Licensure Terms

Assisted Living Facilities

General Approach

The Department of Health, Office of Healthcare Licensing and Surveys, licenses assisted living facilities (ALFs). The rules do not specify a minimum number of residents needed to trigger licensure requirement. There are two levels of licensure: Level 1 is for ALFs that do not have a secure unit, and Level 2 is for ALFs that have a secure unit and are required to meet special staffing and staff education requirements defined under the rules. The licensing level is used for regulatory purposes only.

The state is currently revising the regulations. The process for finalizing the revisions may take several months because the state has to obtain comments on the proposed changes and if the comments lead to further revisions, the state may have to obtain a second round of comments.

Adult Foster Care (AFC). The state has licensure requirements for AFC homes that provide care and supervision for up to five adults who are not related to the provider by blood, marriage or adoption (except in certain circumstances), and who need long- term care in a home-like atmosphere. The AFC home must be the primary residence of the licensee. Residents in the home must have private rooms, which may be shared with spouses, and must have individual accessible bathrooms. At the current time, the state has no AFC providers. 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 means a non-institutional dwelling operated by a person, firm, or corporation engaged in providing limited nursing care, personal care, and boarding home care, but not habilitative care, for persons not related to the owner of the facility.

Boarding home means a non-institutional dwelling or rooming house operated by any person, firm or corporation engaged in the business of operating a home for the purpose of letting rooms for rent and providing meals and personal daily living care, but not habilitative or nursing care, for persons not related to the owner. A boarding home does not include a lodging facility or an apartment in which only room and board is provided.

Resident Agreements

A resident agreement is not required. Facilities must provide an assistance plan that specifies the type, frequency, and duration of services that will be provided and the expected outcome.

Disclosure Provisions

No provisions identified.

Admission and Retention Policy

Individuals may only be admitted if accompanied by a medical history and physical that is completed by a physician or physician extender within 90 days prior to admission.

Individuals cannot be admitted or retained if the facility cannot provide the level of care needed and cannot meet their needs, or if they need any of the following services: (1) continuous assistance with transfers and mobility; (2) total assistance with feeding, bathing, or dressing; (3) catheter or ostomy care; (4) monitoring of continuous oxygen; (5) supervision to prevent wandering that jeopardizes health and safety; (6) wound care requiring sterile dressings; (7) Stage II or higher skin care; (8) highly restrictive therapeutic diets (e.g., renal diets); and (9) incontinence care. Individuals who need limited nursing services may be served, defined as the level of care provided by a certified nursing assistant (CNA) within the scope of ALF licensure.

Residents may be discharged if they exhibit inappropriate social behavior, such as frequent aggression, abuse, or disruptive behavior; or demonstrate chemical abuse that places them or others at risk; or have a documented established pattern, in the facility, of not abiding by agreements necessary for assisted living; or engage in behavior that poses an imminent danger to self and/or to others.

Individuals may not be admitted to or retained in a secure dementia unit if they score more than 20 or less than 10 on the Mini-Mental State Exam (MMSE); if they need ongoing nursing care; or if they require more than limited assistance to evacuate the building.

Services

Facilities must provide core services, which include: assistance with transportation; assistance with obtaining medical, dental, and optometric care, and social services; assistance in adjusting to group living activities; provision of appropriate recreational activities in and out of the facility; partial assistance with personal care (e.g., bathing, shampoos); limited assistance with dressing; minor non-sterile dressing changes; Stage I skin care; infrequent assistance with mobility (the resident may use an assistive device, such as wheelchair, walker, or cane); cuing guidance with activities of daily living (ADLs) for the visually impaired resident, or the intermittently confused and/or agitated resident requiring occasional reminders of time, place, and person; limited care to residents who can independently manage catheter or ostomy care and incontinence; and 24-hour monitoring of each resident.

