SPECIAL CARE UNITS IN NURSING HOMES AND ASSISTED LIVING FACILITIES FOR ALZHEIMER’S DISEASE AND OTHER FORMS OF DEMENTIA

You asked for information on states with regulations and standards for special care units (e. g. Alzheimer’s or dementia) in nursing homes and assisted living facilities.

A recent report by the U. S. Department of Health and Human Services (HHS) states that 44 states have specific regulatory provisions for facilities serving people with Alzheimer’s disease and other related dementias, an increase from 36 states in 2002 and 28 in 2000 (see Robert Mollica and Heather Johnson-Lamarche, State Residential Care and Assisted Living Policy: 2004, March 31, 2005; http: //aspe. hhs. gov/daltcp/reports/04alcom. htm).

These numbers include all states that have any kind of provisions for settings that serve people with Alzheimer’s or other dementias. We have not attempted to treat separately in this report special care units in nursing homes versus such units in assisted living facilities. Definitions of these terms throughout the states are not consistent, and a review of the relevant state laws and regulations does not easily lend itself to separating the two.

A National Conference of State Legislatures (NCSL) report indicates that in 2004, 36 states had dementia-specific training requirements for facility staff and 27 states had disclosure requirements (see Tara Lublin, NCSL Policy Brief, Quality Care for Persons with Alzheimer’s,” September 2005; http: //www. ncsl. org/programs/health/forum/alzheimerqc. htm).

Disclosure requirements generally means that a nursing home or assisted living facility with a special care unit (SCU) must disclose to a state licensing agency or a current or potential client, detailed information about the care offered in that unit.

Some states have established specific licensure or certification requirements for SCUs providing dementia-related care that address admission and discharge criteria, staffing, patient activities, physical layout and design, security, environmental issues, resident activities, medication, family involvement, and other issues. This report highlights some of these states.

The Alzheimer’s Association has issued a report “Dementia Care Practice Recommendations for Assisted Living Residences and Nursing Homes” (attached). The recommendations are based on the latest evidence in dementia care research and experience of care experts according to the report’s introduction. The report’s recommended care practices include comprehensive assessment and care planning, understanding behavior, and effective communication. The Alzheimer’s Association focused on three priority care areas which it believes can make a significant difference in an individual’s quality of life: food and fluid consumption, pain management, and social engagement.

Some states have disclosure requirements for facilities that advertise themselves as operating SCUs, or that care for people with Alzheimer’s disease or other dementias. Generally, these disclosure requirements direct the facility to disclose in writing how they are different from other facilities. The applicable state law or regulations may a require a description of the philosophy of care, admission and discharge criteria, services covered and the cost of care, special activities available, and differences in the environment from other facilities.

The Alzheimer’s Association has developed model legislation on this issue. A copy is attached.

California has a voluntary disclosure process for facilities offering special services for people with dementia. The state has developed a consumer’s guide that alerts family members to key questions that should be asked when seeking residential care for people with dementia. These include how the program meets the needs of people with Alzheimer’s, the facility’s pre-admission assessment process, the transition from the person’s current living arrangement to residential care, the care and activities that will be provided, staffing patterns, and special staff training.

Illinois’ “Alzheimer’s Special Care Disclosure Act” requires a facility offering to provide care to people with Alzheimer’s disease through an SCU to disclose to (1) the state agency responsible for licensing the facility or (2) a potential or actual client of the facility the following information in writing at the request of the agency or client:

1. the form of care or treatment that distinguishes the facility as suitable for with Alzheimer’s patients;

2. the facility’s philosophy concerning the care and treatment of those with Alzheimer’s;

4. the facility’s assessment, care planning, and implementation guidelines in the care and treatment of persons with Alzheimer’s;

5. the facility’s minimum and maximum staffing ratios, specifying the general licensed health care provider and the trainee health care provider to client ratios;

Noncompliance with these requirements can result in a fine of up to $ 500 for a first offense and $ 1,000 for a second or subsequent offense (§ 25).

In Minnesota, SCUs must submit written disclosure to people seeking residence or to their representatives, according to the NCSL report. The disclosure must include a statement of the unit’s philosophy; criteria for determining who may be admitted to the unit; a description of the process used for assessing and establishing the service plan; staff credentials; physical environment, including security features; programs and activities descriptions; availability of family support programs; and fee schedules (see HHS report, pp. 3-177 to 184).

Since 1997, Tennessee has had a law in place that requires facilities that advertise or market specialized care, treatments, or therapeutic activities for Alzheimer’s disease patients to disclose such services in writing. The disclosure must address, among other things, the program’s overall philosophy and mission statement, staff training and education, types and frequency of activities offered, charge structure and additional fees, and involvement with families and family support programs.

Texas requires a disclosure statement that describes the nature of the care or treatment provided, the pre-admission and admission processes, discharge and transfer policies, the planning and implementation of care, policies related to changes in residents’ condition, staff training on dementia care, the physical environment, and staffing (see HHS report, pp. 3-325 to 332).

