Topic:
MEDICAL CARE; DISEASES; ASSISTED LIVING; NURSING HOMES; HOME CARE SERVICES; LEGISLATION;
Location:
ASSISTED LIVING;

OLR Research Report


June 29, 2006

 

2006-R-0422

ASSISTED LIVING REGULATION

By: Helga Niesz, Principal Analyst

You asked how assisted living is regulated in Connecticut and in several surrounding states.

SUMMARY

States define “assisted living” in different ways, so direct comparisons are not easy. Assisted living is primarily for people age 55 or older who do not need full nursing home services, but require some health care, nursing, or assistance with activities of daily living (ADLs), such as dressing, eating, bathing, toileting, walking, or transferring from a bed to a chair. Assisted living can be provided in an apartment, as is required in Connecticut, or in other settings such as a board and care home that can go by different names in different states and usually provide just a room — sometimes shared by two or more residents. Facilities can be freestanding or part of a campus that incorporates other levels of care, such as independent living or nursing homes. Most states license and regulate the facilities where the services are provided and very few, like Connecticut, license the agencies that provide the services, but not the facilities themselves. Some states have multi-tier licensing to accommodate different size facilities or different levels of care.

In Connecticut, assisted living facilities (the buildings) are not licensed, but they have to meet the Department of Public Health (DPH) definition of a “managed residential community (MRC)” and provide certain “core services” in order to be allowed to offer assisted living services there. But the agencies that provide the services, assisted living service agencies (ALSAs), must be licensed with DPH. An MRC facility can either provide the services itself and become licensed as an ALSA or contract with a separate ALSA to provide the services. Another type of entity, residential care homes (RCH), is not included in Connecticut's MRCs but in other states, these entities offer assisted living. State legislation in 2006 requires assisted living facilities, as well as nursing homes and other types of facilities that have special Alzheimer's units, to make certain disclosures to consumers and provide extra training to their staff.

Massachusetts, New York, and Rhode Island license the facilities themselves. Massachusetts requires assisted living residences to be certified by the state. New York law generally requires any residence that holds itself out as providing assisted living to be licensed as an assisted living residence. It must also hold a license as an adult care home or an enriched housing program. Rhode Island has several licensing categories that depend on residents' ability to save themselves in case of fire and their need for medication administration. All three states have additional requirements for facilities that have Alzheimer's or dementia special care units.

The most recent available comprehensive 50-state report on assisted living regulation, “Update: State Residential Care and Assisted Living Policy 2004, by Robert Mollica et al. is available at: http://aspe.hhs.gov/daltcp/reports/04alcom.htm.

OLR Report 2005-R-0839 provides information on special rules and disclosures for Alzheimer's and dementia special care units.

CONNECTICUT

Although people informally refer to an “assisted living facility,” Connecticut law does not use the term as other states do. Instead, the state regulates “assisted living services agencies” (ALSAs) that provide the services. Connecticut statute defines an ALSA as an institution that provides, among other things, nursing services and assistance with ADLs to a population that is chronic and stable (CGS 19a-490). In Connecticut, only a state-licensed ALSA can provide assisted living services. And the ALSA can provide these services only at a “managed residential community” (MRC), which is not licensed as such but must meet the definition of an MRC in DPH regulations and provide certain core services. An MRC can be a number of different settings, such as apartments, continuing care retirement communities, or other structured settings as long as the facility itself provides the basic core services to qualify as an MRC.

DPH regulations define assisted living services as nursing services and assistance with ADLs provided to clients living in a managed group environment (i.e., an MRC) that has support services that encourage clients primarily age 55 or older to maintain a maximum level of independence. The living units must include a full bathroom within the unit, but they need not offer food storage and preparation equipment, only access to it (Conn. Agency Regulations, 19-13-D105).

The MRC must provide the following core services:

1. three regularly scheduled meals per day,

2. regularly scheduled housekeeping and laundry service for personal laundry and linens,

3. regularly scheduled transportation for certain needs (public bus transportation does not qualify as the only mode of transportation),

4. maintenance service for the living units, and

5. social and recreational programs.

In addition, the MRC must provide 24-hour security, emergency call systems in each living unit, washers and dryers, and common use space big enough to accommodate 50% of the tenant population.

Each ALSA must have bylaws and a governing authority, whose responsibilities must include developing a quality assurance program and other policies and programs.

