MEMORY CARE FACILITIES

You asked whether other states have specific regulatory requirements for assisted living (AL) facilities that offer “memory care,” such as minimum staff-to-resident ratios and training.

By “memory” care, we believe you are referring to care for individuals suffering from Alzheimer's disease or who have related diagnoses.

A 2007 compendium of state assisted living regulations compiled by the National Center for Assisted Living suggests that states exercise a wide range of regulatory control over assisted living facilities that offer care to individuals with Alzheimer's or other types of dementia. In some states, staff working in facilities that have special care units must receive extensive initial training, usually within the first few months of employment, and attain continuing education (CE) credits; in others, little, if any training or CE is required.

While most, if not all states require assisted living facilities to have, staff on a 24-hour basis sufficient to meet the expected and unexpected needs of their residents, only a few have staffing requirements specific to residents with memory problems. For example, in South Dakota one caregiver must be on secured units at all times. Utah requires the same, but the staff must have documented training. Illinois, which appears to have the most extensive training expectations of all the states, requires its assisted living facilities' Alzheimer units to provide 1.4 hours of services per resident per day.

Many states require assisted living facilities that advertise themselves as serving this population, including those that maintain separate units within a larger facility, to disclose the types of care provided and other information, often as a condition of licensure.

Table 1 provides summary of state staffing and training requirements for AL facilities providing memory care services.

Table 1: State Regulation of Memory Care Provided in Assisted Living (AL) Facilities

*State*	*Minimum Staffing Requirements Specific to Alzheimer's*	*Minimum Training Requirements for Alzheimer's Care*	*Other Alzheimer's-Related Provisions (e.g., disclosures)*
California	Nothing specific for dementia care but require “awake” night staff for facilities caring for 16 or more residents.	All staff caring for residents with dementia must receive special training. Care staff in facilities advertising that they specialize in dementia care must receive six hours of dementia care orientation within four weeks of employment and at least eight hours of in-service training annually. Generally, administrators must complete 40 hours of CE every two years, with eight of these in Alzheimer's and dementia training.	Facilities may admit residents diagnosed with dementia if certain requirements met, such as annual medical assessment, adequate supervision, and enhanced physical plan safety
Colorado	Staffing must be adequate to meet residents' needs, with at least one trained staff member in secured unit at all times. In adult congregate living, 1:6 ratio of staff to residents	Staff must be trained to meet residents' needs.	Secured units allowed and additional requirements in regulation. Before it can provide direct care, facility must provide adequate training on specific needs of population (e.g., Alzheimer's).
Connecticut	Staffing must be adequate to meet residents' needs.	All licensed and registered direct care staff must receive Alzheimer's and dementia-specific training annually that includes (1) at least eight hours of dementia training to be completed within six months of employment, and at least three hours of ongoing training annually and (2) annual training of not less than two hours in pain recognition and administration of pain management techniques.

*State*	*Minimum Staffing Requirements Specific to Alzheimer's*	*Minimum Training Requirements for Alzheimer's Care*	*Other Alzheimer's-Related Provisions (e.g., disclosures)*
Delaware	None specified	Staff must be adequately trained, certified, and licensed to meet residents' requirements	Facilities offering specialized care for people with memory impairment must disclose policies and procedures describing the form of care provided, in addition to what is otherwise required by law and regulation.
District of Columbia	None specified	None specified
Florida	24-hour staff required for facilities advertising special care units for Alzheimer's or related disorders. Number of staff dependent on number of residents	Staff in special care units must complete 8-hour approved training course and four hours CE per year	Facilities advertising special care units must have physical environment providing for residents' safety and welfare, and they must offer activities specifically designed for these residents.
Georgia	None specified	None specified
Hawaii	None specified	None specified
Idaho	None specified	If facility admits and retains residents with dementia diagnosis, staff must be trained in various areas. If resident with diagnosis is admitted and staff does not possess training, he or she must be trained within 30 calendar days. In the interim, facility must meet resident's needs.	Interior and exterior environments must be secure and safe.