To operate a secure dementia unit, ALFs must be licensed as a Level 2 facility and must meet additional Level 2 requirements. In addition to Level 1 core services, Level 2 must provide the following services: increased assistance with ADLs (dressing, grooming, bathing, mobility, toileting); assistance as needed to maintain nutrition and hydration status; services necessary to maintain the highest continence level and skin integrity; and an activity program developed by an activities professional, at least on a consultation basis, who has been trained in dementia-specific activities. The program must be evaluated and revised as needed to meet residents’ needs.

Service Planning

A registered nurse (RN) must complete an assessment using a state-required screening tool (the Long-Term Care 102 Form) no earlier than 1 week prior to admission and, at a minimum, annually or upon a significant change in condition. The assessment must determine all of the individual’s needs.

Assessment results are used to develop, review, and revise the resident’s individualized assistance plan. The assistance plan must include information about who will provide the care/services; what, when, and how care/services will be provided; and the expected outcome.

Residents must be included in the development of their individual assistance plan to the best of their abilities; a relative or other interested party may participate. The plan must reflect assessed needs and resident decisions (including resident’s level of involvement); and support the principles of dignity, privacy, choice, individuality, independence, and home-like environment.

In addition to all other required assessments, Level 2 facilities must provide an MMSE for each individual considered for admission to the secure unit, and the individual must score between 20 and 10 points. The MMSE must be performed at least annually and upon any significant change in the resident’s mental or physical condition.

Third-Party Providers

Residents may receive services from an outside entity for care beyond those specified in Assisted Living Program Administration Rules. Services include, but are not limited to: hospice care, Medicare/Medicaid certified home health care, private duty care, and Medicaid waiver program services. These services must be arranged by the appropriate professional and be incorporated into the resident’s assistance plan. The resident’s choice of providers must be honored.

A contract between the resident, the facility, and all outside service providers must be in place prior to the time of service delivery. This contract must clearly delineate the services that will be provided, when they will be provided, and by whom they will be provided. Additionally, the service plan must include family members/significant others who participate in the delivery of services.

Medication Provisions

An RN is responsible for the supervision and management of all medication administration as required by the Wyoming Nurse Practice Act, and the Wyoming Board of Nursing Rules and Regulations. An RN must review residents’ medications every 2 months, whenever new medications are prescribed, and when medications are changed.

The RN must document whether a resident is able to self-administer medications. The facility staff are responsible for providing necessary assistance to residents deemed capable of self-medicating, but are unable to take oral medications because of functional limitations. Non-licensed staff can assist only with oral medications.

Medication assistance may include: reminders, removing the medication from a container, assistance with removing caps, assisting with the removal of a medication from a container for residents with a disability that prevents independence in this act, and observation of the resident taking the medication

For residents unable to self-administer, medications may be administered by an RN or a licensed practical nurse (LPN).

Food Service and Dietary Provisions

Facilities must provide a minimum of three balanced, palatable, properly prepared, and attractively served meals that meet the recommended dietary allowances. Special diets may be ordered by a physician or a registered dietician.

Facilities that admit residents who need therapeutic or mechanically modified diets must employ or contract with a registered dietitian who must approve written menus and dietary modifications; approve special diet needs; plan individual diets; and provide guidance to dietary staff in areas of preparation, service, and monitoring. The frequency of visits is determined by the residents’ needs and the competency of the dietary staff, but must include at least a monthly on-site review of dietary services.

Staffing Requirements

Type of Staff. Facilities must designate a manager who is responsible for the facility’s day-to-day operations and staff development and training. If the ALF does not employ a registered nurse, it must contract with one to provide residents’ initial and updated assessments, assistance plans, periodic reviews, and medication management.

Staff Ratios. No minimum ratios. The staffing level must be sufficient to meet the needs of all residents and to ensure the appropriate level of care is provided. Facilities must have at least one staff person on duty and awake at all times. At least one RN, LPN, or CNA must be on-duty every shift.