The ALSA must have a designated office on the MRC site. Each ALSA must establish written criteria for admission to assisted living services, and these criteria may not impose unreasonable restrictions that screen out clients whose needs may be met by the agency. Each ALSA must develop written policies for discharges of clients from the agency and define categories for discharges, including change in the client's condition, routine discharges when goals of care have been met and the client no longer needs the services, emergency discharge, discharge for financial reasons, and premature discharge. Each ALSA must establish a written complaint procedure.

The ALSA must have a written clients' bill of rights and responsibilities and provide and explain it to each client at the start of services. The regulations also specify the types of client health records the ALSA must maintain. They require the ALSA to have a quality assurance committee and specify its duties.

PA 06-195 requires assisted living facilities, as well as nursing homes and other types of facilities that have special Alzheimer's units, to make certain disclosures to consumers and provide extra training to their staff. The relevant text of the OLR summary is enclosed and available at http://cgalites/2006/sum/2006SUM00195-R01SB-00317-SUM.htm.

Staffing

Each MRC must employ an on-site service coordinator who has a human services background and prior supervisory or management experience. His responsibilities include making sure services are made available to the clients, helping tenants meet their needs, establishing collaborative relations with other service agencies and community resources, establishing a tenant council, serving as a liaison with the ALSA, and ensuring that a tenant information “system” is in place.

The ALSA must have written personnel policies, including an orientation policy and an in-service education policy, with an annual average minimum of one hour bimonthly of in-service education for each assisted living aide. In general, staff training varies based on the type of license.

The ALSA must have written policies regarding delivery of nursing services. It must have a supervisor, who must be a registered nurse and whose responsibilities include coordinating and managing all nursing and assisted living aide services rendered to the tenants. The supervisor must be on site (1) at least 20 hours per week for every 10 or less full-time or full-time equivalent licensed nurses (RNs, LPNs) or assisted living aides or (2) at least 40 hours per week for every 20 or less full-time or full-time equivalent licensed nurses or assisted living aides. In addition, there must be at least 10 hours per week of licensed nurse staffing for each additional 10 or less full time or full time equivalent assisted living aides. The ALSA must also designate an RN to be on call 24 hours a day.

Residential Care Homes in Connecticut

Connecticut also has residential care homes (RCHs) previously known as “homes for the aged”), which are licensed and heavily regulated by DPH, but do not fall under the state's definition of assisted living, as similar entities do in some other states. They provide a single or double furnished room and shared common areas such as a lounge or recreation area. They provide residents with three meals a day in a common dining area and some limited personal services, but no nurse supervision. They can serve both elderly people and younger people with physical or mental disabilities, and provide some help with personal care that is not as extensive as assisted living. They were recently authorized by law to train personnel for medication administration.

MASSACHUSETTS

Massachusetts has a certification system for assisted living overseen by the Executive Office of Elder Affairs (Mass. Gen. Laws Ch. 19D 3). An “assisted living residence” is any for-profit or nonprofit entity, however organized, that (1) provides room and board; (2) provides personal care services for three or more unrelated adults, directly by employees or through arrangements with another organization; and (3) collects payments or third party reimbursements to pay for assistance with ADLs.

The regulations (651 CMR 12.00 et seq.) require an assisted living residence to contain only single or double units with lockable entry doors. New construction must provide a private bathroom for each unit (there are some exceptions for older buildings and opportunities for waivers from this requirement). The facility must also provide, at a minimum, either a kitchenette or access to cooking capacity and meet relevant health, fire and safety codes.

The residence must provide certain services, including supervision of and help with ADLs and “instrumental” ADLS, including, at a minimum, bathing, dressing, walking, laundry, housekeeping, socialization, and similar tasks. Aides can help residents self-administer medications if necessary. The residence must have 24-hour on-site staff and provide each resident with a personal emergency response system if their service plan requires it. It must provide at least one and up to three regularly scheduled meals a day. It may arrange to provide ancillary health services (such as skilled nursing care) in the residence through licensed health professionals, but may not use the assisted living staff for these services.

The residence must (1) develop and maintain an individualized service plan for each resident and review the plans at least once every six months, (2) establish a quality assurance program, (3) maintain individual resident records and personnel records, and (4) provide a written residency agreement to the resident.