State

Minimum Staffing Requirements Specific to Alzheimer's

Minimum Training Requirements for Alzheimer's Care

Other Alzheimer's-Related Provisions (e.g., disclosures)

Illinois

Must provide 1.4 hours of services per resident per day; at least one staff member must be awake and on duty at all times

Manager or supervisor of Alzheimer's program must be at least 21 years old and have (1) college degree with documented course work in dementia care, plus one year of experience working with people with dementia or (2) at least two years of management experience with this population. This person must also complete six hours of annual CE in dementia care.

All staff providing care must receive four hours of dementia-specific orientation (with specific areas of study) before assuming job responsibilities.

Direct care staff must receive 16 hours of on-the-job supervision and training (in specified areas) within first 16 hours of employment following orientation. They must also complete 12 hours of annual in-service education regarding Alzheimer's and other related disorders

*State*	*Minimum Staffing Requirements Specific to Alzheimer's*	*Minimum Training Requirements for Alzheimer's Care*	*Other Alzheimer's-Related Provisions (e.g., disclosures)*
Indiana	Nothing specified. (General requirement: (sufficient in number, qualification, and training to meet the needs of residents. Number dependent on number of residents.)	Staff members who have contact with residents in dementia units must have an additional minimum of six hours of dementia-specific training within six months, and three hours of training annually thereafter.	If facility locks, secures, segregates, or provides special program or unit for residents with Alzheimer's or related disorders and advertises that it offers a special care unit, it must provide written disclosure statement. This must be filed annually with state Division of Aging and made available to anyone. Facilities required to submit these disclosures must designate director of the unit.
Iowa	Dementia-specific AL program must have one or more staff on duty 24 hours a day in the proximate area.	Dementia-specific education or training is required for all employees. In dementia-specific AL program, training includes minimum of six hours of relevant education and training before, or within 90 days of, employment. Specific topic areas must be covered. Six hours CE annually.	Program must be designed to meet needs of tenants with dementia. Service plans must include planned and spontaneous activities based on tenant's abilities and personal interests. Programs must have means to disable or remove locks on entrance doors if they present danger to tenant's health or safety.
Kansas	None specified	In facilities that admit residents with dementia, in-service education must be provided.
Kentucky	Nothing specified, but 24-hour staff required for all facilities	Nothing specified but AL facility must maintain a description of dementia-specific staff training provided, including content, number of offered and required hours of training, schedule, and staff required to complete the training.	AL facility must provide any “interested person” with a description of any special programming, staffing, or training if it markets itself as providing such.

*State*	*Minimum Staffing Requirements Specific to Alzheimer's*	*Minimum Training Requirements for Alzheimer's Care*	*Other Alzheimer's-Related Provisions (e.g., disclosures)*
Louisiana	None specified	None specified	Facilities accepting residents with dementia or at risk of wandering must provide enclosed area adjacent to facility for them.
Maine	None specified, but general regulations require minimum ratios depending on time of day	Pre-service training is required for staff working in Alzheimer's or dementia units.	Facilities with Alzheimer's or dementia care units must offer special weekly activities, such as gross motor, self-care, and social skills. Regulations require specific physical plant design for Alzheimer's units. Facilities with these units must make certain disclosures.
Maryland	None specified but 24-hour staffing required for all AL as long as residents in facility.	Minimum of five hours of training on cognitive impairment and mental illness is required within first 90 days of employment. Training must be designed to meet needs of program's residents. At least two hours of ongoing training must be provided annually for those involved with personal care; otherwise, one hour is required. Managers must complete approved 80-hour training program, which must cover cognitive impairment and dementia.	At licensure and renewal, AL program with Alzheimer's special care unit or program must send Department of Mental Health and Hygiene written description of such. It must also submit disclosure statements if it has these units or entire facilities caring for these residents. Specific information must be disclosed to family or other responsible parties before admission, on request. Description of unit or program must include statement of philosophy or mission, staff training and job titles, and any services or training that are beyond what is offered by regular AL program.

