Licensure Terms

Assisted Living Facility

General Approach

The Washington State Department of Social and Health Services (DSHS), Aging and Long-Term Support Administration (Department) licenses assisted living facilities (ALFs), which provide room and board and help with activities of daily living (ADLs) to seven or more residents. Some ALFs provide limited nursing services (LNS); others may specialize in serving people with mental health problems, developmental disabilities, or dementia.

Three levels of services are provided by licensed ALFs that contract with Medicaid: enhanced adult residential care and assisted living services through a 1915(c) waiver program, and adult residential care services through the Medicaid State Plan. Facilities that contract with Medicaid must meet additional contracting requirements and provide specific services not required by licensure, including personal care and medication administration.

Adult Foster Care. The Department also licenses adult family homes that provide room and board and personal and special care for 2-6 adults who are not related by blood or marriage to the person or persons providing the services. Homes do not have to be operated by live-in providers. Regulatory provisions for adult family homes 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 means any home or other setting serving seven or more residents, however named, which is advertised, announced, or maintained for the express or implied purpose of providing housing and basic services, and assuming general responsibility for the safety and well-being of the residents. As of July 1, 2000, ALFs were allowed to provide–directly or indirectly–assistance with ADLs, health support services, or intermittent nursing services.

The term ALF does not include independent senior housing, independent living units in continuing care retirement communities, or other similar living situations, including those subsidized by the U.S. Department of Housing and Urban Development.

Resident Agreements

Facilities must complete a negotiated service agreement using the pre-admission assessment, initial resident service plan, and full reassessment information (described below under service planning). The facility must include the resident and the resident’s legal or other representative if any, in the development of the agreement. If the resident is a Medicaid client, the Department’s case manager must also be involved.

The negotiated service agreement must be completed or updated within 30 days of the move-in date; as-necessary following the annual full assessment of the resident; and whenever the resident’s negotiated service agreement no longer adequately addresses the resident’s current needs and preferences.

Disclosure Provisions

Facilities are required to disclose on a Department-provided form: (1) the scope of care and services offered and their cost; (2) activities not covered by the facility’s per diem rate or applicable public benefit programs; (3) facility operation rules required by regulation; and (4) information that residents or their legal representatives can independently arrange for outside services. The disclosure form must be provided to residents, their representative if any, and to interested consumers upon request.

Residents must be notified in advance if the facility is going to decrease or increase the scope of services it provides.

Admission and Retention Policy

ALFs may not admit or retain any individual requiring nursing or medical care of a type provided by nursing facilities, except when a registered nurse (RN) is available.

Also, facilities may not admit or retain persons who require frequent evaluation by an RN, excluding persons who are receiving hospice care or persons who have a short- term illness that is expected to be resolved within 14 days.

A facility must admit or retain only those individuals whose needs it can safely and appropriately serve in the facility with appropriate available staff and through the provision of reasonable accommodations required by state or federal law. Residents may be discharged for their own welfare or if the health or safety of other individuals in the facility is endangered.

Services

Facilities must assume general responsibility for each resident and promote each resident’s health, safety, and well-being consistent with the resident negotiated care plan.

ALFs are not required to provide assistance with ADLs, health support services, and intermittent nursing services. If they choose to provide assistance with ADLs, they must provide at least the minimal level of assistance with: bathing, dressing, eating, personal hygiene, transferring, toileting, and ambulation/mobility.

Facilities may choose to provide any of the following health support services: blood glucose testing, puree diets, calorie-controlled diabetic diets, dementia care, and mental health care. Facilities may also choose to provide intermittent nursing services through appropriately licensed and credentialed staff. These services include: medication administration, administration of health care treatments, diabetic management, non- routine ostomy care, tube feeding, and nurse delegation.

When providing any of these services, the facility must observe the resident for changes in overall functioning and respond appropriately when there are observable or reported changes in the resident’s physical, mental, or emotional functioning.

