2006 Spring Training Presentation

1. 2006 Spring Training Presentation Assisted Living - State Update Presenter - Roy P. Kemp, Licensure Bureau Chief - DPHHS

2. “Sometimes You Gotta Create What You Want to Be a Part Of…”-Geri Weitzman

3. Assisted Living – What Is It? Assisted living is a significant provider in the long term care spectrum and continues to receive nationwide attention. Assisted living is no longer a provider category “in its infancy” It is a long term care option that is preferred by many individuals and their families because of the emphasis on resident choice, dignity, and privacy. Over 900,000 people, nation wide, live in approximately 36,000 Assisted living Facilities in 2000* * NCAL 2000 National Survey of Assisted Living Residents.

4. Assisted Living – What It Is Not… • Assisted living was never intended to be a substitute for a nursing home level of care • It was intended to be an alternative to a nursing home for those consumers who can thrive in an assisted living environment

5. Regulations…, Why Us…? • Legislature authorizes drafting regulations • Regulations are intended to protect a venerable segment of a population • Regulations are the minimum standards you may not operate below • Regulations do not assure high quality… but are the platform on which to build a quality program or service

6. Regulations… • Good regulations are generally the application of good common sense • Stringent Regulations are generally the result of public scandal or outrage • Overall good providers of a service generally lower the regulatory expectation, which is usually expressed by state rules

7. Avoiding Conflicts • Be careful what you promise or imply to residents and family; either verbally, on a website, or in a brochure • Review the facility/resident agreement • Are there house rules • Is there a resident hand book • Is there a need for a “special Addenda” to the agreement • 30 day notice of any change is required

8. Montana Assisted Living Facility Statistics - 2006 Licensure Bureau - QAD

9. 2004 Facility Size by Number of Beds Total 176 facilities

10. 2005 Facility Size by Number of Beds Total 183 facilities

11. 2006 Facility Size by Number of Beds Total 182 facilities

12. Facility Bed Profile - 2004

13. Facility Bed Profile – 2005

14. Facility Bed Profile – 2006

15. Assisted Living Rules Category C Facility Requirements Licensure Bureau - QAD

16. MCA 50-5-226(4) – A Severe Cognitive Impairment: • (A) a sever cognitive impairment is one that renders the resident incapable of expressing needs or making basic care decisions • (B) the resident may be at risk for leaving the facility without regard for personal safety * • (C) excluding (b) above, the resident may not be a risk to self or others • (D) the resident may not require physical or chemical restraint or placed in locked quarters

17. A.R.M. 37-106-2805(26) Severe Cognitive Impairment • Means the loss of intellectual functions, such as thinking, remembering and reasoning, of sufficient severity to interfere with a persons daily functioning • Such a person is incapable of recognizing danger, self-evacuating, summoning assistance, expressing need and/or making basic care decisions

18. C-facility; Rules Found At ARM 37.106.2891 - 2898 • Must meet category A requirements • If secure unit – must be staffed at all times • Secured unit must have separate dining and activities area • Staff must be awake, dressed, to provide care and supervision

19. C-facility; Administrator ARM 37-106-2891 • Must hold a current MT. NH administrators license or a current out of state NH license, or • completed the self study ALFA modules, or • Be enrolled for the self study modules with 6 month completion, and • 3 years of working in geriatric facilities or caring for disabled adults

20. C-facility; Administrators • Must have 16 contact hours of annual continuing education • 8 hours of the required annual education shall pertain to caring for residents with severe cognitive impairment

21. C-facility; Direct Care Staff ARM 37-106-2892 • Trained in the facility’s philosophy. • Must have skills to care for, intervene and direct residents. • Understand how to minimize challenging behaviors, wandering, hallucinations, illusions and delusions and impaired senses.