*State*	*Minimum Staffing Requirements Specific to Alzheimer's*	*Minimum Training Requirements for Alzheimer's Care*	*Other Alzheimer's-Related Provisions (e.g., disclosures)*
Massachusetts	None specified but 24-hour staffing required.	All staff must receive at least two hours of training on dementia and cognitive impairment. Manager and services coordinator must receive additional two hours of training on these topics. All staff, as part of ongoing training, must receive at least two hours per year of training on these topics.	AL residences can designate a distinct part of entire facility as a special care residence to address residents' specialized needs, including those needing help with care direction due to cognitive or other impairments.
Michigan	None specified	None specified, but direct care staff must be trained and competent to meet needs of residents in their care.	Two types of licensed facilities offer AL services: Homes for the Aged and Adult Foster Care. If either advertises or markets itself as providing specialized care, prospective residents, residents, or surrogate decision-makers must receive written description of care and services that contains specified items.
Minnesota	None specified, but general 24-hour awake staff must be provided.	Supervisors and direct care staff must be trained in dementia care, with specified topic areas. Licensee must provide to consumers written or electronic description of training program, categories of employees trained, frequency of training, and basic topics covered.	Housing with Services that provide special program or unit for residents with Alzheimer's or related disorders and advertise themselves as such are considered “special care units.” Before entering into care agreements, these units must provide written disclosure (details specified) to (1) the health commissioner, if requested, (2) state ombudsman for older residents, and (3) each person (or authorized representative) seeking placement.

State

Minimum Staffing Requirements Specific to Alzheimer's

Minimum Training Requirements for Alzheimer's Care

Other Alzheimer's-Related Provisions (e.g., disclosures)

Mississippi

None specified

Facility must provide orientation, including specific topics, to all new employees assigned to Alzheimer's or dementia units.

Ongoing in-service training must be provided to all direct-care staff on a quarterly basis, which must include training on at least three of eight specified topics.

Regulations for Alzheimer's and dementia care units adopted in 2001 apply to licensed nursing homes and personal care homes and are in addition to other rules and regulations for licensed AL facilities. For example, AL facilities (either Personal Care Homes (PCH)—Residential Living or PCH—Assisted Living) must have registered or licensed practical nurse present on all shifts, but if Alzheimer's/dementia care unit not freestanding, nursing staff can be shared with rest of facility.

AL facilities may only house people with up to Stage II Alzheimer's.

Specific physical plant design requirements apply.

State

Minimum Staffing Requirements Specific to Alzheimer's

Minimum Training Requirements for Alzheimer's Care

Other Alzheimer's-Related Provisions (e.g., disclosures)

Missouri

None specified

Staff of all long-term care facilities providing care to individuals with Alzheimer's disease or other dementias must meet statutory dementia-specific orientation and ongoing training requirements.

Residential Care Facilities (RCF) staff involved in delivering care to individuals with Alzheimer's or related disease must receive specific training covering five areas specified in regulation. Non-direct care staff who have contact with these residents must also receive training, covering two areas specified in regulation.

All dementia-specific training must be incorporated into each facility's new employee orientation and ongoing in-service training.

Two types of facilities licensed to provide AL services: Residential Care Facilities (RCF) and Assisted Living Facilities (ALF).

State

Minimum Staffing Requirements Specific to Alzheimer's

Minimum Training Requirements for Alzheimer's Care

Other Alzheimer's-Related Provisions (e.g., disclosures)

Montana

None specified. Category 3 facilities must have dressed and awake staff during the night.

Direct care staff must comply with regular training for Category A & B –endorsed facilities (see next column) and received additional, documented training in eight specified areas, including techniques for minimizing challenging behaviors and promoting residents' dignity.

Administrator of Category C -endorsed facility must have three or more years experience working in geriatrics or caring for residents with disabilities in a licensed facility or approved equivalent. Must also hold nursing home administrator license or have completed equivalent course of study.

