Course 101: Overview of the Assisted Living Regulations

1. Course 101: Overview of the Assisted Living Regulations Danna Kauffman Vice President of Public Policy, LifeSpan Network Friday, January 16, 2009

2. 2 Overview of Presentation History of the Regulations Overview of the Regulations Resident Care Staff/Training Operation/Management of Facility NOTE: This is an overview and cannot take the place of reviewing the regulations in their entirety. Regulations can be downloaded at www.lifespan-network.org under the Advocacy Non-Legislative Information webpage.

3. 3 History of Regulations Assisted Living Forums began in early 2000. Five drafts of the proposal were circulated between 2006-2008. 1st Informal Draft � September 2006 1st Publication in Maryland Register � May 2007 2nd Informal Draft � October 2007 2nd Publication in Maryland Register � February 2008. 3rd Publication in Maryland Register � August 2008 Final Notice in Maryland Register � December 19th Effective - December 29, 2008 *** Transmittal with roll out plan will be sent by OHCQ to all providers the week of January 12th.

4. 4 Resident Care Requirements .05 and .14 On-Site Nursing .05 and .14 Overnight Awake Staff .13 Quality Assurance Plan and Activity Requirements .13 Family and Resident Councils .26 and .27 Nursing Assessments .27 Resident Care Notes .29 On-Site Pharmacy Review .29 Storage of Narcotics and Shift Counting .37 Use of Restraints

5. 5 Staff/Training Requirements .15 -.17 ALM Education and/or Experience .18 Alternative ALM Requirements .19 Other Staff - Vaccinations .19 Other Staff - Provision of Personal Care Services .20 Delegating Nurse Requirements

6. 6 Management/Operations .06 Advertising .07 Licensure Process, including fees .10 Uniform Disclosure Statement .11 Investigations by DHMH .30 License Renewal Re: Alzheimer�s Special Care Units .41 and .49 Resident Room�s .44 Automated Device at Door .46 Emergency Preparedness Other Items .32 Resident Records .33 Relocations and Discharges .36 Investigations of Abuse and Neglect

7. 7 Resident Care Requirements

8. 8 .05 and .14 Overnight Awake Staff: Requirements Overnight, awake staff must be provided if the resident�s assessment (based on the Resident Assessment Tool) indicates that it is required. If a physician or assessing nurse does not believe that a resident requires overnight, awake staff, it must be documented on the Resident Assessment Tool. Electronic monitoring can be implemented in lieu of overnight awake staff upon the written recommendation of the resident�s physician or assessing nurse. Program must then apply to OHCQ for a waiver. Continued appropriateness of a waiver must be determined and documented upon reassessment of resident. NOTE: Updated tool available on OHCQ website.

9. 9 .05 and .14 On-Site Nursing: Requirements On-site nursing is required when a delegating nurse or physician issues a clinical order for that service based on a resident�s needs. If an ALM determines that the order should not or cannot be implemented, the ALM, DN and resident�s physician must discuss alternatives to safely address resident�s needs. Discussion must be documented in resident�s file. DN is required to report to OHCQ, the resident�s physician and the resident (or legal representative) if a ALM fails to implement a nursing or clinical order without identifying and providing alternatives to the care or service order.

10. 10 .13 Quality Assurance Plan Requires the development and implementation of a quality assurance plan. ALM and DN must meet at least every 6 months (and document the meeting) to review the: Changes in status of the program�s residents; Outcomes of pharmacy review; Service plan requirements; and Written recommendations or findings of the consultant pharmacist. NOTE: OHCQ will be checking to make sure that the first quality assurance meeting takes place six months from the effective date of the regulations (December 29, 2008)

11. 11 .13 Family and Resident Councils Requires that programs must make reasonable attempts to cooperate with a family or resident council if one exists. Resident council must consist of current residents. Family council may consist of: Members of current resident�s family; or An individual appointed by a current resident.

12. 12 .26 and .27 Assessments Full assessment must be completed: Annually Within 48 hours but not later than required by nursing practice and the patient�s condition after: A significant change of condition Each nonroutine hospitalization When the DN determines that a full assessment is not required within 48 hours, the DN must document the determination and ensure that a full assessment is conducted within 7 calendar days. A review of the assessment must be conducted every 6 months for residents who do not have a change.

13. 13 .27 Resident Care Notes Appropriate staff must write care notes for each resident. Care notes must be written on admission and at least weekly. Care notes must be individualized, legible, chronological and signed by the writer. Duplicate care notes are not needed if staff currently writes records or charts with the listed information � any significant change of condition, transfer to a skilled facility, return from medical appointments and when seen by home health provider, on return from nonroutine leaves of absences, discharge. NOTE: Sample weekly care notes available through OHCQ on behalf of LifeSpan.

14. 14 .29 On-Site Pharmacy Review A licensed pharmacist must conduct an on-site review of physician prescriptions, orders and resident records at least every six months. This requirement only applies to residents receiving nine or more medications, including over the counter and PRN. This review must be discussed during quality assurance meeting. NOTE: A separate transmittal will be sent out by OHCQ on this requirement. OHCQ will be checking for compliance four months from the date of this separate transmittal.