Mississippi Health Department regulations allow a licensed nursing or personal care home to establish a separate Alzheimer’s /Dementia Care Unit (A/D Unit) for residents suffering from Alzheimer’s or a form of dementia (Mississippi Board of Health Regs. , § 101. 2). In order for an A/D Unit to receive this designation, the facility must have also been licensed as a nursing home or a personal care home (§ 101. 3).

Staffing. The regulations set the following staffing requirements for these special units in addition to those already in place for nursing homes or personal care homes.

1. Minimum requirements for nursing staff must be based on the ratio of three hours of nursing care per resident per 24 hours. Licensed nursing staff and nursing aides can be included in the ratio. Staffing requirements are based on resident census.

3. If the designated A/D Unit is not freestanding, licensed nursing staff may be shared with the rest of the facility for purposes of meeting the minimum staffing requirements.

4. Only staff trained in the care of persons with Alzheimer’s and other dementia can be assigned to the unit.

5. A minimum of two staff members must be on the A/D Unit at all times. (§ 102. 1).

Additional staffing regulations address staff orientation and in-service training.

Assessment and Individual Care Plans. Prior to admission to an A/D Unit, each individual must (1) receive a medical examination and assessment from a licensed physician or nurse practitioner, and (2) be assessed by a licensed practitioner whose scope of practice includes assessment of cognitive, functional, and social abilities, and nutritional needs. These assessments must include the individual’s family supports, levels of activities of daily living functioning, and level of behavioral impairment. The functional assessment must demonstrate that the individual is appropriate for placement in the unit (§ 103. 1).

Individual care plans must be developed by the staff for each resident. Whenever possible and appropriate, the family must be involved in the development of this plan (§ 103. 2, 103. 3).

Admission and Discharge Criteria. The following criteria must be followed for resident placement in an A/D Unit.

1. Only residents with a primary diagnosis of Alzheimer’s disease or dementia, whose needs can be met by the facility, can be admitted.

2. For licensed personal care homes, a person cannot be admitted or continue to reside in an A/D Unit if he does not meet the admission criteria for the facility unless otherwise exempted by applicable law.

3. The licensed facility must be able to identify at the time of admission and during continued stay, those residents whose needs for services are consistent with these rules and regulations, and those who should be transferred to an appropriate level of care (§ 103. 5).

Therapeutic Activities. Therapeutic activities must be provided to A/D Unit residents at various hours seven days per week and scheduled by a certified or qualified therapeutic recreation specialist, or a certified activity consultant. Leisure activities and self-care activities are also required (§ 104. 1).

Social Services. A licensed social worker, licensed professional counselor, or licensed marriage and family therapist must provide social services to both the resident and support to family members (§ 105. 1).

Nutritional Assessment. A nutritional assessment must be completed for each resident. If it addresses therapeutic nutritional needs, or is ordered by the residents’s physician, a registered dietician must plan a diet for the resident’s needs (§ 106. 1).

Physical Layout and Design. In addition to the physical plant standards for nursing homes and personal care homes, an A/D Unit must meet additional standards. These include:

1. a separate multipurpose room for dining, group, and individual activities, and family visits which is a minimum 40 square feet per resident but no smaller than 320 square feet;

2. a secured area for medication, storage, and workspace;

3. a secure, exterior exercise pathway that allows residents to walk on a level, non-slip path;

4. high visual contrast between floors and walls and doorways and walls in resident use areas;

5. adequate and even lighting that minimizes glare and shadows;

6. service sections (e. g. kitchen) that are removed from resident areas;

7. security controls on all entrances and exits; and

8. exterior fencing (§ 107. 1).

1. provide freedom of movement for the residents to common areas and to their personal spaces;

3. label or inventory all residents’ possessions;

4. provide comfortable chairs;

5. encourage and assist residents to decorate and furnish their rooms with personal items;

6. individually identify residents’ rooms to help them with recognition;

7. keep corridors and passageways through common use areas free of objects which may cause falls; and

8. only use a public address system for emergencies (§ 107. 2).

Rhode Island’s “Assisted Living Residence Licensing Act” (Rhode Island Statutes, § 23-17. 4-2 to 23-17. 4-31) defines “Alzheimer’s dementia special care unit or program” as a distinct living environment within an assisted living residence that has been physically adapted to accommodate the particular needs and behaviors of those with dementia. The unit provides increased staffing, therapeutic activities designed specifically for those with dementia, and staff trained on an ongoing basis on the effective management of the physical and behavioral problems of those with dementia. The residents of the unit or program have had a standard medical diagnostic evaluation and have been determined to have a diagnosis of Alzheimer’s dementia or another dementia (§ 23-17. 4-2(3)).

“Dementia Care” License Requirement. Rhode Island law requires a license in order to operate an assisted living residence (§ 23-17. 4. 4). The Department of Health must establish requirements for a basic license that apply to all assisted living residences. In addition, it must establish additional licensing levels, including “dementia care” licensure. A dementia care license is required when one or more residents have a physician’s diagnosis of dementia or an assessment, as required by law, indicating dementia-related functional impairments, and meet any of the following:

1. safety concerns due to evidence of wandering or other dementia behaviors;

2. inappropriate social behaviors that repeatedly infringe on others’ rights;

3. inability to self preserve due to dementia; and

4. a physician’s recommendation that the resident needs dementia support consistent with this level. A dementia care license is also needed if the residence advertises or represents special dementia services or if the residence segregates residents with dementia.

