General Approach

The state licenses two settings that provide housing, meals, and supportive services to adults who cannot live independently but do not require the type of care provided in a nursing home: assisted living residences (ALRs) and residential care homes (RCHs). RCHs are divided into two groups depending on the level of care they provide–Level III or Level IV.
Assisted living regulations require private apartments that promote resident self- direction and active participation in decision-making while emphasizing individuality, privacy, and dignity. As well as meeting their own licensing requirements, ALRs must meet Level III RCH licensing requirements.
Special care units (SCUs) that provide specialized services to a specific population must meet RCH licensing requirements, which are incorporated by reference into the ALR licensing regulations.
Services in both settings are covered by the Medicaid State Plan program and the 1115 Choices for Care Waiver program. Licensed ALRs and RCHs must be enrolled as Medicaid providers. Requests for continued participation in the Medicaid program must be submitted on an annual basis with the license re-application.
Adult Foster Care. Adult family care is a new Medicaid option provided under the Choices for Care Waiver program to individuals in the highest and high-needs groups. Authorized Agencies contract with private, unlicensed family homes to provide 24-hour care and room and board to 1-2 people who are not related to the home provider.
Services include (but are not limited to) personal care, companion, and adult day services. Providers may also serve residents on a respite basis. Adult family care providers who serve only private pay residents are not regulated by the state. The Medicaid regulatory provisions for adult family care are not included in this profile but a link to them can found at the end.

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

Definitions

Assisted living residence means a program or facility that combines housing and health and other services to support residents’ independence and aging in place. In addition to the services specified in Level III RCH regulations, ALRs are required to offer a private bedroom, private bathroom, living space, kitchen capacity, and a lockable door.

Residential care homes serve three or more residents, who are unrelated to the licensee, and are licensed as either Level III or Level IV. Both licensure levels must provide room and board, assistance with personal care, general supervision, and medication management. Level III homes must provide the additional service of nursing overview.

Admission and Retention Policy

The following admission and retention requirements in each setting also apply to residents in SCUs within the setting.

Assisted Living Residences. The facility may accept and retain any individual– including those whose needs meet the definition of nursing home level of care if those needs can be met by the ALR–with the following exceptions: an individual who: (1) has a serious, acute illness requiring the medical, surgical, or nursing care provided by a general or special hospital; (2) needs a ventilator or respirator; (3) needs treatment for a Stage III or IV decubitus ulcer; or (4) requires nasopharangeal, oral or trachial suctioning, or two-person assistance to transfer from bed or chair or to ambulate.A current resident who develops a need for equipment, treatment, or care as listed above or who develops a terminal illness may remain in the residence so long as the facility can safely meet the resident’s needs and/or the resident’s care needs are met by an appropriate licensed provider.
The expectation is that individuals will be permitted to age in place provided that their mobility, ambulation, and transfer needs can be met by one staff person; cognitive impairment is at a moderate or lesser degree of severity; and behavioral symptoms consistently respond to appropriate intervention.
Residents may only be involuntarily discharged if: (1) they are not capable of entering into a negotiated risk agreement and they pose a serious threat to self, staff, or other residents that cannot be resolved through care planning and interventions; or (2) the resident has care needs that the residence can no longer

Residential Care Homes. The facility may not accept or retain as a resident any individual who meets the level of care eligibility criteria for nursing home admission; has care needs that exceed what the home is able to safely and appropriately provide; or has a serious, acute illness requiring the medical, surgical, or nursing care of a general or special hospital. On admission, each resident must have a physician’s statement with a medical diagnosis, including psychiatric diagnosis if applicable.
Homes may retain residents who need nursing services beyond nursing overview and medication management if they meet a number of conditions specified in the regulations, including the following: (1) residents receiving such care are fully informed of their options and agree to receive such care in the home; (2) the home is able to meet the resident’s needs without detracting from services needed by other residents; and (3) the nursing service provided is limited in nature or is provided by a Medicare- certified Hospice program.
The following services are not permitted in a RCH except under a variance5 granted by the licensing agency: intravenous therapy, ventilators or respirators, daily catheter irrigation, feeding tubes, care of Stage III or IV decubitus ulcers, suctioning, and sterile dressings. Variances are considered and issued on a case-by-case basis.
Residents may be discharged only when their care needs exceed those for which the home is licensed to provide–or approved through a variance–or when the home is unable to meet the resident’s assessed needs, or the resident presents a threat to his or herself or to the welfare of other residents or staff.

Medication Provisions

The following requirements of the RCH licensing regulations apply to both ALRs and RCHs.
The facility manager is responsible for ensuring that all medications are handled according to the home’s policies and that designated staff are fully trained in medication policies and procedures.Residents who are capable of self-administration may purchase and self- administer over-the-counter medications. However, the facility must make every reasonable effort to be aware of such medications and monitor and educate residents about possible adverse reactions or interactions with other medications. If a resident’s over-the-counter medications use poses a significant threat to the resident’s health, staff must notify the physician.
Staff responsible for assisting residents with medications must receive training in the following areas from a licensed nurse:

• he basis for determining “assistance” versus “administration,” and policies and procedures for assisting with medications.
• Residents’ right to direct their own care, including the right to refuse medications.
• Proper techniques for assisting with medications, including hand-washing and checking for the right resident, medication, dose, time, and route.
• Signs, symptoms, and likely side effects to be aware of for any medication a resident receives.

If a resident requires medication administration, unlicensed staff may administer medications under the following conditions:

• A registered nurse (RN) must delegate the responsibility for the administration of specific medications to designated staff for designated residents.
• The RN must accept responsibility for the proper administration of medications, including: (1) teaching designated staff proper techniques for medication administration and providing appropriate information about the resident’s condition, relevant medications, and potential side effects; (2) establishing a process for routine communication with designated staff about the resident’s condition and the effect of medications, as well as changes inmedications; (3) assessing the resident’s condition and the need for any changes in medications; and (4) monitoring and evaluating the designated staffperformance in carrying out the nurse’s instructions.
• All medications must be administered by the person who prepared the doses unless the nurse responsible for delegation approves of an alternative method of medication preparation and administration.

Staff other than a nurse may administer PRN psychoactive medications only when the home has a written plan for their use that describes the specific indications for administering the medication.Staff other than a nurse may administer insulin injections only when: (1) the diabetic resident’s condition and medication regimen is considered stable by the RN who is responsible for delegating the administration; (2) the designated staff to administer insulin to the resident have received additional training in the administration of insulin and the responsible RN has deemed them competent; and (3) the RN monitors the resident’s condition regularly and is available when changes in condition or medication might occur.

Food Service and Dietary Provisions

Assisted Living Residences. The facility must have the capacity to provide three meals a day and snacks, but may allow residents to purchase fewer meals. The facility must also meet the following RCH licensing requirements.

Residential Care Homes.Three nutritionally balanced, attractive, and satisfying meals per day are required and they must provide 100 percent of the Recommended Dietary Allowances as established by the Food and Nutrition Board of the National Research Council of the National Academy of Sciences and comply with the Dietary Guidelines for Americans. Residents must be provided with alternatives to the planned meal upon request and offered snacks between meals and at bedtime. No more than 14 hours may elapse between the end of an evening meal and the morning meal. Written physicians’ orders are needed for therapeutic diets.