22. C-facility; Direct Care Staff • Trained in therapeutic programming to support the highest level of resident function including: • Large motor skills • Small motor skills • Appropriate level of cognitive tasks and • Social/emotional stimulation

23. C-facility; Direct Care Staff • Trained to: • Promote resident dignity, independence, individuality, privacy, and choice • Identify and alleviate safety risks, • Recognize common side effects and untoward reactions to medications, • Techniques to deal with bowel and bladder aberrant behaviors

24. C-facility; Direct Care Staff What Is Not in the Rules • For people with dementia in assisted living facilities, quality of life depends on the quality of the relationships they have with direct care staff • People with dementia are able to experience joy, comfort, meaning and growth in their lives

25. C-facility; Direct Care Staff What Is Not in the Rules • Staffing patterns should ensure C residents have sufficient assistance to complete their health and personal routines and to participate in the daily life of the residence • Consistent staffing assignments help to promote the quality of the relationships between staff and residents

26. Care For Dementia Residents Falls Into Two Broad Areas • Aspects of activities of daily living (ADL) • Eating, drinking, toileting, sleep, bathing, grooming, dressing, and ambulation • Psychiatric and behavioral symptoms Each of these categories is a fundamentally important aspect of care for residents with dementia, which contribute directly to a resident’s quality of life.

27. C-facility; Health Care Plan ARM 37-106-2895 • Within 21 days of admission a resident certification must be conducted • A written health care plan must be developed • It must include a detailed assessment, therapeutic management, and intervention techniques for behaviors and resident needs

28. C-facility; Health Care Plan • The plan shall include consideration of: • Memory • Judgment • Ability to care for self • Problem solving abilities • Mood and character changes • Behavioral patterns • Wandering • Dietary needs

29. What the Rules Do Not Say… • To provide good dementia care… a holistic assessment of the residents abilities is necessary to provide care and assistance that is tailored to the resident’s needs • To use information about a resident to develop “person-centered” strategies designed for individual needs

30. C-facility; Resident Disclosure ARM 37-106-2896 • The facility shall disclose in writing • The overall philosophy regarding meeting residents needs and the form of care or treatment provided • The process and criteria for move-in, transfer and discharge • The process used for resident assessment • The process to establish, implement, and update a health care plan • Staff training and continuing education practices

31. C-facility; Resident Disclosure • The facility shall disclose in writing: • The physical environment and design features to support the cognitively impaired • The frequency and types of activities • The level of family involvement expected • Any additional costs of care or fees • Written acknowledgement must be kept as part of resident permanent file

32. So What Makes Me a C Facility? • If you advertise that you “specialize in Alzheimer or dementia care • If you maintain a secured unit within the facility • If you secure the facility, restricting resident access to come and go

33. So What If I Don’t Do Any of Those Things… • If you have a resident that wanders outside the facility if left unsupervised you will need a C endorsement MCA 50-5-226(4)(B) the resident may be at risk for leaving the facility without regard for personal safety

34. Notice for Resident Move Out • Involuntary notice rule ARM 37-106-2824 • The rule does not cover all circumstances – • Unable to meet family member expectations, even those not empowered to make resident decisions • Abrasive or abusive residents impact on staff, visitors and other residents • The agreement should reflect that either party may terminate the resident agreement by serving the other a written 30 day notice

35. Legislative Up-date – HB 648 • MCA 50-40-102 Montana clean indoor air act of 1979 • MCA 50-40-103(3)(e) - health care facilities • MCA 50-40-104(5)(b)(iii) – the act does not apply to a private residence unless it is licensed as a health care facility

36. Smoking Ban Continued… • Enforcement is by the department or its designees • Or the local boards of health or their designees under direction of the department • Administrative rules are in development • Penalties are found at MCA 50-40-115

37. The Top 5 Deficiencies Cited July 2004 – June 2005 #1 & 2 • 37.106 2838 Resident Toilets & Bathing (4) all doors to resident bathrooms shall open outward or slide into the wall…. • # Cited 16 • 37.106.2822 Resident Service Plan: Category A(1) Based on the initial resident’s needs assessment, an initial service plan shall be developed for all category A residents… • # Cited 14