Service Planning

Except in cases of emergency, the facility must not admit an individual before obtaining a thorough assessment of his or her needs and preferences. The assessment must cover recent medical history; necessary and contraindicated medications; a licensed medical or other health professional’s diagnosis, unless the individual objects for religious reasons; significant known behaviors or symptoms that may cause concern or require special care; mental illness; level of personal care needs; activities and service preferences; and preferences regarding other issues important to the resident applicant, such as food and daily routines.

Based on the assessment, the facility must complete an initial resident service plan upon move-in to identify the resident’s immediate needs and to provide direction to staff and caregivers. Within 14 days after move-in, the facility must complete a full assessment of the resident’s functional and health needs as specified in regulation.

Facilities must repeat a limited assessment when a resident’s condition changes and the resident’s negotiated service agreement no longer addresses the resident’s needs.

Third-Party Providers

Facilities must permit the resident, or the resident’s legal or other representative if any, to independently arrange for or contract with licensed health care professions, or a licensed home health, hospice, or home care agency, to provide on-site care and services to the resident. The ALF licensee may establish policies and procedures that describe limitations, conditions, or requirements that must be met prior to an outside service provider being allowed on site.

Facilities are not required to supervise the activities of a person providing care or services to a resident when the resident, or legal representative, has independently arranged for or contracted with the person and the person is not directly or indirectly controlled or paid by the ALF. However, the ALF is required to coordinate services with such persons to the extent allowed by the resident, or legal representative, and consistent with the resident’s negotiated care plan. Further, the ALF is required to observe the resident and respond appropriately to any changes in the resident’s overall functioning.

Medication Provisions

Facilities may provide medication services, which include medication administration, medication administration provided through nurse delegation, medication assistance, or resident self-administration of medication. Residents negotiated service agreements must state whether they will receive medication assistance or medication administration services.

If licensed to do so, a facility may permit a resident’s family member to administer medications or treatments or to provide medication or treatment assistance to the resident. If so, the facility must request and family member provide a written medication or treatment plan, with information specified in the rules.

Food Service and Dietary Provisions

Facilities must provide a minimum of three meals a day at regular intervals with no more than 14 hours between the evening meal and breakfast, unless the facility provides a nutritious snack after the evening meal and before breakfast. Meals must be nourishing and palatable and must be adjusted to meet individual preferences to the extent reasonably possible. Facilities must also make available, as needed by residents, prescribed general low-sodium, general diabetic, and mechanical soft food diets, and nutrient concentrates and supplements when prescribed in writing by a health care practitioner.

Staffing Requirements

Type of Staff. Facilities must have an administrator. Facilities that admit and retain individual requiring LNS or medical care of a type provided by nursing facilities, must have a registered nurse available.

Staff Ratios. No minimum ratios. Facilities must provide sufficient, trained staff to furnish the services and care needed by each resident consistent with his or her negotiated service agreement, to maintain the facility free of safety hazards, and to implement fire and disaster plans. Facilities must also ensure that at least one staff person 18 years of age or older has current cardiopulmonary resuscitation (CPR) and first-aid certification and is present and available to assist residents at all times.

Training Requirements

Orientation and training requirements are presented in the table below. Orientation must cover the following topics: residents’ rights, communication skills, fire and life safety, and universal precautions. Orientation must be provided before the employees have routine interaction with residents.

Training Requirements

Type of Training

ALF Administrator or Designee

ALF Long-Term Care (LTC) Worker

DSHS Required to Approve

Curriculum?

First-aid and CPR

Within 30 days of

employment; maintain valid card.

Within 30 days of

employment; maintain valid card.

No

Orientation 2 hours

Prior to providing care to a resident unless exempt from training.

Prior to providing care unless exempt from training.

Yes

Safety training 3 hours

Prior to providing care to a resident unless exempt from training.

Prior to providing care to a resident unless exempt from training.

Yes

Basic training 70 hours

Within 120 days of

employment unless exempt from training.

Within 120 days of

employment unless exempt from training.

Yes

Continuing education

12 hours per year.

12 hours per year

Yes

HIV/AIDS

All ALF staff, 2 hours within 30 days of employment. Basic training includes this topic.

All ALF staff, 2 hours within 30 days of employment. Basic training includes this topic.