Training Requirements

Facilities must provide an orientation to new employees that covers resident rights and evacuation and emergency procedures, and must also provide training and competent supervision designed to improve resident care.

Administrators must complete at least 16 hours of continuing education annually.

Provisions for Apartments and Private Units

Apartment-style units are not required. No more than two people may share a bedroom.

Two residents may, by consent of both parties, or by approval of the appropriate responsible party, be permitted to use one bed no smaller than double size, and occupy a single-bed sleeping room.

One flush toilet and sink must be provided for every two residents and one tub and shower is required for every ten residents. One half of licensed beds must be in private rooms.

In 2009, Medicaid required apartment-style living units shared only by resident choice. 

Provisions for Serving Persons with Dementia

Dementia Care Staff. A licensed nurse must be on-duty on all shifts to administer PRN medications and to perform ongoing resident evaluations in order to ensure appropriate, timely interventions. The nurse may be an LPN if an RN is available on the premises or reachable by phone. At least one staff member with specialized training (described below) must be available on the unit at all times to provide supervision and care to the residents, as well as to assist the residents to evacuate the facility.

Dementia Staff Training. In addition to meeting all Level I training requirements, direct care staff in secure dementia units must receive additional documented training in the following areas:

  • The facility philosophy and approaches to providing care and supervision of persons with severe cognitive impairment. 
  • Techniques for minimizing challenging behaviors, such as wandering and delusions.
  • Therapeutic programming to support the highest level of residents’ functioning. 
  • Promoting residents’ dignity, independence, individuality, privacy, and choice. 
  • Identifying and alleviating safety risks to residents. 
  • Recognizing common side effects and reactions to medications. 
  • Techniques for dealing with bowel and bladder aberrant behavior. 

Administrators must complete at least 16 hours of continuing education annually, at least 8 of which must pertain to caring for persons with severe cognitive impairments. Staff must complete at least 12 hours of continuing education annually related to the care of persons with dementia.

Dementia Facility Requirements. Facilities with secure units must meet health care occupancy requirements.

Background Checks

All ALF staff must successfully complete, at a minimum, a Wyoming Division of Criminal Investigation fingerprint background check and a Department of Family Services Central Registry Screening before direct resident contact.

Inspection and Monitoring

The Survey Division’s designated representative performs initial and periodic surveys for licensure renewal. Facilities are surveyed at least annually and as-needed to investigate complaints. When conditions are such that residents’ needs are not being met by the ALF, the Licensing Division may place a Departmental-approved monitor at the ALF owner’s expense to ensure that residents’ health or safety is not in jeopardy.

Public Financing

The state covers services in both levels of ALFs through a Medicaid 1915(c) waiver program called Assisted Living Facility Home and Community-Based Services.

Room and Board Policy

In 2009, room and board charges were determined by the facility and were not capped by state policy. The state did not provide a supplement to residents of ALFs nor specify a personal needs allowance (PNA). Family supplementation was allowed to help pay for room and board costs.

Location of Licensing, Certification, or Other Requirements

Rules and Regulations for Licensure of Assisted Living Facilities, Chapter 4. http://soswy.state.wy.us/Rules/RULES/4451.pdf

Wyoming Department of Health, Aging Division Rules for Program Administration of Assisted Living Facilities, Chapter 12. [December 12, 2007] http://soswy.state.wy.us/Rules/RULES/6796.pdf

Wyoming Department of Health website: Assisted Living Facility–Wyoming Licensure Information.

http://www.health.wyo.gov/ohls/Wyoming_Assisted_Living.html

Department of Health, Rules for Pilot Project–Adult Foster Care Homes, Chapter 13. http://soswy.state.wy.us/Rules/RULES/7158.pdf

Information Sources

Laura Hudspeth
Chief
Healthcare Surveillance Branch
Wyoming Aging Division, Healthcare Licensing and Surveys

Linda Flynn
Home Care Services Program Manager
Wyoming Division of Healthcare Financing