At least half of 16 hours of CE required for Category C administrators must pertain to caring for people with severe cognitive impairment.

AL facilities have three categories of licensing “endorsements” depending on the care level required, with A being more independent and C being the least (i.e., people with severe cognitive impairment rendering them incapable of expressing needs or making basic decision)

Category C- endorsed facilities require additional administrator and staff training and specialized accommodations. Each facility providing this category of services must make available to resident's guardian or family member a list of nine items ranging from additional fees to facility's overall philosophy for meeting the special needs of these residents.

Nebraska

None specified

Direct care staff must be trained in facility or unit's philosophy and approaches to providing care and supervision for people with Alzheimer's and other areas.

Facilities must assess each resident to identify his or her abilities and needs, provide specially trained staff, prepare service agreements, and provide physical environment that conforms to and accommodates the special needs.

State

Minimum Staffing Requirements Specific to Alzheimer's

Minimum Training Requirements for Alzheimer's Care

Other Alzheimer's-Related Provisions (e.g., disclosures)

Nevada

At least one member of staff must be awake and on duty at all times in Alzheimer's unit.

Each employee of facility providing any form of dementia care must successfully complete, within 40 hours of beginning employment, at least two hours of training in care provision.

Eight hours training required for staff supervising residents with Alzheimer's disease within three months of employment.

All staff must complete eight hours per year of CE related to facility's population.

If employee is licensed or certified by an occupational licensing board, at least three hours of required CE must be in providing care to residents with dementia and must be completed on or before the first anniversary of employment.

Administrators of Alzheimer's facilities must have three years' experience in caring for residents with this or related diagnosis.

New Hampshire

None specified

None specified but licensees must provide staff with training that meets residents' needs

State has two levels of AL licensure: AL Residence—Supported Residential Health Care (greater care needs) and AL Residence—Residential Care—latter may not have locked or secure buildings

*State*	*Minimum Staffing Requirements Specific to Alzheimer's*	*Minimum Training Requirements for Alzheimer's Care*	*Other Alzheimer's-Related Provisions (e.g., disclosures)*
New Jersey	None specified. “Sufficient” standard applies to all facilities. At least one awake personal care assistant and one additional employee must be on site 24-hours per day, with an RN available 24 hours.	All staff required to have mandatory training for care of residents with Alzheimer's and related dementia conditions. Personal care assistants must complete at least 20 hours of CE every two years in AL concepts and related topics, including cognitive and physical impairment and dementia	Facilities that advertise as having an Alzheimer's unit must establish written policies and procedures for the unit; establish criteria for unit admissions and discharge; have staff attend mandatory training program; compile staffing information; and provide, when requested, a list of activities directed toward these residents and safety policies and procedures.
New Mexico	None specified but minimum staff-to-resident ratio is one awake staff to 15 or fewer awake residents; staffing levels commensurate with numbers of residents Program description must specify that facility provides care that meets residents' needs	None specified
New York	None specified. Staff for AL must be sufficient to meet care needs of residents. Ratios listed in regulation.	None specified	Adult Care Facilities Continuum—provider decides if he or she wishes to operate AL-level program, which requires special license Dementia units have special requirements.
North Carolina	None specified.	Staff in special care units must have (1) six hours orientation within first week of employment, (2) 20 hours of dementia-specific training within six months of employment, and (3) 12 hours of CE annually.	Staffing rules apply only to advertised special care units. These facilities must also provide disclosure statements of policies and special services.