Educational materials are supplied by the Office on AIDS

Nurse delegation and core diabetes

Must be a certified or RN assistant, or certified home care aide and complete nurse delegation core training before accepting a delegated task.

Must be a certified or RN assistant or certified home care aide and complete nurse delegation core training before accepting a delegated task. Must complete Special Focus on Diabetes training before accepting insulin

injections as delegated task.

Must use DSHS curriculum.

Instructors must be DSHS-contracted community instructors.

 

Type of Training

ALF Administrator or Designee

ALF Long-Term Care (LTC) Worker

DSHS Required to Approve

Curriculum?

Specialty training

If an ALF serves 1 or more residents with special needs, the administrator or designee must complete manager specialty training and demonstrate competency by passing the DSHS test.

 

If a resident develops special needs while living in an ALF without a specialty designation, the administrator or designee have 120 days to complete manager

specialty training and demonstrate competency.

If an ALF serves one or more residents with special needs, all LTC workers must receive training regarding the specialty needs of individual residents in the facility.

Yes

 

Instructors must be DSHS-contracted community instructors to provide manager specialty training.

 Basic training consists of modules on the core knowledge and skills that caregivers need to effectively and safely provide care to residents, including specific duties and responsibilities; how to report resident abuse and neglect; policies, procedures, and equipment necessary to perform duties; and the needs and service preferences identified in the negotiated service agreements of residents with whom the staff persons will be working. Basic training must be outcome-based, and its effectiveness measured by demonstrated competency in the core areas through the use of a competency test.

Provisions for Apartments and Private Units

Private apartments or rooms are not required. No more than two residents may live in an apartment, and both must mutually agree to share a sleeping room. For facilities licensed before July 1, 1989, no more than four residents may share a room; if after this date, no more than two residents.

When providing common-use toilet rooms and bathrooms for residents who do not have a private toilet room, a facility must provide one toilet and one sink for every eight residents. When providing common-use bathrooms, facilities must provide one bathing fixtures for every 12 residents. Facilities must locate a toilet room on the same floor or level as the sleeping room of the resident served.

Facilities that want to provide assisted living services covered by the Washington State DSHS Aging and Disability Services Administration must provide private apartment-like units to Medicaid-eligible residents; shared units are not permitted unless the residents are married and both agree and understand that they are entitled to separate apartments. The unit must have a separate private bathroom, which includes a sink, toilet, and a shower or bathtub; a lockable entry door; a kitchen area equipped with a refrigerator, a microwave oven or stovetop and a counter or table for food preparation; and a living area wired for telephone and, where available in the geographic location, wired for television service.

Private apartments are not required in facilities that contract with the Department to provide enhanced adult residential care and adult residential care; units may be shared but no more than two people may share a unit.

Provisions for Serving Persons with Dementia

The state has a specialized dementia care program for persons with dementia who need residential care. The Department pays for the person to receive a package of specialized dementia care services in a contracted ALF. (Due to limited funding, the Department contracts with a small number of ALFs throughout the state to offer this program.)

The package of specialized dementia care services a contracted ALF must provide include (in part): (1) care, supervision, and activities tailored to the specific needs, interests, abilities, and preferences of the person; (2) coordination with the person’s family to ensure the person’s routines and preferences are honored; and (3) intermittent nursing services, help with medications, personal care, and other support services.

Dementia Care Staff. Facilities that offer specialized dementia care must have awake staff 24 hours a day.

Dementia Staff Training. For facilities that serve residents with special needs, including dementia, specialty training is required of administrators, or designees, and caregivers. Specialty training consists of modules on the core knowledge and skills that caregivers need to effectively and safely provide care to residents with special needs. Specialty training must be outcome-based, and the effectiveness of the specialty training measured by demonstrated competency in the core specialty areas through the use of a competency test.

Caregivers must complete specialty training within 120 days of the date on which they begin to provide hands-on care to a resident having special needs. However, if specialty training is not integrated with basic training, the specialty training must be completed within 90 days of completion of basic training. Until competency in the core specialty areas has been demonstrated, caregivers must not provide hands-on personal care to residents with special needs without direct supervision.