Licensing requirements for the “dementia care” level include (1) staff training and requirements specific to dementia care as determined by the health department; (2) an RN on staff and available for consultation at all times; and (3) a secure environment appropriate for the resident population. These are in addition to the requirements for the basic assisted living license.

Assessments. Before admitting a resident, the facility administrator must have an RN conduct a comprehensive assessment of the resident’s health, physical, social, functional, activity, and cognitive needs and preferences. The assessment is used to determine if the residence can meet these needs and preferences. The assessment must be reviewed and updated periodically and each time a resident’s condition changes significantly (§ 23-17. 4-15. 6).

Special Care Unit Disclosure. The law requires any assisted living residence which offers services to residents with Alzheimer’s disease or other dementia in an SCU to disclose the type of services provided, in addition to those services required for all assisted living residences. The disclosure must be made to the licensing agency and to the person seeking admission to the special care unit. The disclosure must address the unit’s overall philosophy; pre-occupancy, occupancy and termination of residence; assessment, service planning and implementation; staffing patterns and training; physical environment; resident activities; family role; and program costs (§ 23-17. 4-16. 2).

According to NCSL, about 36 states have dementia or Alzheimer’s –specific training requirements for facility staff.

A recently enacted state law requires the state’s Office of Long-Term Care to adopt regulations to implement an aide training program for all long-term care facilities in the state. These regulations must require that the training programs provide at least 90 clock hours of training that include at least 15 clock hours of training specific to Alzheimer’s and related dementia. The law specifies that the training programs take effect only if funding is available. (HB 1442, 2005 Session of the Arkansas General Assembly).

Indiana requires a minimum six hours of dementia-specific training for staff caring for residents in dementia-specific units. The training must be completed within six months of employment, with three hours annually required thereafter.

Special care unit supervisors and direct care staff must be trained in dementia care. Direct care staff must receive four hours of training within the first month of employment and four hours a year thereafter. Training is required in the following areas: an explanation of Alzheimer’s disease and related disorders, assistance with activities of daily living, problem solving with challenging behaviors, and communication skills (see HHS report, pp. 3-177 to 184).

Missouri law requires the state’s Division of Aging to establish minimum dementia-specific training requirements for employees involved in the delivery of care to persons with Alzheimer’s disease or related dementias. This requirement includes employees of skilled nursing, intermediate care, and residential care facilities; agencies providing in-home care services authorized by the division; adult day care programs; independent contractors providing direct care to person’s with Alzheimer’s disease or related dementias; and the Division of Aging. This training must be incorporated into new employee orientation and ongoing in-service curricula for all covered employees (Missouri Revised Statutes, Sec. 660. 050. 8).

For employees providing direct care to people with Alzheimer’s disease or related dementias, the training must include an overview of Alzheimer’s disease and related dementias, communicating with persons with dementia, behavior management, promoting independence in activities of daily living, and understanding and dealing with family issues. (§ 660. 050. 8(1)).

Training for employees who do not provide direct care for, but may have daily contact with such persons, must include an overview of dementias and communicating with persons with dementia. (Sec. 660. 050. 8. (2)).

A new Oklahoma law (SB 950, effective November 1, 2005), directs the state Department of Health to require the training for certified nurse aides to include a minimum of 10 hours in the care of Alzheimer’s patients.

In Texas, managers or supervisors of facilities that market or advertise services to persons with Alzheimer’s disease must be at least age 21; have an associate’s degree in nursing, health care management, or a related field; a bachelor’s degree in psychology, gerontology, nursing, or a related field; or have at least one year of experience working with people with Alzheimer’s. Administrators in special care facilities must have a college degree (in psychology, social work, counseling, gerontology, nursing or a related field); an associate’s degree in nursing or health care management; or one year of experience working with persons with dementia and complete six hours of continuing education in dementia care.

1. four hours of dementia specific orientation on basic information about the causes, progression , and management of dementia;

2. 16 hours of on-the-job supervision with 16 hours of orientation providing assistance with activities of daily living, emergency and evacuation procedures, and managing dysfunctional behavior; and

3. 12 hours of annual in-service training regarding Alzheimer’s disease covering assessing resident capabilities and developing service plans; promoting dignity, independence, and privacy; planning and running activities; communicating with families; resident rights and principles of self-determination; care of persons with physical, cognitive, behavioral, and social disabilities; common psychotropic drugs and side effects; and local community resources (HHS report, pp. 3-330-331).


November 10, 2005		2005-R-0839
SPECIAL CARE UNITS IN NURSING HOMES AND ASSISTED LIVING FACILITIES FOR ALZHEIMER’S DISEASE AND OTHER FORMS OF DEMENTIA

By: John Kasprak, Senior Attorney