The facilities can designate special care units for people with Alzheimer's or other cognitive impairments and the regulations contain provisions for these special care services.

The regulations specify residents' rights and require the facility to post a written notice prominently containing them and disclose them to residents and prospective residents. They also specify what the residency agreement must contain.

The Executive Office of Elder Affairs conducts compliance reviews of residences every two years; the regulations specify what the reviews must include.

Staffing

The assisted living residence manager must have demonstrated administrative experience, supervisory and management skills, and a bachelor's degree or equivalent experience in human services, housing, or nursing home management. The residence must also have a service coordinator who is qualified by training and experience. Other staff must be sufficient to meet the 24-hour per day scheduled and unscheduled needs of the residents and to respond promptly and effectively to emergencies. Special care units must have sufficient staff qualified by training and experience awake and on duty at all times to meet the 24-hour per day needs of the residents and respond to emergencies. The residence must conduct a quarterly assessment of the appropriateness of staffing levels.

The regulations set training requirements, including seven hours of orientation (two hours of which must be devoted to dementia and cognitive impairments and an additional hour on self-administration management must be provided to staff who provide personal care services). Staff in special care units must receive seven additional hours of training related to special care needs. The regulations also require at least 10 hours a year of ongoing education and training (with two of these hours spent on the specialized needs of residents with Alzheimer's or related dementia and an extra four hours on these topics for staff actually working in a special care unit).

Staff providing personal care services must receive 54 hours of training before providing the services (including 20 hours specifically covering personal care services).

The regulations prohibit anyone convicted of a felony from working in an assisted living residence.

Massachusetts' assisted living regulations are available at: http://www.massalfa.org/docs/al_regulations.html.

NEW YORK

The “Assisted Living Reform Act,” passed in 2004 (New York Laws, Article 46-B, enclosed) defines “assisted living residence,” requires licensure of facilities fitting the definition by the Department of Health (DOH), requires a written residency agreement that contains consumer protections, and lists residents' rights and responsibilities and requires the facility to disclose them to the resident. Any residence that holds itself out as assisted living must obtain a license as an assisted living residence. The law specifies what the residency agreement must contain and requires the facility to provide as part of its marketing a consumer information guide developed by the DOH.

The law defines “assisted living” and “assisted living residence” as an entity that provides or arranges for housing, on-site monitoring, and personal care or home care services, either directly or indirectly, in a homelike setting to five or more unrelated adults. (There are some exclusions for entities regulated under other statutes). To qualify, the facility must also provide daily food service, 24-hour on-site monitoring, case management services, and an individualized service plan for each resident. The law specifies that the operator must provide each resident with considerate and respectful care and promote the resident's dignity, autonomy, independence, and privacy in the least restrictive and most homelike setting commensurate with the resident's preferences and physical and mental status. The facility must conduct an initial pre-admission evaluation of prospective residents to determine whether or not they are appropriate for admission.

Assisted living residences must also hold a license as an adult care home (similar to Connecticut's RCHs) or an enriched housing program (more like our apartment-style assisted living). In addition, those operators who wish to provide a broader range of services (known as 'aging in place' services), must obtain an Enhanced Assisted Living Certificate from the DOH. This certificate allows the facilities to maintain people who are chronically “chairfast” and unable to transfer without someone else's help, are dependent on medical equipment or have other special needs. Depending on the services they offer, they must also be licensed as or contract with a home care or home health care agency.

Facilities seeking to provide enhanced services to special needs residents, such as those with Alzheimer's or dementia, must obtain a Special Needs Certificate from the DOH.

Staffing

Staffing requirements can vary depending on the level of service. Adult care homes must have a case manager and staffing sufficient to provide the care residents need. The state offers training to adult care home operators and staff, including medication administration training. In general, training requirements vary based on the license type.

The text of the law, more details, and related materials can be found at: http://www.health.state.ny.us/facilities/assisted_living/.

RHODE ISLAND

Rhode Island's “Assisted Living Residence Licensing Act” (Rhode Island Statutes, 23-17.4-2 to 23-17.4-31) requires licensing of “assisted living residences” by the Department of Health and defines them as a publicly or privately operated residence that provides (directly or indirectly through contracts or arrangements) personal assistance to meet the resident's changing needs and preferences, lodging, and meals to two or more unrelated adults (excluding certain types of entities regulated by other departments). Residences include sheltered care homes and board and care residences or other facilities that provide assisted living services.