*State*	*Minimum Staffing Requirements Specific to Alzheimer's*	*Minimum Training Requirements for Alzheimer's Care*	*Other Alzheimer's-Related Provisions (e.g., disclosures)*
North Dakota	None specified	None specified, but all staff in basic care facilities receive annual training on mental and physical needs of residents, including behavior problems.	State has two types of facilities that offer AL services: basic care facilities (BCF) and assisted living facilities. Alzheimer's units are only available in BCFs.
Ohio	None specified	None specified, but if facility has residents with behavioral problems or increased emotional needs, staff members must receive training on appropriate interventions.
Oklahoma	None specified	Staff working in specialized units must be trained to meet residents' needs.	Assisted living center must disclose whether it has special care units. If it does, it must outline the scope of services unit provides and specific staffing.
Oregon	None specified	None specified, but direct care staff training must include changes associated with aging process, including dementia and response to behavior issues	Facilities advertising themselves as Alzheimer's care providers must obtain state Alzheimer's special care unit endorsement.
Pennsylvania	None specified, but staff must be available to meet residents' needs	Each direct care staff person working in secured dementia unit must have six hours of related annual training, on top of 12 hours of annual training required of direct care staff in a standard personal care home.	Residents must have written cognitive preadmission screening in collaboration with physician or geriatric assessment team. Residents must be re-assessed annually for continuing need for dementia care. Resident-home contract must include services provided in dementia care unit, admission, and costs, among other specified items.

*State*	*Minimum Staffing Requirements Specific to Alzheimer's*	*Minimum Training Requirements for Alzheimer's Care*	*Other Alzheimer's-Related Provisions (e.g., disclosures)*
Rhode Island	None specified, but sufficient staff to maintain residents' “highest practicable” physical, mental, and psychosocial well-being	Within 30 days of hire and before working alone in the AL “residence,” staff in licensed residences licensed for dementia care must receive at least 12 hours orientation and training on variety of topics, including understanding various dementias.	Residence offering or providing services to residents with Alzheimer's or other dementia through a special unit or program must disclose type of services provided, in addition to minimum state requires. Disclosure, with specified elements, must be submitted to licensing agency for review and provided to anyone wishing to move in.
South Carolina	None specified, but must have one staff person for every eight residents during “peak” activity times	Training must be provided to all staff members and direct care volunteers before resident contact and as often as facility determines is necessary, but at least annually.	Facilities offering special care units or programs for residents with Alzheimer's disease must disclose treatment that distinguishes it as being “especially suitable.”
South Dakota	One caregiver must be on secured unit at all time	Staff working in secured units must have specific training regarding residents' needs.	Each facility with secured units must comply with six requirements, including providing and documenting therapeutic programming. Any new secured unit must be located at grade level and have direct access to outside area, which must be enclosed by a fence.
Tennessee	None specified	Staff working on secured units must have annual in-service training, including a minimum of five relevant topic areas	Facilities can have secured units and “retain” residents up to the last stages of Alzheimer's. They must provide to state survey staff specific information and documentation accumulated during previous 12 months, such as staffing patterns and care provision.

*State*	*Minimum Staffing Requirements Specific to Alzheimer's*	*Minimum Training Requirements for Alzheimer's Care*	*Other Alzheimer's-Related Provisions (e.g., disclosures)*
Texas	None specified, but facilities must disclose and post staffing patterns monthly.	All staff must receive dementia-specific orientation before assuming job responsibilities. Direct care staff in an Alzheimer's-certified AL facility must annually complete 12 hours of in-service disease education	Any facility advertising, marketing, or promoting itself as providing specialized care for people with Alzheimer's or related disorders must be certified. They must also disclose nature of treatment and care for this population.
Utah	One staff with documented training required in secured Alzheimer's/dementia unit at all times	Nothing specific to memory care, but all staff in AL facilities must complete orientations and “extensive” in-service training	Type II facilities (higher care need) with approved secured units can admit residents with Alzheimer's or dementia diagnosis if resident able to exit facility with limited assistance from one person.
Vermont	None specified, but 24-hour, on-site staff required to meet resident needs.	Staff with any direct care responsibility must have training in communication skills specific to people with Alzheimer's and related disease.	Special care units must meet special licensing requirements and obtain approval from licensing agency. Approval is based on facility's demonstrating that it will provide specialized services. Approval requests must include certain items, including staff description.
Virginia	At least two direct care staff members must be in the special care unit at all times, with exceptions in limited circumstances.	On top of regular training, facility administrator and direct care staff must complete four hours of training in cognitive impairments due to dementia within two months of employment and six more hours within first year. Topics to be covered specified.	Regulations cover facilities caring for adults with serious cognitive impairment due to primary psychiatric diagnosis of dementia who cannot recognize danger or protect their own safety and welfare.

