufficient number of qualified direct care staff must be in the facility 24 hours a day to provide the level of care residents need. An RN must be available as needed to provide or delegate medication administration for any resident who is unable to self-medicate or to self-direct medication management.

Assisted Living Facility Type II

Type of Staff. Facilities must have an administrator whose duties are described under ALF Type I above, certified nursing aides who provide personal care services, and a licensed nurse who is either employed or contracted with to provide health monitoring and to provide or delegate nursing tasks to staff.

Staff Ratios. No minimum ratios.  Direct care worker requirements are the same as for Type I. At least one certified nurse aide must be on-duty 24 hours per day, and an RN must be available as needed.

Training Requirements

Both facility types require that all employees receive an orientation as well as in- service training relevant to their job duties. The orientation must include job descriptions; ethics, confidentiality, and residents’ rights; fire and disaster plans; policies and procedures; and reporting responsibility for abuse, neglect, and exploitation.

In-service training must be tailored to include all of the subjects that are relevant to an employee’s job, including nutrition and food preparation; housekeeping standards; personal and social care; medication assistance; early signs of illness and when to seek professional help; accident prevention; communication skills that enhance resident dignity; first-aid; residents’ rights and reporting requirements; and the needs of residents with Alzheimer’s disease or other dementias.

Provisions for Apartments and Private Units

Both facility types must provide each resident with a separate living unit. No more than two residents may share a unit and only when both residents request to do so in writing.

A unit is described as having a living and sleeping space, bathroom, and optional kitchen area. However, the rules also state that in Type I ALFs, at least one toilet and sink must be available on each floor for each six residents not otherwise served by a toilet and sink in the residents’ rooms, and at least one bathtub or shower for each ten residents not otherwise served by bathing facilities in residents’ rooms. A large Type I ALF must have separate toilet and bathing facilities for live-in family and staff.

In Type II ALFs, if resident living units do not have a private bathroom, the facility must provide a toilet and sink for every four residents and a bathtub or shower for every ten residents; the shower must accommodate residents in wheelchairs and have sufficient space to allow staff to assist a resident in taking a shower. If resident living units have private bathrooms that do not allow staff assistance, then each floor must provide a bathroom equipped with a bathtub or shower, toilet, and sink that opens from a corridor and provides wheelchair clearances and allows for staff assistance in bathing.

Apartment-style units are required for Medicaid waiver program participants, which may be shared by residents’ choice.

Provisions for Serving Persons with Dementia

Dementia Care Staff. Type II ALF staffing requirements must be met and at least one staff with documented training in Alzheimer’s disease/dementia care must be present in the secure unit at all time.

Dementia Staff Training. No additional provisions identified.

Dementia Facility Requirements. Each secure unit must have an emergency evacuation plan that addresses the ability of the secure unit staff to evacuate the residents in case of emergency.

Background Checks

All staff must undergo criminal background checks.

Inspection and Monitoring

Licenses are issued for a 2-year period. Facilities are surveyed “as possible” by the Department, or in response to a formal complaint.

Public Financing

The state pays for adult residential services in ALFs and other residential settings under the Medicaid New Choices 1915(c) Waiver program. The program serves adults over the age of 21 with disabilities and adults age 65 or older who have been covered by Medicaid in a nursing home for at least 90 days and want to relocate to the community; or who receive services in another waiver program and are at immediate or near immediate need of admission to a nursing home; or who have been residing in a licensed ALF on an extended stay basis of 180 days or more.

Room and Board Policy

In 2009, the room and board payment amount was negotiated between the facility and each individual, and family supplementation was allowed. The state does not provide an Supplemental Security Income payment to ALF residents.

Location of Licensing, Certification, or Other Requirements

Utah Administrative Code, Rule R432-270: Assisted Living Facilities. [February 1, 2015] http://www.rules.utah.gov/publicat/code/r432/r432-270.htm

Utah Administrative Code, Rule R432-6: Assisted Living Facility General Construction. [February 1, 2015]

http://www.rules.utah.gov/publicat/code/r432/r432-006.htm

Utah Administrative Code, Rule R501-17: Adult Foster Care. [February 1, 2015] http://www.rules.utah.gov/publicat/code/r501/r501-17.htm

Assisted Living Type I and Type II Nursing Guidelines. [March 14, 2011] http://health.utah.gov/hflcra/forms/AssistedLivingNursingGuidelines.pdf

Utah Department of Health website, Utah Home and Community-Based Waiver Programs: New Choices Waiver information and links to provider resources. http://health.utah.gov/ltc/NC/NCHome.htm

Information Sources

Dirk Anjewierden
Executive Director
Utah Health Care Association

Carmen Richins
Utah Department of Health