STAFFING
A full-time employee must be designated as the operator of the licensed facility; this person is responsible for the management of the facility. The operator must be at least
21 years old; must be a high school graduate or have a GED; and must not be a resident of the facility. The operator must document that he or she is not listed on the Mississippi Nurses Aide Abuse Registry.
Staffing patterns must meet the following ratios: one resident attendant per 15 or fewer residents between of 7:00 a.m. and 7:00 p.m., and one resident attendant per 25 or fewer residents between 7:00 p.m. and 7:00 a.m.
All direct care employees must be at least 18 years of age and not listed on the
Mississippi Nurses Aide Abuse Registry. Employees shall be on duty, awake, and fully dressed to provide personal care to the residents.
TRAINING
Personnel shall receive training on a quarterly basis on topics and issues related to the population served in the licensed facility. Training shall be documented by a narrative of the content and signatures of those attending.
OVERSIGHT AND MONITORING
MISSOURI
BACKGROUND
Assisted living and residential care facility regulations apply to facilities serving three or more persons.
Web Site Content
http://www.sos.mo.gov/adrules/csr/current/19csr/19csr.asp General rules
DEFINITION
An assisted living facility is any premises—other than a residential care facility II, intermediate care facility, or skilled nursing facility—that is used by its owner, operator, or manager to provide 24-hour care and services and protective oversight to three or more residents who are provided with shelter and board, and who need and are provided with the following: assistance with any activities of daily living and any instrumental activities of daily living; storage, distribution, or administration of medications; and supervision of health care under the direction of a licensed physician, provided that such services are consistent with a social model of care. The term “assisted living facility” does not include a facility in which all the residents are related within the fourth degree of consanguinity or affinity to the owner, operator, or manager.
ADMISSION/RETENTION CRITERIA
Assisted living facilities (ALFs) may admit and retain persons who do not require
hospitalization or skilled nursing placement only if the facility provides for or coordinates oversight and services to meet the needs of the resident; has 24-hour staff appropriate in numbers and with appropriate skills to provide such services; has a written plan for the protection of all residents in the event of a disaster, including keeping residents in place, evacuating residents to areas of refuge, evacuating residents from the building, or other methods of protection depending on the disaster and the building design; completes a pre- move-in screening with participation of the prospective resident; completes for each resident a community-based assessment conducted by appropriately trained and qualified persons; and develops an individualized service plan in partnership with the resident or his or her legal representative that outlines the person’s needs and preferences. ALFs must prepare a plan to protect the rights, privacy, and safety of all residents and to protect against financial exploitation. Facilities may not accept or retain a resident who has exhibited behaviors that present a reasonable likelihood of serious harm to himself or herself or others; requires physical or chemical restraint; requires skilled nursing services for which the facility is not licensed; requires more than one person to simultaneously physically assist the resident with any activity of daily living, with the exception of bathing and transferring; is bedbound or similarly immobilized owing to a debilitating or chronic condition.
ASSESSMENT AND CARE PLANNING PROCESS
Facilities must provide coordination, oversight and services to meet the resident’s needs and social and recreational preferences in accordance with the individualized service plan as documented in a written contract signed by the resident or legal representative. Staff must complete a pre-move-in screening that documents basic information and analysis provided by appropriately trained and qualified persons of the prospective resident’s abilities and needs in activities of daily living, instrumental activities of daily living, vision/hearing, nutrition, social participation and support, and cognitive functioning. The screening is designed to determine whether the person is eligible for admission to the assisted living facility.
The facility must complete a community-based assessment within five days of admission, at least twice a year, and whenever there is a change in the resident’s condition. Staff develop an individualized service plan in response to the assessment that outlines the resident’s needs and preferences, services provided, and goals expected by the resident or the resident’s legal representative in partnership with the facility.
SERVICES
Assisted living facilities provide self-care and leisure activity programs and person- centered activities appropriate to individual needs, preferences, background, and culture. The state requires use of a standard preadmission screening and assessment tool. The assisted living facility must complete the individualized service plan (ISP) and the resident or legal representative of the resident must review the plan at least annually. An authorized representative of the facility and the resident or resident’s legal representative must sign the ISP.
MEDICATIONS
Certified medication technicians (CMTs) may administer medications in all licensed facilities. Level I medication aides may administer medications in residential care facilities and assisted living facilities. Injections shall be administered only by a
physician or a licensed nurse, except for insulin injections, which may be administered by a CMT (all levels of care) or a Level I medication aide who has successfully completed the state-approved course for insulin administration taught by an approved instructor. A pharmacist or registered nurse must review medications every other month in Level II facilities and every three months in Level I facilities.
RESIDENT AGREEMENT/CONTRACT/DISCLOSURE
The assisted living facility must disclose to a prospective resident or legal representative information regarding the services the facility can provide or coordinate, the cost of these services, and conditions that will require discharge or transfer, including the following: exhibits behaviors that present a reasonable likelihood of serious harm to himself or herself or others; requires physical restraint or chemical restraint; requires skilled nursing services that the facility is not licensed or able to provide; requires more than one person to simultaneously physically assist with any activity of daily living, with the exception of bathing and transferring; or is bedbound or similarly immobilized owing to a debilitating or chronic condition.