The department has several categories of licenses, which depend to some extent on (1) whether the resident is capable of self-preservation in a fire or other emergency and (2) his medication administration needs. A residence can have areas within the facility that are licensed separately.

The law also requires a special dementia care license when one or more residents have a physician's diagnosis of dementia or an assessment indicating dementia-related functional impairments, and there are safety concerns due to evidence of wandering or other dementia behaviors; the person exhibits inappropriate social behaviors that repeatedly infringe on others' rights or is unable to self preserve in an emergency due to dementia; and a physician recommends 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 segregates residents 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. 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. The law requires any assisted living residence that offers services to residents with Alzheimer's disease or other dementia in a special care unit to disclose the type of services provided.

More details on Rhode Island and other states' rules concerning Alzheimer's and dementia special care units in assisted living and nursing homes can be found in OLR Report 2005-R-0839, enclosed.

Staffing

The facility must have an administrator certified by the Department of Health and it must have 24-hour awake staff. Nurse review is needed for medication licensure. A registered nurse must visit the facility at least every 30 days to evaluate residents' health status and monitor medication regimen.

Staffing levels vary depending on licensing level. A dementia special care unit must provide 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 unit must have an RN on staff and available for consultation at all times. Training levels vary depending on service types.

STATE-BY-STATE COMPARISON OF ASSISTED LIVING SERVICES

Table 1 compares the highlights of assisted living regulation in the four states.

TABLE 1: ASSISTED LIVING REGULATION IN CONNECTICUT, MASSACHUSETTS,
NEW YORK, AND RHODE ISLAND

Requirement

CT

MA

NY

RI

Licensing

ALSA licensed by DPH, no licensing for MRC, but must meet certain requirements in regulation

Certification of facility by Executive Office of Elder Affairs

Licensing as “assisted living residence” for entities holding themselves out as such, with several licensing levels. Must also be licensed as adult care home or enriched housing program. Special needs certificate required for Alzheimer's or dementia units

Licensing of facility by DOH at several levels, based on self-preservation ability and medication administration status. Also special license for dementia care

Accommodation

Private apartments with full bath and access to food storage and preparation equipment

Only single or double units with lockable doors and kitchenettes or access to cooking capability, with exceptions for older buildings

Varies, can be shared rooms or private apartments, depending on other licenses facility has

Can be rooms with no more than 2 beds. Bath and toilets can be shared by people in more than one room

Staffing

ALSA registered nurse supervisor must be on-site minimum number of hours depending on how many nurses or assisted living aides she supervises; registered nurse must be on call 24 hours. No other set staffing ratios. MRC must have service coordinator

Facility must have service coordinator and “sufficient” 24-hour on-site staff

Must be sufficient to meet residents' needs. Varies for different types of facilities

Facility administrator must be certified by DOH. Must have 24-hr. awake staff. Nurse review needed for medication licensure; registered nurse must visit facility at least every 30 days to evaluate residents' health status and monitor medication regimen

Staff Training

Specific requirements for Alzheimer's or dementia units (see below)

7 hours orientation; 54 hours of training for personal care staff, and additional in-service training

Varies depending on license type

2 hrs. orientation training. Direct personal care employees receive 10 hours of orientation

Service agreement content specified

Yes

Yes

Yes

Yes

Disclosures

ALSA must provide patients with a bill of rights (see below for new special care unit disclosures).

Must post and disclose residents' rights

Must provide residency agreement and disclosures to resident. Must post residents' rights

Residents' rights must be posted and disclosed.

Additional Requirements for Alzheimer's or Dementia Special Care Units

Yes, disclosures and 8 hours dementia-specific training, followed by 3 hrs. annually and 2 hrs. training annually in pain management, PA 06-195.

Must have sufficient trained staff to meet residents' 24-hr. needs. Seven additional hours of training and an extra four hours of on-going training on related topics

Yes. Must obtain special license, submit a special needs plan, and make certain disclosures. Department of Health sets standards and training requirements.

Yes. Special license and additional staff training. Disclosures concerning Alzheimer's special care units are also required and listed in law.

Criminal background rules

No requirement

Personal care staff cannot be felons

Not specified

All new employees subject to criminal records checks through state or local police

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