State

Minimum Staffing Requirements Specific to Alzheimer's

Minimum Training Requirements for Alzheimer's Care

Other Alzheimer's-Related Provisions (e.g., disclosures)

Washington

None specified

If boarding home serves residents with dementia, it must provide specialized training with specific learning outcomes to staff working with these residents.

Boarding homes must collect additional assessment information for residents who are found to have dementia. Homes with dementia care units with restricted egress must ensure that residents or other responsible party consents to the living arrangement, as well as make specific provisions regarding well-being and safety.

West Virginia

None specified, but 24 –hour staff (who can read and write) required.

All licensed AL facilities must provide at least two hours of training (specific topics) to all new employees within 15 days of employment, and annually thereafter, on Alzheimer's and related dementia.

If facility has licensed Alzheimer's unit or program, a minimum of 30 hours of training related to unit residents' care is required.

Facilities must obtain separate license if they advertise or promote specialized memory loss, dementia, or Alzheimer's unit.

State

Minimum Staffing Requirements Specific to Alzheimer's

Minimum Training Requirements for Alzheimer's Care

Other Alzheimer's-Related Provisions (e.g., disclosures)

Wisconsin

None specified and differ depending on licensed type (see Other Provisions)

Specified only for community-based residential facilities category (see Other Provisions) Staff in these facilities must receive training specific to client group within six months of employment.

Resident care staff in Residential Care Apartment Complexes must have documented training or experience in needs and techniques for assisting with activities of daily living and physical, functional, and psychological characteristics associated with aging.

State has three types of AL: community-based residential facilities (CBRF), adult family homes (AFH), and residential care apartment complexes (RCAC). All three can serve special populations.

CBRFs must identify client groups it can serve. Two categories are people with functional impairments related to advanced age and people with irreversible dementia. A full description of residents' special needs and how they will be met, including structured activity, must be provided as part of licensing.

AFHs can serve the same two categories of residents. As part of licensing, AFH must develop program statement describing number and types of individuals it is willing to accept and how it will meet individuals' needs.

Wyoming

None specified, but must be sufficient to meet residents' needs

None specified

Source: National Center for Assisted Living, Assisted Living State Regulatory Review 2007, March 2007


December 3, 2007		2007-R-0679
MEMORY CARE FACILITIES

By: Robin K. Cohen, Principal Analyst

*State*	*Minimum Staffing Requirements Specific to Alzheimer's*	*Minimum Training Requirements for Alzheimer's Care*	*Other Alzheimer's-Related Provisions (e.g., disclosures)*
Alabama	None	Yes, on specific topics. At least six hours continuing education (CE) annually.	Facilities not specifically licensed as specialty care facilities may neither admit nor retain residents with severe cognitive impairments and may not advertise themselves as such.
Alaska	None specific to Alzheimer's, must be sufficient to meet residents' needs	None specified	Facility must provide safe environment for these residents. Must have Division of Public Health-approved delayed exit or alarm system.
Arizona	None specific to Alzheimer's; must be sufficient to provide services consistent with level of service for which facility licensed.	Overview of Alzheimer's and other dementia required for “directed” care	Significant general training specified in regulations
Arkansas	Nothing specific to cognitively impaired; ratios based on number of residents	All staff must be trained within five months of hiring, with at least eight hours of training per month during that time in related areas (e.g., etiology, stages of disease). At least two hours ongoing training is required quarterly.	State has “Level I and II” designation for facilities providing AL services, with former providing constant supervision (e.g., 24-hour nursing). Facilities may not admit or retain residents whose needs are greater than what facility licensed to provide.