Regulations require that residents be fully informed in writing before or at admission of the services available and related charges; charges for services not covered in the basic rate; procedures in a medical emergency; services that may be available outside the facility; the resident’s right to make treatment decisions; and state laws concerning advance directives.
PUBLIC FINANCING
Personal care and advanced personal care services are reimbursed as a Medicaid state plan service in residential care facilities. The program serves elders, people with disabilities, people with mental retardation and developmental disabilities, and people with mental illness.
STAFFING
Facilities must have adequate staffing. Assisted living facilities must have staff 24 hours a day sufficient in numbers and skills to provide the services specified in the
individualized service plan for each resident. Staffing patterns are higher for ALFs that serve residents with physical, cognitive, or other impairments that would prevent them from safely evacuating the facility with minimal assistance. Residential care facilities (those formerly licensed as RCF I and those formerly licensed as RCF II that will continue to meet those standards) must have an adequate number and type of personnel for the proper care of residents and upkeep of the facility.
ALFs serving 3–30 residents who would need more than minimal assistance with
evacuation must have one staff person per 15 residents during the day and evening shifts and one staff person per 20 residents at night.
TRAINING
New employees receive at least one hour of orientation to their job functions. The minimum orientation includes job responsibilities, how to handle emergency situations, the importance of infection control and hand washing, confidentiality of resident information, preservation of resident dignity, how to report abuse/neglect to the department, information regarding the Employee Disqualification List, instruction regarding the rights of residents and protection of property, and instructions for working with residents with mental illness. New ALF employees must receive instruction
regarding person-centered care and the concept of a social model of care, as well as techniques that are effective to enhance resident’s choice and control over his or her environment. Training is also required regarding safely transferring residents.
OVERSIGHT AND MONITORING
MONTANA
BACKGROUND
The Department of Public Health and Human Services licenses adult foster homes (AFHs). AFHs are small, owner-occupied homes. In 2008, there were 95 licensed homes with 246 beds; the supply has been stable in recent years.
Adult foster family care homes offer light personal care, custodial care, and supervision to aged or disabled adults who require assistance in meeting their basic needs. An adult foster family care home does not provide skilled nursing care. The licensing requirements for operating an adult foster home do not apply to persons in a mutual or shared living arrangement.
Among the provider tools on the Department of Public Health and Human Services Web site are the licensing application, sample forms, and policies, including a placement agreement, grievance policy, accident or sudden illness report, emergency preparedness statement, resident money policy, and a medication record form.
Web Site Content
http://www.dphhs.mt.gov/qad/adultfostercare/index.shtml
http://www.dphhs.mt.gov/qad/healthcarefacilitieslist/adultfostercarefacilities.pdf
Rules, provider tools List
DEFINITION
The statute defines an adult foster home as a private home or other facility that offers (except as provided in §50-5-216, which allows persons who have a developmental disability or adults who were served before age 18 years and who may need skilled nursing care or restraints, are nonambulatory or bedridden, are incontinent, or who are unable to self-administer medications) only light personal care or custodial care to four or fewer disabled adults or aged persons who are not related to the owner or manager of the home by blood, marriage, or adoption, and who are not under the full guardianship of the owner or manager.
ADMISSION/RETENTION CRITERIA
The statute states that the types of care offered by adult foster care homes are limited to light personal care or custodial care and may not include skilled nursing care. Exceptions are listed for an adult who receives state-funded services through the developmental disabilities program of the department or an adult who resided in the home before age 18 who needs skilled nursing care; needs medical, physical, or chemical restraint; is nonambulatory or bedridden; is incontinent to the extent that bowel or bladder control is absent; or is unable to self-administer medications. Homes licensed for these exceptions must have a signed statement—renewed annually—from a physician, physician assistant, nurse practitioner, or registered nurse whose work is unrelated to the operation of the home and who has visited the home within the year covered by the statement. The statement certifies that the services available to the resident in the home or in the community, or services that may be brought into the home from the community, including nursing services or therapies, are appropriate to meet the health care or other
needs of the resident; and that the health care status of the resident does not necessitate placing the resident in a more intensive residential service setting.
ASSESSMENT AND CARE PLANNING PROCESS
Not described.
SERVICES
Homes provide light personal care, custodial care, and supervision for residents, and a minimum of three regular, nutritious, attractively prepared meals per day served family style. Light personal care means assisting with personal hygiene tasks such as bathing, dressing, hair grooming, and supervision of self-medication.
Custodial care means providing a sheltered, family-type setting for an aged person or disabled adult to provide for the basic needs of food and shelter, and having a specific person available to help the adult meet these basic needs. A physician may prescribe temporary in-home skilled nursing services for less than 30 days and not more than two hours a day to prevent a hospital admission.
