Regulation: collaborating with the state

Nursing Homes, June, 2004 by Ann McDermott

Because assisted living is regulated at the state level, industry advocates are looking continually for models of ways they can work effectively with state regulators and health agencies. The quest is for strategies that produce results not only for providers, but also for residents--results, in other words, that everyone applauds.

The California Assisted Living Association (CALA), a state affiliate of the Assisted Living Federation of America (ALFA), recently illustrated how to lighten administrative loads for residences and state officials alike, while simultaneously addressing residents' needs more appropriately. By actively working the regulatory front on behalf of its members, CALA helped shape new rules for the exceptions process and dementia care.

On January 1, the state implemented emergency regulations altering the exceptions process that assisted living operators must follow when caring for residents with restricted health conditions. In California, where assisted living care is provided in Residential Care Facilities for the Elderly (RCFEs), the new rules eliminate the need for RCFEs to receive prior approval from the state's Department of Social Services (DSS) when admitting or retaining residents with certain health-related conditions. These conditions include diabetes, incontinence, and colostomies, or restrictions such as half-bed rails and postural supports.

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Providers still must file for an exception under special circumstances. For example, an RCFE must submit a waiver if the residence is currently on probation, or if it has received a deficiency notice regarding care for residents with these health-related conditions.

As a result of the changes, valuable time and dollars will be saved at both ends of the exceptions process, by RCFEs and DSS alike, making resident care delivery more effective and efficient. "CALA advocated strongly for this change and is very pleased the department was able to act as quickly as it did," says Heather Harrison, CALA's vice-president of public policy. "This change benefits the state, providers, and residents by streamlining the system and clarifying expectations up front."

Dementia Workgroup

CALA also participated in a DSS work group that was assembled recently to incorporate changes prompted by the enactment of dementia care legislation, which was sponsored by the state chapter of the Alzheimer's Association. The work group attempted to strike a better balance between resident rights and safety in caring for individuals with dementia. Revisions in the dementia care rules are expected to be finalized in the next few months (see sidebar).

DSS apparently had been restricting the rights of residents whenever they received a diagnosis of dementia, regardless of whether their behavior necessitated a change. For example, personal grooming items were routinely confiscated from residents who clearly had the capacity to use them, simply because they received a dementia diagnosis.

The proposed rules seek to address this concern by adding a diagnosis other than dementia, called mild cognitive impairment. A person with mild cognitive impairment experiences only short-term memory loss and none of the other symptoms commonly associated with dementia.

Under the proposed rule, if a physician diagnoses a resident with this condition, the RCFE would not be required to implement dementia standards of care. With regard to grooming items, DSS would allow such a resident to retain these personal effects unless there is reason to believe the resident cannot safely manage them.

CALA was successful in having DSS accept many of its recommendations during the rule-making process. "The association appreciates the department's willingness to work through this challenging issue," says Harrison. "Although the new rules may be short of ideal, they will be an improvement over the current system."

RELATED ARTICLE: Focus on Training and Marketing

California's new assisted living regulations regarding dementia care generally concentrate on two major areas:

* Training rules stipulate that direct-care staff, including individuals who assist dementia residents during mealtimes and breaks, must receive six hours in dementia care training during the first four weeks of employment and eight hours of in-service training within 12 months of beginning work in the residence and each succeeding 12-month period. The rules also specify six subject areas that RCFEs must address in training sessions during a three-year period. These six training topics are:

1. Effects of medications on behavior of residents with dementia

2. Common problems such as wandering, aggression, or inappropriate sexual behavior

3. Positive therapeutic interventions and activities

4. Communication skills (resident/staff relations)

5. Promoting resident dignity, independence, individuality, privacy, and choice

6. End-of-life issues, including hospice

* Marketing materials must include a thorough description of the community's plan of operation, from philosophy to success indicators, to aid in identifying whether the plan of care is meeting residents' needs. Perhaps the most unusual provision in the regulations is the requirement that the RCFE give a 30-day notice to the state, residents, and responsible parties when it plans to discontinue advertising dementia care services. This doesn't mean that services to current residents would stop, only that the provider is no longer advertising the program.