38. Top Five Continued… #3 • 37.106.2815 Written Policies and Procedures (1) A policy and procedure manual for the organization and operation of the facility shall be developed, implemented, kept current and reviewed as necessary to assure the continuity of care and the day to day operations of the facility… • # Cited 13

39. Top Five Continued… #4 • 37.106.2866 Construction, Building and Fire Codes (7) An Assisted living facility must have an annual fire inspection conducted by the appropriate local fire authority or the state fire marshal’s office and maintain a record… • # Cited 13, - Upon correction, 1 year license is issued

40. Top Five Continued… #5 • 37.106.2816 Assisted living facility staffing (2) The administrator shall develop policies and procedures for screening, hiring, and assessing staff which include practices that assist the employer in identifying employees that may pose risk or threat to the health, safety, or welfare of any resident and provide written documentation of findings and the outcome in the employee’s file • # Cited 12

41. Community Services Bureau • Additional Rent for Medicaid Resident • Must be reported as Income for resident • May change Medicaid eligibility • Smaller room, less amenities • Violation of resident rights?

42. Who Is in Charge? • The resident - if not adjudicated as incompetent • Statutory power of attorney – but may not decide medical or other health care decisions • Guardianship or a conservator • Durable Power of Attorney – only when disabled, incapacitated, or incompetent

43. Resident’s Right to Appeal an Involuntary Relocation • Montana resident rights act at MCA 50-5-1100 entitles residents of personal care facilities to the same rights which the federal government applies to skilled and intermediate care facilities participating in Medicare or Medicaid programs under “42 USC 1395i-3(a) implemented by regulation at 42 CFR part 883, subpart B. (See 42 CFR 483.1)

44. “Admission, Transfer, Discharge” - 42 CFR 483.12 • 30 day written notice of intent to transfer or discharge must be given to the resident and a family member or legal representative before transfer or discharge, except that notice may be made “as soon as practicable before transfer or discharge” when: • The safety of individuals in the facility would be endangered; • The health of the individual would be endangered;

45. Exception to 42 CRF 483.12 • That Notice May Be Made “As Soon As Practicable Before Transfer or Discharge” When: • The residents health improves sufficiently to allow a more immediate transfer or discharge • An immediate transfer or discharge is required by the resident’s urgent medical needs, or • The resident has not resided in the facility for 30 days

46. Written 30 Day Notice of Intent to Transfer or Discharge • Must Also Inform the Resident Of: • The reason for transfer or discharge; • The effective date of transfer or discharge; • The location to which the resident is transferred or discharged; • A statement that the resident has the right to appeal the action to the state; And • The name, address, & phone number of the state long term care ombudsman

47. 42 CFR 483.12 - Prohibition of Transfer or Discharge : • except under the following circumstances: • The safety of individuals in the facility is endangered; • the transfer or discharge is appropriate because the resident’s health has improved sufficiently so the resident no longer needs the services provided by the facility; • The transfer or discharge is necessary for the resident’s welfare and the residents needs cannot be met in the facility;

48. Prohibition of Transfer or Discharge... Except under the following Circumstances: • The health of individuals in the facility would other wise be endangered; • The resident has failed, (after reasonable and appropriate notice) to pay for a stay at the facility; or • The facility ceases to operate.

49. Residential Landlord and Tenant Act of 1977, MCA 70-24-104 • “Residence at a public or private institution if incidental to detention or the provision of medical, geriatric, educational, counseling, religious, or similar service” are arrangements not governed by the act. • Therefore, the landlord and tenant act does not apply to residents in a personal care facility.

50. Resident/facility Contracts • Any provision in a contract between a facility and resident which limits or alters the rights recognized in MCA 50-5-1100 is: • Neither enforceable against the resident, • Nor does it excuse the the facility from meeting the minimum requirements of licensure, including compliance with the Montana long term care residents bill of rights.