If a facility serves one or more residents with dementia, the administrator or designee must complete specialty training and demonstrate competency within 120 days from the date on which the administrator or designee is hired.

Dementia Facility Requirements. Facilities that contract with the state to provide specialized dementia care must have a safe outdoor environment with walking paths and access to a secure outdoor area.

Background Checks

All facility owners, partners, officers, directors and managerial employees, group or association members, and the administrator must undergo a background check when applying for licensure.

It is the licensee’s responsibility to require and submit fingerprint background check authorization forms on all individuals associated with the ALF who have unsupervised access to residents, including, but not limited to, employees, managers, volunteers who are not residents, contractors, and students.

Facilities must not employ, directly or by contract, an administrator or caregiver who has been convicted of a crime or pending charge for a disqualifying crime as specified in the rules, or who has been found in any disciplinary board final decision to have abused a vulnerable adult, or found by the Department to have abused, neglected, or exploited a vulnerable person in any manner.

Inspection and Monitoring

The Department inspects all ALFs at least every 18 months with an annual average of 15 months. The Department may delay an inspection to 24 months if the ALF has had three consecutive inspections with no written notice of violations and has received no written notice of violations resulting from complaint investigation during that same time period. The Department may at any time make an unannounced inspection of a licensed facility to ensure that the licensee is in compliance with all rules.

Public Financing

The state’s Medicaid 1915(c) Waiver program–Community Options Program Entry System (COPES)–pays for personal care and other services in adult family homes, adult residential care facilities, and ALFs. 

Three levels of services are provided by licensed ALFs that contract with Medicaid: enhanced adult residential care and assisted living services through the COPES Waiver program, and adult residential care services through the Medicaid State Plan. Facilities that provide enhanced adult residential care services may also contract with the Department to provide specialized dementia care.

Adult residential care services include assistance with self-administration of medications, limited supervision for safety, and assistance with ADLs (personal care). Enhanced adult residential care services include all of the adult residential care services, plus medication administration, and some types of nursing care on an occasional basis. (No more than two people may share a room.) Assisted living services include some types of nursing care on an occasional basis, medication administration, and personal care. (A private apartment is required.)

Room and Board Policy

The room and board rates for Medicaid waiver participants and Supplemental Security Income (SSI) recipients are capped at the SSI rate–$733 in 2015–minus a personal needs allowance of $62.79. The state does not supplement the federal SSI payment for residents in ALFs.

Family supplementation is allowed for items or services not covered by Medicaid.

Location of Licensing, Certification, or Other Requirements

Revised Code of Washington, Title 18, Chapter 18.20 RCW: Assisted Living Facilities (Formerly Boarding Homes).

http://apps.leg.wa.gov/rcw/default.aspx?cite=18.20

Revised Code of Washington, Title 388, Chapter 388-76 RCW: Adult Family Home Minimum Licensing Requirements. [June 24, 2014]

http://apps.leg.wa.gov/WAC/default.aspx?cite=388-76

Washington Administrative Code, Title 388, Chapter 388-78A WAC: Assisted Living Facility Licensing Rules. [June 24, 2014]

http://app.leg.wa.gov/WAC/default.aspx?cite=388-78A

Washington Administrative Code, Title 388, Chapter 388-78A, Section 24641: Background checks. [July 25, 2014]

http://app.leg.wa.gov/WAC/default.aspx?cite=388-78A-24641

Washington Administrative Code, Chapter 388-110 WAC: Contracted Residential Care Services. (Provisions for facilities contracting to provide services to Department of Social and Health Services, Aging and Long-Term Support Administration clients.) [March 7, 2014] http://apps.leg.wa.gov/WAC/default.aspx?cite=388-110

Washington State Department of Social and Health Services, Aging and Long-Term Support Administration Website: Information for Assisted Living Professionals. http://www.dshs.wa.gov/altsa/residential-care-services/information-assisted-living-facility- professionals

Information Sources

Elena Madrid Director
Assisted Living, Residential Care, and Quality Washington Health Care Association