MEDICATIONS
All residents must take their own medications. The licensee is, as necessary, responsible for providing the following assistance: reminding the resident to take medications; assisting with the removal of a cap; assisting with the removal of a medication from a container for residents with a disability that prevents this act; or watching the resident take the medication. If the licensee must help the resident take medicine in any way, the licensee shall have on file a medication record noting the doses taken and not taken.
RESIDENT AGREEMENT/CONTRACT/DISCLOSURE
The licensee completes a written placement agreement with the agency or person placing the elderly or disabled adult in the home that specifies the responsibilities of the licensee and the placing agency or person requesting care and the charges that will be made to the resident for care, as well as an itemized list of expenses in addition to the cost of basic care that will be charged to the resident.
PUBLIC FINANCING
The Medicaid HCBS waiver in licensed adult foster homes and assisted living facilities covers adult residential care services. Adult residential care is a bundled service that includes personal care, homemaker services, nutritional meals and snacks, medication oversight (to the extent permitted under state law), social and recreational activities, and 24-hour onsite response to ensure that the care, well-being, health, and safety needs of residents are met at all times. Adult foster homes serve fewer than 50 waiver participants, compared with more than 600 in assisted living facilities.
The payment rate is based on an assessment completed by the HCBS case manager. The basic service payment of $652 a month covers meal service, homemaking, socialization and recreation, emergency response system, medical transportation, and 24-hour
availability of staff for safety and supervision. Additional payments are calculated on the basis of ADL and other impairments. Points are calculated for each impairment. The maximum reimbursement for services is $61.80 a day. The functions measured are
bathing, mobility, toileting, transfer, eating, grooming, medication, dressing,
housekeeping, socialization, behavior management, and cognitive functioning. Each function is rated as follows:
With aides/difficulty: needs consistent availability of mechanical assistance or expenditure of undue effort.
With help: requires consistent human assistance to complete the activity, but the person participates actively in the completion of the activity.
Unable: the person cannot meaningfully contribute to the completion of the task. Each point equals $34 a month. For example, a resident who consistently needs help with toileting would be scored a “2” and would earn $68 a month for that impairment. The SSI payment, with state supplement, is $689.75. The personal needs allowance is $100.
STAFFING
An adult member of the foster family or another adult employee of the licensee must always be present when a resident is in the home, except as may be specified in a resident’s individual assessment plan.
TRAINING
Not described. Licensing agency staff are working on a proposed rule that will require first aid and CPR training for all providers and staff. Training requirements may be included in contracts with state agencies that serve individuals with mental illness and developmental disabilities.
OVERSIGHT AND MONITORING
A department social worker evaluates persons who apply to provide adult foster care. The social worker evaluates the person in terms of personal qualifications to provide such care and the physical facilities he or she will use to provide these services. The social service supervisor, who males the final decision as to whether or not the department will certify for adult foster care, reviews the evaluation. The department may license homes for one to three years.
NEBRASKA
BACKGROUND
Standards for adult family homes are contained in a program manual. Adult family homes provide a living arrangement to meet the needs of residents who are unable to live
independently but who can function adequately with minimal supervision and protection in a homelike living arrangement. Adult family homes enable adults to continue
maximum normal functioning in a community. The Department of Health and Human Services is planning to revise the rules.
Web Site Content
http://www.sos.state.ne.us/rules-and-regs/regsearch/Rules/Health_and_Human_
Services_System/Title-473/Chapter-6.pdf Rules (scroll to chapter 6)
DEFINITION
An adult family home (AFH) is a residential living unit certified by the Nebraska Department of Health and Human Services to provide full-time residence and minimal supervision and guidance to not more than three residents age 19 years or older. Services include room and board, standard furnishings, equipment, household supplies, laundry service, and facilities to ensure resident comfort.
An adult family home sponsor is an adult, 19 years or older, who manages and provides caretaker responsibilities in an adult family home. The sponsor accepts responsibility for maintaining the facility and meeting the needs of residents.
ADMISSION/RETENTION CRITERIA
The sponsor and the case manager ensure that no adult family home resident has health conditions or handicaps that require ongoing medical treatment and supervision other than self-administered medications and physician office visits. An adult who requires an occasional reminder to take medications may be appropriate for adult family home care.
ASSESSMENT AND CARE PLANNING PROCESS
Local case managers are responsible for ensuring that residents receive appropriate care. They may require a potential adult family home resident or his or her representative to present any documentation regarding medications necessary to make a decision about the amount of care required in that area. If the case manager questions the resident’s ability to self-administer medication, he or she may request an opinion from the resident’s physician. The case manager informs the provider (with the consent and input of the resident) of the resident’s background, medical history, special needs, and other relevant information, and helps the provider determine whether adult family care is appropriate. The case manager may require the provider to complete a written needs assessment and may develop a service plan with the resident if her or she has needs beyond those the sponsor can meet (e.g., transportation or adult protective services).
SERVICES