15. 15 .29 Narcotics and Controlled Drugs Requires all Schedule II and III narcotics to be maintained under a double lock system. Requires staff to count controlled drugs before the close of every shift. NOTE: A sample narcotic count sheet will be placed on the OHCQ website.

16. 16 .37 Use of Restraints Restraints must be ordered by a physician, cannot be �as needed�, and must be for a specified time. Must be renewed every 7 days. DN must provide training in the appropriate use of the restraint. Restraint cannot be used for longer than 2 hours without a change in position and toileting opportunity. Family or family�s representative must be notified about the use of restraints. Bed rails may be considered restraints depending on the reason for the use of beds rails and how the bed rails are used. OHCQ expects the use of restraint to be very rare in an assisted living setting.

17. 17 Staff Training and Requirements

18. 18 .15 Assisted Living Manager � Education and/or Experience For level 3 programs, an ALM must have: A 4-year, college-level degree; OR 2 years experience in a health care related field (includes experience in AL) AND 1 year of experience as an ALM or alternative ALM; OR 2 years experience in a health care related field and successful completion of the 80-hour assisted living manager training program. NOTE 1: Degree does not have to be completed in U.S. Documentation of education can be copy of transcripts (unofficial), copy of diploma, written verification from school. Experience can be from a resume or application where the individual affirms that the information is true and accurate. NOTE 2: Current managers (as of December 29th) exempted from requirement in their current program.

19. 19 .15 Assisted Living Manager � Training and Knowledge Requirements Initial and annual training in: Fire and Safety; Infection Control, including standard precautions; Emergency disaster plans; and Basic Food Safety Certification in basic first aid and CPR. All managers have to get initial certification but only have to get recertified in providing direct care. NOTE 1: Currently, ALMs only had to have knowledge in the above areas. NOTE 2: Managers who successfully complete the 80-hour course satisfy the training and knowledge requirements, except for the CPR and first aid certification. Verifiable knowledge in: Health and psychosocial needs of residents; Resident assessment process; Use of service plans; Cuing, coaching and moniotring residents who self-administer medications, with or without assistance; Providing assistance with ambulation, personal hygiene, dressing, toileting and feeding; and Resident rights. NOTE 1: Currently, only needed �knowledge.� NOTE 2: From December 29th on, �verifiable� knowledge can be documented through the successful completion of training or appropriate licensure/certification.

20. 20 .15 Assisted Living Manager � Added Responsibilities Implementing a nursing or clinical order of the DN or documenting in the resident�s record why the order should not be implemented. Notifying OHCQ when the manager terminates the program�s contract with or employment of a DN and the reason. NOTE: Note should be placed in facility file. All forms of communication acceptable � phone, mail, or e-mail. Time frame for notifying must be reasonable. Notifying the resident or legal representative of any: Significant change in condition of the resident; Adverse event that may result in a change in condition; Outcome of the resident�s care that results in an unanticipated consequence; and Corrective action, if any.

21. 21 .16 and .17 ALM � Manager Course In addition to requirements in .15, a program that is licensed for five beds or more must have a manager that has completed the 80-hour course BY AUGUST 2009. 20-hour CEUs required by all managers employed in facilities for five beds by August 2011 regardless of below exemption. Exemptions for 80-hour course but not 20 CEUs: NHA Those employed as a manager in Maryland for one year prior to January 1, 2008.

22. 22 .18 Alternative ALM - Requirements Must have 2 years experience in a health-care related field (includes experience in assisted living). Must have the same qualifications of �other staff� - .19B). Initial and annual training in: Fire and life safety, including the use of fire extinguishers; Infection Control, including standard precautions; Emergency disaster plans; Basic Food Safety; and Basic first aid. Training or experience in: Health and psychosocial needs of residents; Resident assessment process; Use of service plans; and Resident rights.

23. 23 .19 Other Staff - Vaccinations and Other Training Requirements Required to be free from tuberculosis, measles, mumps, rubella and varicella through appropriate screening procedures such as TB skin tests, positive disease histories, or antibody serologies. Initial and annual training in: Fire and life safety, including the use of fire extinguishers; Infection Control, including standard precautions; Emergency disaster plans; Basic Food Safety; and Basic first aid. Training or experience in: Health and psychosocial needs of residents; Resident assessment process; Use of service plans; and Resident rights. NOTE: For training, no minimum number of hours. Experience may be in the form of working experience and may be validated on resume/application.

24. 24 .19 Other Staff - Provision of Personal Care Services If job duties involve the provision of personal care services (ADLs), an employee must demonstrate competence to the DN before performing these services. However, an employee can work for 7 days before demonstrating competency to the DN if the employee is performing tasks with a CNA or GNA or an individual who has been approved by the DN. CNAs and GNAs do not have to demonstrate (ADL) competency to the DN under this regulation.

25. 25 .20 Delegating Nurse Requirements Program must have a current and signed agreement with a RN for delegating nurse services. An employment contract satisfies this requirement. NOTE: Written contract should be in place by July 1, 2009. Program must maintain documentation that the DN has completed mandatory training by the Board of Nursing. New Duties: Notify OHCQ if the contract or employment is terminated and the reason for the termination; Notify OHCQ, the resident�s physician and the resident (or legal representative) if the ALM fails to implement nursing or clinical orders without identifying alternatives to care. Nursing Assessment requirements � See Regulations .26 and .27 Quality Assurance Plan and Meetings � See Regulation .13

26. 26 Management/Operations

27. 27 .06 Advertising Requirements Current law now incorporated in regulations. A person cannot advertise, represent or imply to the public that a program is authorized to provide a service that the program is not licensed, certified or otherwise authorized by DHMH to provide. Civil money penalties for violations.

28. 28 .06 and .35 Adult Day Care Services Prohibitions Prohibits a program from providing day, partial or hourly adult day care services without a medical adult day care license. Adult day care attendance may be encouraged but cannot be mandatory. Adult medical day care availability and policies must be disclosed in the program�s admission agreement.

29. 29 .07 Licensing Fees Increases the licensing fees by moving from $100/year for programs with less than 16 beds and $100/year plus $6/bed for programs with 16 or more beds to a tiered system: 1-3 beds: $100 4-15 beds: $150 16 or more: $150 plus $8 per bed for each bed over 15. NOTE: Applies to relicensure when the facility license needs to be renewed. Allows, for initial licensure, DHMH to charge $250 per additional on-site visit or deny the license if the facility fails to comply with the regulations and requires DHMH to conduct more than one on-site pre-licensure visit.

30. 30 .07 Licensure Requirements Initial and Renewal: Identification of any individual or corporate owner of 25% or more interest. Initial: Demonstrate financial or administrative ability to operate a program, including business plan and one year operating budget. Policies and procedures to be implemented as designated in the application for licensure.

31. 31 .30 License Renewal � Alzheimer�s Special Care Units On renewal, program no longer has to submit the entire description of the unit. Instead, program only has to provide a description of any changes to the program. The changes must explain how the care and treatment in the special care unit is different than the care and treatment in the non-special care unit.

32. 32 .10 Uniform Disclosure Statement Current law now incorporated into the regulations. All programs must complete a statement and send to OHCQ. Statement must be part of marketing materials and provided to individuals upon request. Any changes to the form must be filed within 30 days with OHCQ. NOTE: Statement is available in electronic format under the Forms Section of Assisted Living on the OHCQ website: www.dhmh.state.md.us/ohcq

33. 33 .11 Investigation by the Department Programs must be available at all times for announced and unannounced inspections. Any part of the facility and any surrounding accessory buildings which can be entered by staff or residents are considered part of the facility. Staff rooms can be inspected if residents have access to them.

34. 34 .11 Investigation: IDR �Internal Dispute Resolution� � Licensee can question violations in writing within 10 calendar days of receiving the statement or violations. At the discretion of OHCQ, process can be held in-person, by telephone or in-writing. Unless expressly directed by OHCQ, items brought to IDR do not have to be included in plans of correction until five days after a decision.

35. 35 .41 and .49 General Physical Plant Requirements � Resident Rooms Storage in resident�s rooms must be secured, fixed and locked rather than just locked. Allows a resident to have his/her own cleaning and personal hygiene items provided that the ALM or DN determine that the products would not present a threat to the safety of the resident or others and the products are kept in the resident�s room and out of view of others. Resident furnishings should be specified in the resident agreement.

36. 36 .44 Security Facility must provide an effective automated devise or system to alert staff to individuals entering or leaving the building unless the door is staffed by an individual who views and maintains a log of individuals entering or exiting.

37. 37 .46 Emergency Preparedness October 1, 2009, all facilities with more than 50 beds must have an emergency electrical power generator. Facilities must develop an emergency plan that includes procedures that will be followed before, during and after an emergency that addresses: Evacuation, transportation, or shelter in-place of residents; Notification to families, staff and OHCQ regarding the action that will be taken concerning the safety and well-being of staff; Staff coverage, organization and assignment of responsibilities; and The continuity of operations, including procuring essential goods, equipment and services and relocation to alternative facilities. NOTE: OHCQ will begin enforcing full compliance by August 2009.

38. 38 Other Items: .31 Indicates what must be included in an incident report. .32 Medical records must be maintained for five years after a resident is discharged and must be maintained and disposed of in accordance with State law. .33 Differentiates b/w relocation and discharge. Relocation within facility and residents must be given five days notice for non-emergency situations and obtain resident consent. Discharge is from the facility and notice must be given 30 days before a non-emergent discharge. .36 ALP must provide on-site written documentation of its investigation of all allegations of abuse, neglect or exploitation rather than just investigate.

39. 39 Contact Information Danna Kauffman � LifeSpan Network 410-279-5572 dkauffman@lifespan-network.org www.lifespan-network.org Lestor Brown � AL Program Manager, OHCQ 410-402-8217 lbrown@dhmh.state.md.us www.dhmh.state.md.us/ohcq